DVBCQWR2 ;;ALB-CIOFO/SBW - Wrist Conditions ; 6/JUN/2011
;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
;
TXT ;
;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
;; disability benefits. VA will consider the information you provide on this
;; questionnaire as part of their evaluation in processing the Veteran's claim.
;;
;; 1. Diagnosis
;; Does the Veteran now have or has he/she ever had a wrist condition?
;; ___ Yes ___ No
;;
;; If yes, provide only diagnoses that pertain to wrist conditions:
;; Diagnosis #1: ___________________
;; ICD code: ______________________
;; Date of diagnosis: ______________
;; Side affected: ___ Right ___ Left ___ Both
;;
;; Diagnosis #2: ___________________
;; ICD code: ______________________
;; Date of diagnosis: ______________
;; Side affected: ___ Right ___ Left ___ Both
;;
;; Diagnosis #3: ___________________
;; ICD code: ______________________
;; Date of diagnosis: ______________
;; Side affected: ___ Right ___ Left ___ Both
;;
;; If there are additional diagnoses that pertain to wrist conditions, list
;; using above format: ________________________________________________________
;;
;; 2. Medical history
;; a. Describe the history (including onset and course) of the Veteran's current
;; wrist condition(s) (brief summary): ________________________________________
;;
;; b. Dominant hand:
;; ___ Right ___ Left ___ Ambidextrous
;;
;; 3. Flare-ups
;; Does the Veteran report that flare-ups impact the function of the wrist?
;; ___ Yes ___ No
;; If yes, document the Veteran's description of the impact of flare-ups in his
;; or her own words: __________________________________________________________
;;
;; 4. Initial range of motion (ROM) measurements
;; Measure ROM with a goniometer, rounding each measurement to the nearest 5
;; degrees. During the measurements, document the point at which painful motion
;; begins, evidenced by visible behavior such as facial expression, wincing, etc.
;; Report initial measurements below.
;;
;; Following the initial assessment of ROM, perform repetitive use testing. For
;; VA purposes, repetitive use testing must be included in all joint exams. The
;; VA has determined that 3 repetitions of ROM (at a minimum) can serve as a
;; representative test of the effect of repetitive use. After the initial
;; measurement, reassess ROM after 3 repetitions. Report post-test measurements
;; in section 5.
;;
;; a. Right wrist palmar flexion
;; Select where palmar flexion ends (endpoint of palmar flexion is 80 degrees):
;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45 ___50
;; ___55 ___60 ___65 ___70 ___75 ___80 or greater
;;
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45 ___50
;; ___55 ___60 ___65 ___70 or greater
;;
;; b. Right wrist dorsiflexion (extension)
;; Select where dorsiflexion (extension) ends (endpoint of dorsiflexion
;; (extension) is 70 degrees):
;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45 ___50
;; ___55 ___60 ___65 ___70 or greater
;;
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45 ___50
;; ___55 ___60 ___65 ___70 or greater
;;
;; c. Left wrist palmar flexion
;; Select where palmar flexion ends (endpoint of palmar flexion is 80 degrees):
;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45 ___50
;; ___55 ___60 ___65 ___70 ___75 ___80 or greater
;;
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45 ___50
;; ___55 ___60 ___65 ___70 or greater
;;
;; d. Left wrist dorsiflexion (extension)
;; Select where dorsiflexion (extension) ends (endpoint of dorsiflexion
;; (extension) is 70 degrees):
;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45 ___50
;; ___55 ___60 ___65 ___70 or greater
;;
;; Select where objective evidence of painful motion begins:
;; ___ No objective evidence of painful motion
;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45 ___50
;; ___55 ___60 ___65 ___70 or greater
;;
;; e. If ROM does not conform to the normal range of motion identified above but
;; is normal for this Veteran (for reasons other than a wrist condition, such as
;; age, body habitus, neurologic disease), explain: ___________________________
;;^TOF^
;; 5. ROM measurements after repetitive use testing
;; a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?
;; ___ Yes ___ No If unable, provide reason: ______________________________
;; If Veteran is unable to perform repetitive-use testing, skip to section 6.
;; If Veteran is able to perform repetitive-use testing, measure and report ROM
;; after a minimum of 3 repetitions.
;;
;; b. Right wrist post-test ROM
;; Select where palmar flexion ends:
;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45 ___50
;; ___55 ___60 ___65 ___70 ___75 ___80 or greater
;;
;; Select where dorsiflexion (extension) ends:
;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45 ___50
;; ___55 ___60 ___65 ___70 or greater
;;
;; c. Left wrist post-test ROM
;; Select where palmar flexion ends:
;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45 ___50
;; ___55 ___60 ___65 ___70 ___75 ___80 or greater
;;
;; Select where dorsiflexion (extension) ends:
;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45 ___50
;; ___55 ___60 ___65 ___70 or greater
;;
;; 6. Functional loss and additional limitation in ROM
;; The following section addresses reasons for functional loss, if present, and
;; additional loss of ROM after repetitive-use testing, if present. The VA defines
;; functional loss as the inability to perform normal working movements of the
;; body with normal excursion, strength, speed, coordination and/or endurance.
;;
;; a. Does the Veteran have additional limitation in ROM of the wrist following
;; repetitive-use testing?
;; ___ Yes ___ No
;;
;; b. Does the Veteran have any functional loss and/or functional impairment of
;; the wrist?
;; ___ Yes ___ No
;;
;; c. If the Veteran has functional loss, functional impairment and/or additional
;; limitation of ROM of the wrist after repetitive use, indicate the contributing
;; factors of disability below (check all that apply and indicate side affected):
;; ___ No functional loss for right upper extremity
;; ___ No functional loss for left upper extremity
;; ___ Less movement than normal ___ Right ___ Left ___ Both
;; ___ More movement than normal ___ Right ___ Left ___ Both
;; ___ Weakened movement ___ Right ___ Left ___ Both
;; ___ Excess fatigability ___ Right ___ Left ___ Both
;; ___ Incoordination, (impaired ___ Right ___ Left ___ Both
;; ability to execute skilled movements smoothly)
;; ___ Pain on movement ___ Right ___ Left ___ Both
;; ___ Swelling ___ Right ___ Left ___ Both
;; ___ Deformity ___ Right ___ Left ___ Both
;; ___ Atrophy of disuse ___ Right ___ Left ___ Both
;;
;; 7. Pain (pain on palpation)
;; Does the Veteran have localized tenderness or pain on palpation of joints/soft
;; tissue of either wrist?
;; ___ Yes ___ No
;; If yes, side affected: ___ Right ___ Left ___ Both
;;
;; 8. Muscle strength testing
;; Rate strength according to the following scale:
;; 0/5 No muscle movement
;; 1/5 Palpable or visible muscle contraction, but no joint movement
;; 2/5 Active movement with gravity eliminated
;; 3/5 Active movement against gravity
;; 4/5 Active movement against some resistance
;; 5/5 Normal strength
;; Wrist flexion: Right: ___5/5 ___4/5 ___3/5 ___2/5 ___1/5 ___0/5
;; Left: ___5/5 ___4/5 ___3/5 ___2/5 ___1/5 ___0/5
;; Wrist extension: Right: ___5/5 ___4/5 ___3/5 ___2/5 ___1/5 ___0/5
;; Left: ___5/5 ___4/5 ___3/5 ___2/5 ___1/5 ___0/5
;;
;; 9. Ankylosis
;; Does the Veteran have ankylosis of either wrist joint?
;; ___ Yes ___ No
;; If yes, indicate severity and side affected:
;; ___ Extremely unfavorable ___ Right ___ Left ___ Both
;; ___ Unfavorable, with ulnar or radial ___ Right ___ Left ___ Both
;; deviation
;; ___ Unfavorable, in any degree of ___ Right ___ Left ___ Both
;; palmar flexion
;; ___ Any other unfavorable position ___ Right ___ Left ___ Both
;; ___ Favorable in 20º to 30º ___ Right ___ Left ___ Both
;; dorsiflexion
;;^TOF^
;; 10. Joint replacement and/or other surgical procedures
;; a. Has the Veteran had a total wrist joint replacement?
;; ___ Yes ___ No
;; If yes, indicate side and severity of residuals.
;; ___ Right wrist
;; Date of surgery: ___________________
;; Residuals:
;; ___ None
;; ___ Intermediate degrees of residual weakness, pain and/or
;; limitation of motion
;; ___ Chronic residuals consisting of severe painful motion and/or
;; weakness
;; ___ Other, describe: _____________
;; ___ Left wrist
;; Date of surgery: ___________________
;; Residuals:
;; ___ None
;; ___ Intermediate degrees of residual weakness, pain and/or
;; limitation of motion
;; ___ Chronic residuals consisting of severe painful motion and/or
;; weakness
;; ___ Other, describe: _____________
;;
;; b. Has the Veteran had arthroscopic or other wrist surgery?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;; Date and type of surgery: _____________
;;
;; c. Does the Veteran have any residual signs and/or symptoms due to
;; arthroscopic or other wrist surgery?
;; ___ Yes ___ No
;; If yes, indicate side affected: ___ Right ___ Left ___ Both
;; If yes, describe residuals: _________________________
;;
;; 11. Other pertinent physical findings, complications, conditions, signs
;; and/or symptoms
;; a. Does the Veteran have any scars (surgical or otherwise) related to any
;; conditions or to the treatment of any conditions listed in the Diagnosis
;; section above?
;; ___ Yes ___ No
;; If yes, are any of the scars painful and/or unstable, or is the total area of
;; all related scars greater than 39 square cm (6 square inches)?
;; ___ Yes ___ No
;; If yes, also complete a Scars Questionnaire.
;;^TOF^
;; b. Does the Veteran have any other pertinent physical findings,
;; complications, conditions, signs and/or symptoms related to any conditions
;; listed in the Diagnosis section above?
;; ___ Yes ___ No
;; If yes, describe (brief summary): __________________________________________
;;
;; 12. Remaining effective function of the extremities
;; Due to the Veteran's wrist conditions, is there functional impairment of an
;; extremity such that no effective function remains other than that which would
;; be equally well served by an amputation with prosthesis? (Functions of the
;; upper extremity include grasping, manipulation, etc)
;; ___ Yes, functioning is so diminished that amputation with prosthesis would
;; equally serve the Veteran.
;; ___ No
;; If yes, indicate extremity(ies) (check all extremities for which this applies):
;; ___ Right upper ___ Left upper
;; For each checked extremity, describe loss of effective function, identify the
;; condition causing loss of function, and provide specific examples (brief
;; summary): __________________________________________________________________
;; ____________________________________________________________________________
;;
;; 13. Diagnostic Testing
;; The diagnosis of degenerative arthritis (osteoarthritis) or traumatic arthritis
;; must be confirmed by imaging studies. Once such arthritis has been documented,
;; no further imaging studies are indicated, even if arthritis has worsened.
;;
;; a. Have imaging studies of the wrist been performed and are the results
;; available?
;; ___ Yes ___ No
;; If yes, is degenerative or traumatic arthritis documented?
;; ___ Yes ___ No
;; If yes, indicate wrist: ___ Right ___ Left ___ Both
;;
;; b. Are there any other significant diagnostic test findings and/or results?
;; ___ Yes ___ No
;; If yes, provide type of test or procedure, date and results (brief summary):
;; ____________________________________________________________________________
;;
;; 14. Functional impact
;; Does the Veteran's wrist condition impact his or her ability to work?
;; ___ Yes ___ No
;; If yes, describe the impact of each of the Veteran's wrist conditions
;; providing one or more examples: ____________________________________________
;; ____________________________________________________________________________
;;^TOF^
;; 15. Remarks, if any: ______________________________________________________
;; ____________________________________________________________________________
;;
;; Physician signature: _____________________________________ Date: ____________
;;
;; Physician printed name: _____________________________________________________
;;
;; Medical license #: __________________________________________________________
;;
;; Physician address: __________________________________________________________
;;
;; Phone: _____________________________ FAX: _______________________________
;;
;; NOTE: VA may request additional medical information, including additional
;; examinations if necessary to complete VA's review of the Veteran's application.
;;^END^
Q
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCQWR2 14719 printed Sep 23, 2025@19:24:24 Page 2
DVBCQWR2 ;;ALB-CIOFO/SBW - Wrist Conditions ; 6/JUN/2011
+1 ;;2.7;AMIE;**173**;Apr 10, 1995;Build 2
+2 ;
TXT ;
+1 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for
+2 ;; disability benefits. VA will consider the information you provide on this
+3 ;; questionnaire as part of their evaluation in processing the Veteran's claim.
+4 ;;
+5 ;; 1. Diagnosis
+6 ;; Does the Veteran now have or has he/she ever had a wrist condition?
+7 ;; ___ Yes ___ No
+8 ;;
+9 ;; If yes, provide only diagnoses that pertain to wrist conditions:
+10 ;; Diagnosis #1: ___________________
+11 ;; ICD code: ______________________
+12 ;; Date of diagnosis: ______________
+13 ;; Side affected: ___ Right ___ Left ___ Both
+14 ;;
+15 ;; Diagnosis #2: ___________________
+16 ;; ICD code: ______________________
+17 ;; Date of diagnosis: ______________
+18 ;; Side affected: ___ Right ___ Left ___ Both
+19 ;;
+20 ;; Diagnosis #3: ___________________
+21 ;; ICD code: ______________________
+22 ;; Date of diagnosis: ______________
+23 ;; Side affected: ___ Right ___ Left ___ Both
+24 ;;
+25 ;; If there are additional diagnoses that pertain to wrist conditions, list
+26 ;; using above format: ________________________________________________________
+27 ;;
+28 ;; 2. Medical history
+29 ;; a. Describe the history (including onset and course) of the Veteran's current
+30 ;; wrist condition(s) (brief summary): ________________________________________
+31 ;;
+32 ;; b. Dominant hand:
+33 ;; ___ Right ___ Left ___ Ambidextrous
+34 ;;
+35 ;; 3. Flare-ups
+36 ;; Does the Veteran report that flare-ups impact the function of the wrist?
+37 ;; ___ Yes ___ No
+38 ;; If yes, document the Veteran's description of the impact of flare-ups in his
+39 ;; or her own words: __________________________________________________________
+40 ;;
+41 ;; 4. Initial range of motion (ROM) measurements
+42 ;; Measure ROM with a goniometer, rounding each measurement to the nearest 5
+43 ;; degrees. During the measurements, document the point at which painful motion
+44 ;; begins, evidenced by visible behavior such as facial expression, wincing, etc.
+45 ;; Report initial measurements below.
+46 ;;
+47 ;; Following the initial assessment of ROM, perform repetitive use testing. For
+48 ;; VA purposes, repetitive use testing must be included in all joint exams. The
+49 ;; VA has determined that 3 repetitions of ROM (at a minimum) can serve as a
+50 ;; representative test of the effect of repetitive use. After the initial
+51 ;; measurement, reassess ROM after 3 repetitions. Report post-test measurements
+52 ;; in section 5.
+53 ;;
+54 ;; a. Right wrist palmar flexion
+55 ;; Select where palmar flexion ends (endpoint of palmar flexion is 80 degrees):
+56 ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45 ___50
+57 ;; ___55 ___60 ___65 ___70 ___75 ___80 or greater
+58 ;;
+59 ;; Select where objective evidence of painful motion begins:
+60 ;; ___ No objective evidence of painful motion
+61 ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45 ___50
+62 ;; ___55 ___60 ___65 ___70 or greater
+63 ;;
+64 ;; b. Right wrist dorsiflexion (extension)
+65 ;; Select where dorsiflexion (extension) ends (endpoint of dorsiflexion
+66 ;; (extension) is 70 degrees):
+67 ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45 ___50
+68 ;; ___55 ___60 ___65 ___70 or greater
+69 ;;
+70 ;; Select where objective evidence of painful motion begins:
+71 ;; ___ No objective evidence of painful motion
+72 ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45 ___50
+73 ;; ___55 ___60 ___65 ___70 or greater
+74 ;;
+75 ;; c. Left wrist palmar flexion
+76 ;; Select where palmar flexion ends (endpoint of palmar flexion is 80 degrees):
+77 ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45 ___50
+78 ;; ___55 ___60 ___65 ___70 ___75 ___80 or greater
+79 ;;
+80 ;; Select where objective evidence of painful motion begins:
+81 ;; ___ No objective evidence of painful motion
+82 ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45 ___50
+83 ;; ___55 ___60 ___65 ___70 or greater
+84 ;;
+85 ;; d. Left wrist dorsiflexion (extension)
+86 ;; Select where dorsiflexion (extension) ends (endpoint of dorsiflexion
+87 ;; (extension) is 70 degrees):
+88 ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45 ___50
+89 ;; ___55 ___60 ___65 ___70 or greater
+90 ;;
+91 ;; Select where objective evidence of painful motion begins:
+92 ;; ___ No objective evidence of painful motion
+93 ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45 ___50
+94 ;; ___55 ___60 ___65 ___70 or greater
+95 ;;
+96 ;; e. If ROM does not conform to the normal range of motion identified above but
+97 ;; is normal for this Veteran (for reasons other than a wrist condition, such as
+98 ;; age, body habitus, neurologic disease), explain: ___________________________
+99 ;;^TOF^
+100 ;; 5. ROM measurements after repetitive use testing
+101 ;; a. Is the Veteran able to perform repetitive-use testing with 3 repetitions?
+102 ;; ___ Yes ___ No If unable, provide reason: ______________________________
+103 ;; If Veteran is unable to perform repetitive-use testing, skip to section 6.
+104 ;; If Veteran is able to perform repetitive-use testing, measure and report ROM
+105 ;; after a minimum of 3 repetitions.
+106 ;;
+107 ;; b. Right wrist post-test ROM
+108 ;; Select where palmar flexion ends:
+109 ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45 ___50
+110 ;; ___55 ___60 ___65 ___70 ___75 ___80 or greater
+111 ;;
+112 ;; Select where dorsiflexion (extension) ends:
+113 ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45 ___50
+114 ;; ___55 ___60 ___65 ___70 or greater
+115 ;;
+116 ;; c. Left wrist post-test ROM
+117 ;; Select where palmar flexion ends:
+118 ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45 ___50
+119 ;; ___55 ___60 ___65 ___70 ___75 ___80 or greater
+120 ;;
+121 ;; Select where dorsiflexion (extension) ends:
+122 ;; ___0 ___5 ___10 ___15 ___20 ___25 ___30 ___35 ___40 ___45 ___50
+123 ;; ___55 ___60 ___65 ___70 or greater
+124 ;;
+125 ;; 6. Functional loss and additional limitation in ROM
+126 ;; The following section addresses reasons for functional loss, if present, and
+127 ;; additional loss of ROM after repetitive-use testing, if present. The VA defines
+128 ;; functional loss as the inability to perform normal working movements of the
+129 ;; body with normal excursion, strength, speed, coordination and/or endurance.
+130 ;;
+131 ;; a. Does the Veteran have additional limitation in ROM of the wrist following
+132 ;; repetitive-use testing?
+133 ;; ___ Yes ___ No
+134 ;;
+135 ;; b. Does the Veteran have any functional loss and/or functional impairment of
+136 ;; the wrist?
+137 ;; ___ Yes ___ No
+138 ;;
+139 ;; c. If the Veteran has functional loss, functional impairment and/or additional
+140 ;; limitation of ROM of the wrist after repetitive use, indicate the contributing
+141 ;; factors of disability below (check all that apply and indicate side affected):
+142 ;; ___ No functional loss for right upper extremity
+143 ;; ___ No functional loss for left upper extremity
+144 ;; ___ Less movement than normal ___ Right ___ Left ___ Both
+145 ;; ___ More movement than normal ___ Right ___ Left ___ Both
+146 ;; ___ Weakened movement ___ Right ___ Left ___ Both
+147 ;; ___ Excess fatigability ___ Right ___ Left ___ Both
+148 ;; ___ Incoordination, (impaired ___ Right ___ Left ___ Both
+149 ;; ability to execute skilled movements smoothly)
+150 ;; ___ Pain on movement ___ Right ___ Left ___ Both
+151 ;; ___ Swelling ___ Right ___ Left ___ Both
+152 ;; ___ Deformity ___ Right ___ Left ___ Both
+153 ;; ___ Atrophy of disuse ___ Right ___ Left ___ Both
+154 ;;
+155 ;; 7. Pain (pain on palpation)
+156 ;; Does the Veteran have localized tenderness or pain on palpation of joints/soft
+157 ;; tissue of either wrist?
+158 ;; ___ Yes ___ No
+159 ;; If yes, side affected: ___ Right ___ Left ___ Both
+160 ;;
+161 ;; 8. Muscle strength testing
+162 ;; Rate strength according to the following scale:
+163 ;; 0/5 No muscle movement
+164 ;; 1/5 Palpable or visible muscle contraction, but no joint movement
+165 ;; 2/5 Active movement with gravity eliminated
+166 ;; 3/5 Active movement against gravity
+167 ;; 4/5 Active movement against some resistance
+168 ;; 5/5 Normal strength
+169 ;; Wrist flexion: Right: ___5/5 ___4/5 ___3/5 ___2/5 ___1/5 ___0/5
+170 ;; Left: ___5/5 ___4/5 ___3/5 ___2/5 ___1/5 ___0/5
+171 ;; Wrist extension: Right: ___5/5 ___4/5 ___3/5 ___2/5 ___1/5 ___0/5
+172 ;; Left: ___5/5 ___4/5 ___3/5 ___2/5 ___1/5 ___0/5
+173 ;;
+174 ;; 9. Ankylosis
+175 ;; Does the Veteran have ankylosis of either wrist joint?
+176 ;; ___ Yes ___ No
+177 ;; If yes, indicate severity and side affected:
+178 ;; ___ Extremely unfavorable ___ Right ___ Left ___ Both
+179 ;; ___ Unfavorable, with ulnar or radial ___ Right ___ Left ___ Both
+180 ;; deviation
+181 ;; ___ Unfavorable, in any degree of ___ Right ___ Left ___ Both
+182 ;; palmar flexion
+183 ;; ___ Any other unfavorable position ___ Right ___ Left ___ Both
+184 ;; ___ Favorable in 20 to 30 ___ Right ___ Left ___ Both
+185 ;; dorsiflexion
+186 ;;^TOF^
+187 ;; 10. Joint replacement and/or other surgical procedures
+188 ;; a. Has the Veteran had a total wrist joint replacement?
+189 ;; ___ Yes ___ No
+190 ;; If yes, indicate side and severity of residuals.
+191 ;; ___ Right wrist
+192 ;; Date of surgery: ___________________
+193 ;; Residuals:
+194 ;; ___ None
+195 ;; ___ Intermediate degrees of residual weakness, pain and/or
+196 ;; limitation of motion
+197 ;; ___ Chronic residuals consisting of severe painful motion and/or
+198 ;; weakness
+199 ;; ___ Other, describe: _____________
+200 ;; ___ Left wrist
+201 ;; Date of surgery: ___________________
+202 ;; Residuals:
+203 ;; ___ None
+204 ;; ___ Intermediate degrees of residual weakness, pain and/or
+205 ;; limitation of motion
+206 ;; ___ Chronic residuals consisting of severe painful motion and/or
+207 ;; weakness
+208 ;; ___ Other, describe: _____________
+209 ;;
+210 ;; b. Has the Veteran had arthroscopic or other wrist surgery?
+211 ;; ___ Yes ___ No
+212 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+213 ;; Date and type of surgery: _____________
+214 ;;
+215 ;; c. Does the Veteran have any residual signs and/or symptoms due to
+216 ;; arthroscopic or other wrist surgery?
+217 ;; ___ Yes ___ No
+218 ;; If yes, indicate side affected: ___ Right ___ Left ___ Both
+219 ;; If yes, describe residuals: _________________________
+220 ;;
+221 ;; 11. Other pertinent physical findings, complications, conditions, signs
+222 ;; and/or symptoms
+223 ;; a. Does the Veteran have any scars (surgical or otherwise) related to any
+224 ;; conditions or to the treatment of any conditions listed in the Diagnosis
+225 ;; section above?
+226 ;; ___ Yes ___ No
+227 ;; If yes, are any of the scars painful and/or unstable, or is the total area of
+228 ;; all related scars greater than 39 square cm (6 square inches)?
+229 ;; ___ Yes ___ No
+230 ;; If yes, also complete a Scars Questionnaire.
+231 ;;^TOF^
+232 ;; b. Does the Veteran have any other pertinent physical findings,
+233 ;; complications, conditions, signs and/or symptoms related to any conditions
+234 ;; listed in the Diagnosis section above?
+235 ;; ___ Yes ___ No
+236 ;; If yes, describe (brief summary): __________________________________________
+237 ;;
+238 ;; 12. Remaining effective function of the extremities
+239 ;; Due to the Veteran's wrist conditions, is there functional impairment of an
+240 ;; extremity such that no effective function remains other than that which would
+241 ;; be equally well served by an amputation with prosthesis? (Functions of the
+242 ;; upper extremity include grasping, manipulation, etc)
+243 ;; ___ Yes, functioning is so diminished that amputation with prosthesis would
+244 ;; equally serve the Veteran.
+245 ;; ___ No
+246 ;; If yes, indicate extremity(ies) (check all extremities for which this applies):
+247 ;; ___ Right upper ___ Left upper
+248 ;; For each checked extremity, describe loss of effective function, identify the
+249 ;; condition causing loss of function, and provide specific examples (brief
+250 ;; summary): __________________________________________________________________
+251 ;; ____________________________________________________________________________
+252 ;;
+253 ;; 13. Diagnostic Testing
+254 ;; The diagnosis of degenerative arthritis (osteoarthritis) or traumatic arthritis
+255 ;; must be confirmed by imaging studies. Once such arthritis has been documented,
+256 ;; no further imaging studies are indicated, even if arthritis has worsened.
+257 ;;
+258 ;; a. Have imaging studies of the wrist been performed and are the results
+259 ;; available?
+260 ;; ___ Yes ___ No
+261 ;; If yes, is degenerative or traumatic arthritis documented?
+262 ;; ___ Yes ___ No
+263 ;; If yes, indicate wrist: ___ Right ___ Left ___ Both
+264 ;;
+265 ;; b. Are there any other significant diagnostic test findings and/or results?
+266 ;; ___ Yes ___ No
+267 ;; If yes, provide type of test or procedure, date and results (brief summary):
+268 ;; ____________________________________________________________________________
+269 ;;
+270 ;; 14. Functional impact
+271 ;; Does the Veteran's wrist condition impact his or her ability to work?
+272 ;; ___ Yes ___ No
+273 ;; If yes, describe the impact of each of the Veteran's wrist conditions
+274 ;; providing one or more examples: ____________________________________________
+275 ;; ____________________________________________________________________________
+276 ;;^TOF^
+277 ;; 15. Remarks, if any: ______________________________________________________
+278 ;; ____________________________________________________________________________
+279 ;;
+280 ;; Physician signature: _____________________________________ Date: ____________
+281 ;;
+282 ;; Physician printed name: _____________________________________________________
+283 ;;
+284 ;; Medical license #: __________________________________________________________
+285 ;;
+286 ;; Physician address: __________________________________________________________
+287 ;;
+288 ;; Phone: _____________________________ FAX: _______________________________
+289 ;;
+290 ;; NOTE: VA may request additional medical information, including additional
+291 ;; examinations if necessary to complete VA's review of the Veteran's application.
+292 ;;^END^
+293 QUIT
