DVBCWBS1 ;ALB/CMM BRAIN AND SPINAL CORD WKS TEXT - 1 ; 6 MARCH 1997
;;2.7;AMIE;**12**;Apr 10, 1995
;
;
TXT ;
;;A. Review of Medical Records:
;;
;;
;;
;;B. Medical History (Subjective Complaints):
;;
;; Comment on:
;; 1. If flare-ups exist, describe precipitating factors,
;; aggravating factors, alleviating factors, alleviating
;; medications, frequency, severity, duration, and whether the
;; flare-ups include pain, weakness, fatigue, or functional loss.
;;
;;
;; 2. Current treatment, response, and side effects.
;;
;;
;; 3. State whether condition has stabilized.
;;
;;
;; 4. Seizures - type, frequency.
;;
;;
;; 5. Headache, dizziness, etc.
;;
;;
;;C. Physical Examination (Objective Findings):
;;
;; Address each of the following and fully describe current findings:
;; 1. If a tumor is or was present, note location, type, and
;; whether or not it is malignant. If a malignancy is present
;; but is now cured or in remission, report the date of last
;; surgery, radiation therapy, chemotherapy, or other treatment.
;;
;;
;; 2. Describe in detail the motor and sensory impairment of all
;; affected nerves.
;;
;;
;; 3. Describe in detail any functional impairment of the peripheral
;; and autonomic systems.
;;
;;TOF
;; 4. A DETAILED ASSESSMENT OF EACH AFFECTED JOINT IS REQUIRED.
;; a. Using a goniometer, measure the PASSIVE and ACTIVE range
;; of motion, including movement against gravity and against
;; strong resistance.
;;
;;
;; b. If the joint is painful on motion, state at what point in
;; the range of motion pain begins and ends.
;;
;;
;; c. State to what extent, if any, the range of motion or
;; function is ADDITIONALLY LIMITED by pain, fatigue, weakness,
;; or lack of endurance. If more than one of these is
;; present, state, if possible, which has the major
;; functional impact.
;;
;;
;; 5. Describe any psychiatric manifestations in detail - see
;; worksheets for mental disorders.
;;
;;
;; 6. Eye examination.
;;
;;
;; 7. State if the veteran has bladder or bowel functional impairment.
;; If present, state whether partial or total, intermittent or
;; constant and what measures are taken as a result of the impairment.
;;
;;
;; 8. State if the veteran is capable of managing his or her benefit
;; payments in his or her own best interest without restriction.
;; (A physical disability which prevents the veteran from attending
;; to financial matters in person is not a proper basis for a
;; finding of incompetency unless the veteran is, by reason of
;; that disability, incapable of directing someone else in
;; handling the individual's financial affairs.)
;;
;;
;; 9. If smell or taste is affected, also complete the appropriate
;; worksheet.
;;
;;
;;D. Diagnostic and Clinical Tests:
;;
;; 1. Skull X-rays to measure bony defect, if there was surgery;
;; spine X-rays if there was spinal cord surgery.
;; 2. Include results of all diagnostic and clinical tests conducted
;; in the examination report.
;;
;;E. Diagnosis:
;;
;;
;;Signature: Date:
;;END
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWBS1 3554 printed Dec 13, 2024@01:49:56 Page 2
DVBCWBS1 ;ALB/CMM BRAIN AND SPINAL CORD WKS TEXT - 1 ; 6 MARCH 1997
+1 ;;2.7;AMIE;**12**;Apr 10, 1995
+2 ;
+3 ;
TXT ;
+1 ;;A. Review of Medical Records:
+2 ;;
+3 ;;
+4 ;;
+5 ;;B. Medical History (Subjective Complaints):
+6 ;;
+7 ;; Comment on:
+8 ;; 1. If flare-ups exist, describe precipitating factors,
+9 ;; aggravating factors, alleviating factors, alleviating
+10 ;; medications, frequency, severity, duration, and whether the
+11 ;; flare-ups include pain, weakness, fatigue, or functional loss.
+12 ;;
+13 ;;
+14 ;; 2. Current treatment, response, and side effects.
+15 ;;
+16 ;;
+17 ;; 3. State whether condition has stabilized.
+18 ;;
+19 ;;
+20 ;; 4. Seizures - type, frequency.
+21 ;;
+22 ;;
+23 ;; 5. Headache, dizziness, etc.
+24 ;;
+25 ;;
+26 ;;C. Physical Examination (Objective Findings):
+27 ;;
+28 ;; Address each of the following and fully describe current findings:
+29 ;; 1. If a tumor is or was present, note location, type, and
+30 ;; whether or not it is malignant. If a malignancy is present
+31 ;; but is now cured or in remission, report the date of last
+32 ;; surgery, radiation therapy, chemotherapy, or other treatment.
+33 ;;
+34 ;;
+35 ;; 2. Describe in detail the motor and sensory impairment of all
+36 ;; affected nerves.
+37 ;;
+38 ;;
+39 ;; 3. Describe in detail any functional impairment of the peripheral
+40 ;; and autonomic systems.
+41 ;;
+42 ;;TOF
+43 ;; 4. A DETAILED ASSESSMENT OF EACH AFFECTED JOINT IS REQUIRED.
+44 ;; a. Using a goniometer, measure the PASSIVE and ACTIVE range
+45 ;; of motion, including movement against gravity and against
+46 ;; strong resistance.
+47 ;;
+48 ;;
+49 ;; b. If the joint is painful on motion, state at what point in
+50 ;; the range of motion pain begins and ends.
+51 ;;
+52 ;;
+53 ;; c. State to what extent, if any, the range of motion or
+54 ;; function is ADDITIONALLY LIMITED by pain, fatigue, weakness,
+55 ;; or lack of endurance. If more than one of these is
+56 ;; present, state, if possible, which has the major
+57 ;; functional impact.
+58 ;;
+59 ;;
+60 ;; 5. Describe any psychiatric manifestations in detail - see
+61 ;; worksheets for mental disorders.
+62 ;;
+63 ;;
+64 ;; 6. Eye examination.
+65 ;;
+66 ;;
+67 ;; 7. State if the veteran has bladder or bowel functional impairment.
+68 ;; If present, state whether partial or total, intermittent or
+69 ;; constant and what measures are taken as a result of the impairment.
+70 ;;
+71 ;;
+72 ;; 8. State if the veteran is capable of managing his or her benefit
+73 ;; payments in his or her own best interest without restriction.
+74 ;; (A physical disability which prevents the veteran from attending
+75 ;; to financial matters in person is not a proper basis for a
+76 ;; finding of incompetency unless the veteran is, by reason of
+77 ;; that disability, incapable of directing someone else in
+78 ;; handling the individual's financial affairs.)
+79 ;;
+80 ;;
+81 ;; 9. If smell or taste is affected, also complete the appropriate
+82 ;; worksheet.
+83 ;;
+84 ;;
+85 ;;D. Diagnostic and Clinical Tests:
+86 ;;
+87 ;; 1. Skull X-rays to measure bony defect, if there was surgery;
+88 ;; spine X-rays if there was spinal cord surgery.
+89 ;; 2. Include results of all diagnostic and clinical tests conducted
+90 ;; in the examination report.
+91 ;;
+92 ;;E. Diagnosis:
+93 ;;
+94 ;;
+95 ;;Signature: Date:
+96 ;;END
