Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire Instructions
This form contains 439 fields organized into 140 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Active Range of Motion Values | ||
| Forward Flexion Endpoint | Number |
Enter the value for the forward flexion endpoint in degrees, up to 90 degrees.
|
| Left Lateral Flexion Endpoint | Number |
Enter the value for the left lateral flexion endpoint in degrees, up to 30 degrees.
|
| Extension Endpoint | Number |
Enter the value for the extension endpoint in degrees, up to 30 degrees.
|
| Right Lateral Rotation Endpoint | Number |
Enter the value for the right lateral rotation endpoint in degrees, up to 30 degrees.
|
| Right Lateral Flexion Endpoint | Number |
Enter the value for the right lateral flexion endpoint in degrees, up to 30 degrees.
|
| Left Lateral Rotation Endpoint | Number |
Enter the value for the left lateral rotation endpoint in degrees, up to 30 degrees.
|
| Additional Diagnoses | ||
| Additional Diagnoses List | Text |
Provide a list of any additional diagnoses pertaining to thoracolumbar spine conditions, including their ICD Codes and Dates of diagnosis. Fill only if 'Other (specify)' is 'Yes'.
Depends on:
Other (specify)
|
| Additional Factors Contributing to Disability | ||
| None | Checkbox |
Check this box if there are no additional factors contributing to disability beyond those already addressed.
|
| Interference with sitting | Checkbox |
Check this box if interference with sitting is an additional contributing factor to disability.
|
| Interference with standing | Checkbox |
Check this box if interference with standing is an additional contributing factor to disability.
|
| Swelling | Checkbox |
Check this box if swelling is an additional contributing factor to disability.
|
| Deformity | Checkbox |
Check this box if deformity is an additional contributing factor to disability.
|
| Disturbance of locomotion | Checkbox |
Check this box if disturbance of locomotion is an additional contributing factor to disability.
|
| Less movement than normal | Checkbox |
Check this box if less movement than normal is an additional contributing factor to disability.
|
| More movement than normal | Checkbox |
Check this box if more movement than normal is an additional contributing factor to disability.
|
| Weakened movement | Checkbox |
Check this box if weakened movement is an additional contributing factor to disability.
|
| Atrophy of disuse | Checkbox |
Check this box if atrophy of disuse is an additional contributing factor to disability.
|
| Instability of station | Checkbox |
Check this box if instability of station is an additional contributing factor to disability.
|
| Other | Checkbox |
Check this box if there are other additional factors contributing to disability not listed, and provide a description in the space provided.
|
| Other Contributing Factor | Text |
Enter the description for any other additional contributing factor to disability not listed. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Additional Loss of Function Details | ||
| Yes | Radiobutton |
Check this box if there is additional loss of function or range of motion after three repetitions.
|
| No | Radiobutton |
Check this box if there is no additional loss of function or range of motion after three repetitions.
|
| Forward Flexion Endpoint (90 Degrees) | Number |
Enter the forward flexion endpoint in degrees after completion of the three repetitions, assuming an initial range of motion of 90 degrees. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Left Lateral Flexion Endpoint (30 Degrees) | Number |
Enter the left lateral flexion endpoint in degrees after completion of the three repetitions, assuming an initial range of motion of 30 degrees. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Extension Endpoint (30 Degrees) | Number |
Enter the extension endpoint in degrees after completion of the three repetitions, assuming an initial range of motion of 30 degrees. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Right Lateral Rotation Endpoint (30 Degrees) | Number |
Enter the right lateral rotation endpoint in degrees after completion of the three repetitions, assuming an initial range of motion of 30 degrees. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Ankylosing Spondylitis Diagnosis | ||
| Ankylosing spondylitis | Checkbox |
Check this box if Ankylosing spondylitis is a diagnosis associated with the claimed condition(s).
|
| Ankylosing Spondylitis ICD Code | Text |
Please provide the International Classification of Diseases (ICD) code for Ankylosing Spondylitis. Fill only if 'Ankylosing spondylitis' is 'Yes'.
Depends on:
Ankylosing spondylitis
|
| Ankylosing Spondylitis Diagnosis Date | Date |
Please provide the date when Ankylosing Spondylitis was diagnosed. Fill only if 'Ankylosing spondylitis' is 'Yes'.
Depends on:
Ankylosing spondylitis
|
| Ankylosis of the Spine | ||
| Yes | Radiobutton |
Check this box if there is ankylosis of the spine.
|
| No | Radiobutton |
Check this box if there is no ankylosis of the spine.
|
| Assistive Device Usage Details | ||
| Assistive Device Details | Text |
Provide a detailed explanation of any assistive devices used, including the specific condition, the affected side, and the device used for each condition.
|
| Brace(s) Details | ||
| Brace(s) | Checkbox |
Check this box if the Veteran uses Brace(s) as an assistive device. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Occasional | Radiobutton |
Check this box if the Veteran uses Brace(s) occasionally. Fill only if 'Yes', 'Brace(s)' is 'Yes' and Brace(s) is 'Yes' for all.
Depends on:
Yes, Brace(s)
|
| Regular | Radiobutton |
Check this box if the Veteran uses Brace(s) regularly. Fill only if 'Yes', 'Brace(s)' is 'Yes' and Brace(s) is 'Yes' for all.
Depends on:
Yes, Brace(s)
|
| Constant | Radiobutton |
Check this box if the Veteran uses Brace(s) constantly. Fill only if 'Yes', 'Brace(s)' is 'Yes' and Brace(s) is 'Yes' for all.
Depends on:
Yes, Brace(s)
|
| Cane(s) Assistive Device | ||
| Cane(s) Used | Checkbox |
Check this box if the veteran uses a cane as an assistive device.
|
| Occasional Use | Radiobutton |
Check this box if the veteran uses a cane(s) occasionally.
|
| Regular Use | Radiobutton |
Check this box if the veteran uses a cane(s) regularly.
|
| Constant Use | Radiobutton |
Check this box if the veteran uses a cane(s) constantly.
|
| Circumference Measurements | ||
| Circumference of Normal Side | Number |
Enter the circumference measurement of the normal side. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Circumference of Atrophied Side | Number |
Enter the circumference measurement of the atrophied side. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Claimed Conditions | ||
| Claimed Conditions | Text |
Provide a list of all claimed conditions that are relevant to this questionnaire.
|
| Comments | ||
| Comments | Text |
Provide any additional comments or relevant information for section 9B.
|
| Additional Comments | Text |
Please provide any additional comments or information not covered in the preceding sections.
|
| Constant Pain Severity - Left Lower Extremity | ||
| None | Radiobutton |
Check this box if the patient experiences no constant pain in the left lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Mild | Radiobutton |
Check this box if the patient experiences mild constant pain in the left lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Moderate | Radiobutton |
Check this box if the patient experiences moderate constant pain in the left lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Severe | Radiobutton |
Check this box if the patient experiences severe constant pain in the left lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Constant Pain Severity - Right Lower Extremity | ||
| None | Radiobutton |
Check this box if the constant pain severity in the right lower extremity is none. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Mild | Radiobutton |
Check this box if the constant pain severity in the right lower extremity is mild. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Moderate | Radiobutton |
Check this box if the constant pain severity in the right lower extremity is moderate. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Severe | Radiobutton |
Check this box if the constant pain severity in the right lower extremity is severe. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Crutch(es) Details | ||
| Crutches | Checkbox |
Check this box if the Veteran uses crutches. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Crutches - Occasional use | Radiobutton |
Check this box if the Veteran uses crutches occasionally. Fill only if 'Yes', 'Crutches' is 'Yes' and Crutch(es) is 'Yes' for all.
Depends on:
Yes, Crutches
|
| Crutches - Regular use | Radiobutton |
Check this box if the Veteran uses crutches regularly. Fill only if 'Yes', 'Crutches' is 'Yes' and Crutch(es) is 'Yes' for all.
Depends on:
Yes, Crutches
|
| Crutches - Constant use | Radiobutton |
Check this box if the Veteran uses crutches constantly. Fill only if 'Yes', 'Crutches' is 'Yes' and Crutch(es) is 'Yes' for all.
Depends on:
Yes, Crutches
|
| Degenerative Arthritis Diagnosis | ||
| Degenerative arthritis | Checkbox |
Check this box if the veteran has been diagnosed with degenerative arthritis associated with the claimed condition(s).
|
| Degenerative Arthritis ICD Code | Text |
Provide the ICD code for the diagnosis of degenerative arthritis. Fill only if 'Degenerative arthritis' is 'Yes'.
Depends on:
Degenerative arthritis
|
| Degenerative Arthritis Diagnosis Date | Date |
Provide the date when the degenerative arthritis was diagnosed. Fill only if 'Degenerative arthritis' is 'Yes'.
Depends on:
Degenerative arthritis
|
| Degenerative Disc Disease Diagnosis | ||
| Degenerative disc disease other than intervertebral disc syndrome (IVDS) | Checkbox |
Check this box if the veteran has been diagnosed with degenerative disc disease, but it is not classified as intervertebral disc syndrome (IVDS).
|
| Degenerative Disc Disease ICD Code | Text |
Provide the ICD code for the degenerative disc disease diagnosis. Fill only if 'Degenerative disc disease other than intervertebral disc syndrome (IVDS)' is 'Yes'.
Depends on:
Degenerative disc disease other than intervertebral disc syndrome (IVDS)
|
| Degenerative Disc Disease Date of Diagnosis | Date |
Enter the date when the degenerative disc disease was diagnosed. Fill only if 'Degenerative disc disease other than intervertebral disc syndrome (IVDS)' is 'Yes'.
Depends on:
Degenerative disc disease other than intervertebral disc syndrome (IVDS)
|
| Degenerative or Post-Traumatic Arthritis Documented | ||
| Yes | Radiobutton |
Check this box if degenerative or post-traumatic arthritis is documented. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if degenerative or post-traumatic arthritis is not documented. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Description of Additional Contributing Factors of Disability | ||
| Additional Contributing Factors Description | Text |
Provide a detailed description of any additional factors contributing to the disability. Fill only if 'Interference with sitting', 'Interference with standing', 'Swelling', 'Deformity', 'Disturbance of locomotion', 'Less movement than normal', 'More movement than normal', 'Weakened movement', 'Atrophy of disuse', 'Instability of station', 'Other' is 'Yes' for any of the fields.
Depends on:
Interference with sitting, Interference with standing, Swelling, Deformity, Disturbance of locomotion, Less movement than normal, More movement than normal, Weakened movement, Atrophy of disuse, Instability of station, Other
|
| Description of Other Signs or Symptoms | ||
| Description of Other Signs or Symptoms of Radiculopathy | Text |
Please provide a detailed description of any other signs or symptoms of radiculopathy. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Documented Medical History | ||
| Medical history as shown and documented in the Veteran's file. | Checkbox |
Check this box if the medical history supporting a 'yes' response to question 11B is already present and documented in the Veteran's file. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Treatment Record Dates Reviewed | Date |
Enter the individual date(s) of each treatment record reviewed. Fill only if 'Medical history as shown and documented in the Veteran's file.' is checked.
Depends on:
Medical history as shown and documented in the Veteran's file.
|
| Facility or Provider | Text |
Provide the name of the medical facility or healthcare provider where treatment was received. Fill only if 'Medical history as shown and documented in the Veteran's file.' is checked.
Depends on:
Medical history as shown and documented in the Veteran's file.
|
| Treatment Description | Text |
Describe the treatment provided or received as part of the medical history. Fill only if 'Medical history as shown and documented in the Veteran's file.' is checked.
Depends on:
Medical history as shown and documented in the Veteran's file.
|
| Does the Veteran have localized tenderness, guarding or muscle spasm of the thoracolumbar spine? | ||
| Yes | Radiobutton |
Check this box if the Veteran has localized tenderness, guarding, or muscle spasm of the thoracolumbar spine.
|
| No | Radiobutton |
Check this box if the Veteran does not have localized tenderness, guarding, or muscle spasm of the thoracolumbar spine.
|
| Does the Veteran use any assistive devices as a normal mode of locomotion | ||
| Yes | Radiobutton |
Check this box if the Veteran uses any assistive devices as a normal mode of locomotion, even if occasional locomotion by other methods is possible.
|
| No | Radiobutton |
Check this box if the Veteran does not use any assistive devices as a normal mode of locomotion.
|
| Episodes of Acute Signs and Symptoms Requiring Bed Rest | ||
| Yes | Radiobutton |
Check this box if the Veteran has had episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment in the past 12 months. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if the Veteran has not had any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and treatment in the past 12 months. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Evidence and Description of Localized Tenderness or Pain | ||
| Yes | Radiobutton |
Check this box if there is objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue.
|
| No | Radiobutton |
Check this box if there is no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue.
|
| Localized Tenderness/Pain Description | Text |
Please describe the location, severity, and relationship to condition(s) of any localized tenderness or pain. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Evidence for Flare-up Range of Motion Estimate | ||
| Flare-up Evidence Discussion | Text |
Provide a detailed discussion and cite specific evidence relevant to the case, based on all procurable information regarding flare-up range of motion estimates.
|
| Evidence for Repeated Use Range of Motion Estimate | ||
| Evidence Discussion | Text |
Provide a detailed discussion and citation of all procurable evidence related to the repeated use range of motion estimate, ensuring specificity to the case.
|
| Evidence of Crepitus | ||
| Yes | Radiobutton |
Check this box if there is objective evidence of crepitus.
|
| No | Radiobutton |
Check this box if there is no objective evidence of crepitus.
|
| Evidence of Functional Limitation During Flare-ups | ||
| Yes | Radiobutton |
Check this box if procured evidence suggests pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with flare-ups.
|
| No | Radiobutton |
Check this box if procured evidence does not suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with flare-ups.
|
| Evidence of Functional Limitation with Repeated Use | ||
| Yes | Radiobutton |
Check this box if procured evidence suggests pain, fatigability, weakness, lack of endurance, or incoordination significantly limits functional ability with repeated use over time.
|
| No | Radiobutton |
Check this box if procured evidence does not suggest pain, fatigability, weakness, lack of endurance, or incoordination significantly limits functional ability with repeated use over time.
|
| Evidence of Pain | ||
| Yes | Radiobutton |
Check this box if there is evidence of pain.
|
| No | Radiobutton |
Check this box if there is no evidence of pain.
|
| Evidence Review | ||
| No records were reviewed | Radiobutton |
Check this box if no records were reviewed as part of the evidence review process.
|
| Records reviewed | Radiobutton |
Check this box if records were reviewed as part of the evidence review process.
|
| Evidence Reviewed Details | Text |
Provide a detailed description of the evidence reviewed, including its type (e.g., service treatment records, VA treatment records, private treatment records) and the date range of the records. Fill only if 'Records reviewed' is 'Yes'.
Depends on:
Records reviewed
|
| Examination Method | ||
| Yes | Radiobutton |
Check this box if the Veteran was examined in person.
|
| No | Radiobutton |
Check this box if the Veteran was not examined in person.
|
| Examination Method Details | Text |
Provide a detailed description of how the examination was conducted if it was not performed in person. Fill only if 'No' is 'Yes'.
Depends on:
No
|
| Examined During Flare-Up | ||
| Yes | Radiobutton |
Check this box if the Veteran is being examined during a flare-up.
|
| No | Radiobutton |
Check this box if the Veteran is not being examined during a flare-up.
|
| Examined Immediately After Repeated Use | ||
| Yes | Radiobutton |
Check this box if the Veteran is being examined immediately after repeated use over time.
|
| No | Radiobutton |
Check this box if the Veteran is not being examined immediately after repeated use over time.
|
| Examiner's Certification and Signature | ||
| Examiner's Signature | Text |
Provide the examiner's signature.
|
| Examiner's Printed Name and Title | Text |
Enter the examiner's printed name and professional title, such as MD, DO, DDS, DMD, Ph.D, Psy.D, NP, or PA-C.
|
| Examiner's Area of Practice/Specialty | Text |
Enter the examiner's primary area of practice or specialty, for example, Cardiology, Orthopedics, Psychology/Psychiatry, or General Practice.
|
| Date Signed | Date |
Enter the date the form was signed.
|
| Examiner's Phone/Fax Numbers | Text |
Provide the examiner's phone and/or fax numbers.
|
| NPI Number | Number |
Enter the examiner's National Provider Identifier (NPI) number.
|
| Medical License Number and State | Text |
Enter the examiner's medical license number and the state where it was issued.
|
| Examiner's Address | Text |
Provide the examiner's full mailing address.
|
| Explanation for "Unable to test" or "Not indicated" | ||
| Explanation for Unable to Test or Not Indicated | Text |
Please provide a detailed explanation if initial ROM measurements were 'Unable to test' or 'Not indicated'. Fill only if 'Unable to test', 'Not indicated' is 'Yes' for any.
Depends on:
Unable to test, Not indicated
|
| Explanation for Inability to Perform Straight Leg Test | ||
| Explanation for Inability to Perform Straight Leg Test | Text |
Provide a detailed explanation if the straight leg raising test could not be performed. Fill only if 'Straight Leg Raise Outcome – Right: Unable to perform', 'Unable to perform' is 'Yes', for any.
Depends on:
Straight Leg Raise Outcome – Right: Unable to perform, Unable to perform
|
| Explanation of Neurological Findings | ||
| Explanation of Neurological Findings Cause | Text |
Provide a detailed explanation of the likely cause for any abnormal or positive neurological findings identified in Sections 4-8.
|
| Factors Causing Functional Loss | ||
| N/A | Checkbox |
Check if none of the listed factors contribute to this functional loss.
|
| Pain | Checkbox |
Check this box if pain is a factor causing functional loss.
|
| Fatigability | Checkbox |
Check this box if fatigability is a factor causing functional loss.
|
| Weakness | Checkbox |
Check this box if weakness is a factor causing functional loss.
|
| Lack of endurance | Checkbox |
Check this box if lack of endurance is a factor causing functional loss.
|
| Incoordination | Checkbox |
Check this box if incoordination is a factor causing functional loss.
|
| Other | Checkbox |
Check this box if there is another factor causing functional loss not listed here.
|
| Other Factor | Text |
Provide details for any other factor causing functional loss not listed. Fill only if 'Other' is selected.
Depends on:
Other
|
| Factors Causing Functional Loss After Repeated Use | ||
| N/A | Checkbox |
Check this box if none of the specific factors listed (pain, fatigability, weakness, lack of endurance, or incoordination) are applicable or cause functional loss after repeated use, based on procured evidence. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Pain | Checkbox |
Check this box if pain is a factor that significantly limits functional ability after repeated use over time, based on procured evidence. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Fatigability | Checkbox |
Check this box if fatigability is a factor that significantly limits functional ability after repeated use over time, based on procured evidence. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Weakness | Checkbox |
Check this box if weakness is a factor that significantly limits functional ability after repeated use over time, based on procured evidence. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Lack of endurance | Checkbox |
Check this box if lack of endurance is a factor that significantly limits functional ability after repeated use over time, based on procured evidence. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Incoordination | Checkbox |
Check this box if incoordination is a factor that significantly limits functional ability after repeated use over time, based on procured evidence. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other | Checkbox |
Check this box if a factor not explicitly listed (other than N/A) significantly limits functional ability after repeated use over time, based on procured evidence. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Factors Causing Functional Loss | Text |
Provide details for other factors causing functional loss not listed above. Fill only if 'Other' is selected.
Depends on:
Other
|
| Factors Causing Functional Loss During Flare-ups | ||
| N/A | Checkbox |
Check this box if none of the listed factors cause functional loss during flare-ups. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Pain | Checkbox |
Check this box if pain causes functional loss during flare-ups. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Fatigability | Checkbox |
Check this box if fatigability causes functional loss during flare-ups. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Weakness | Checkbox |
Check this box if weakness causes functional loss during flare-ups. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Lack of endurance | Checkbox |
Check this box if lack of endurance causes functional loss during flare-ups. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Incoordination | Checkbox |
Check this box if incoordination causes functional loss during flare-ups. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other | Checkbox |
Check this box if another factor not listed causes functional loss during flare-ups, and specify it on the line provided. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Factor Causing Functional Loss | Text |
Specify any other factors not listed that cause functional loss during flare-ups. Fill only if 'Other' is selected.
Depends on:
Other
|
| Femoral Nerve Involvement | ||
| Involvement of L2/L3/L4 nerve roots (femoral nerve) | Checkbox |
Check this box if there is involvement of the L2/L3/L4 nerve roots, also known as the femoral nerve.
|
| Right | Radiobutton |
Check this box if the femoral nerve involvement affects the right side. Fill only if 'Involvement of L2/L3/L4 nerve roots (femoral nerve)' is 'Yes'.
Depends on:
Involvement of L2/L3/L4 nerve roots (femoral nerve)
|
| Left | Radiobutton |
Check this box if the femoral nerve involvement affects the left side. Fill only if 'Involvement of L2/L3/L4 nerve roots (femoral nerve)' is 'Yes'.
Depends on:
Involvement of L2/L3/L4 nerve roots (femoral nerve)
|
| Both | Radiobutton |
Check this box if the femoral nerve involvement affects both the right and left sides. Fill only if 'Involvement of L2/L3/L4 nerve roots (femoral nerve)' is 'Yes'.
Depends on:
Involvement of L2/L3/L4 nerve roots (femoral nerve)
|
| Flare-up Report | ||
| Yes | Radiobutton |
Check this box if the Veteran reports flare-ups of the thoracolumbar spine.
|
| No | Radiobutton |
Check this box if the Veteran does not report flare-ups of the thoracolumbar spine.
|
| Flare-up Description | Text |
Provide the Veteran's description of the flare-ups, including the frequency, duration, characteristics, precipitating and alleviating factors, severity, and extent of functional impairment experienced during a flare-up of symptoms. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Functional Impact | ||
| Yes | Radiobutton |
Check this box if the diagnosed conditions impact the Veteran's ability to perform any type of occupational task.
|
| No | Radiobutton |
Check this box if the diagnosed conditions do not impact the Veteran's ability to perform any type of occupational task.
|
| Functional Impact Description | Text |
Provide a detailed description of the functional impact of each condition, including one or more examples. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Functional loss explanation | ||
| Explanation of ROM Functional Loss Contribution | Text |
Please provide a detailed explanation of how the abnormal range of motion itself contributes to a functional loss. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Functional Loss Report | ||
| Yes | Radiobutton |
Check this box if the Veteran reports having any functional loss or functional impairment of the joint or extremity being evaluated on this questionnaire.
|
| No | Radiobutton |
Check this box if the Veteran does not report having any functional loss or functional impairment of the joint or extremity being evaluated on this questionnaire.
|
| Veteran's Functional Loss Description | Text |
Provide a detailed description of the Veteran's functional loss or impairment in their own words. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Guarding | ||
| Guarding - None | Radiobutton |
Check this box if no guarding is observed in the thoracolumbar spine. Fill only if the 'Does the Veteran have localized tenderness, guarding or muscle spasm of the thoracolumbar spine?' is 'Yes'. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Guarding - Resulting in abnormal gait or abnormal spine contour | Radiobutton |
Check this box if guarding results in an abnormal gait or abnormal spinal contour. Fill only if the 'Does the Veteran have localized tenderness, guarding or muscle spasm of the thoracolumbar spine?' is 'Yes'. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Guarding - Not resulting in abnormal gait or abnormal spinal contour | Radiobutton |
Check this box if guarding does not result in an abnormal gait or abnormal spinal contour. Fill only if the 'Does the Veteran have localized tenderness, guarding or muscle spasm of the thoracolumbar spine?' is 'Yes'. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Guarding - Unable to evaluate, describe below | Radiobutton |
Check this box if guarding cannot be evaluated; provide description below. Fill only if the 'Does the Veteran have localized tenderness, guarding or muscle spasm of the thoracolumbar spine?' is 'Yes'. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Guarding Description | Text |
Please provide a description and/or etiology for the guarding condition. Fill only if 'Yes', 'Guarding - Unable to evaluate, describe below' is 'Yes' and checkbox 14 is selected.
Depends on:
Yes, Guarding - Unable to evaluate, describe below
|
| Height Loss | ||
| Yes | Radiobutton |
Check this box if there is a loss of 50 percent or more of height. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if there is no loss of 50 percent or more of height. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Imaging Studies Performed | ||
| Yes | Radiobutton |
Check this box if imaging studies have been performed in conjunction with this examination.
|
| No | Radiobutton |
Check this box if imaging studies have not been performed in conjunction with this examination.
|
| Imaging Test Details | ||
| Imaging Test Details Summary | Text |
Provide a brief summary of the type of test or procedure performed, its date, and the results of the imaging studies. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Initial Range of Motion Endpoints | ||
| Right Lateral Flexion Endpoint | Number |
Enter the measured right lateral flexion endpoint in degrees.
|
| Left Lateral Rotation Endpoint | Number |
Enter the measured left lateral rotation endpoint in degrees.
|
| Initial ROM measurements | ||
| All Normal | Radiobutton |
Check this box if all initial Range of Motion (ROM) measurements are normal.
|
| Abnormal or outside of normal range | Radiobutton |
Check this box if initial Range of Motion (ROM) measurements are abnormal or outside the normal range.
|
| Unable to test | Radiobutton |
Check this box if initial Range of Motion (ROM) measurements could not be tested.
|
| Not indicated | Radiobutton |
Check this box if initial Range of Motion (ROM) measurements are not indicated for evaluation.
|
| Intermittent Pain Severity - Left Lower Extremity | ||
| None | Radiobutton |
Check this box if the veteran experiences no intermittent pain in the left lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Mild | Radiobutton |
Check this box if the veteran experiences mild intermittent pain in the left lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Moderate | Radiobutton |
Check this box if the veteran experiences moderate intermittent pain in the left lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Severe | Radiobutton |
Check this box if the veteran experiences severe intermittent pain in the left lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Intermittent Pain Severity - Right Lower Extremity | ||
| None | Radiobutton |
Check this box if the veteran experiences no intermittent pain in the right lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Mild | Radiobutton |
Check this box if the veteran experiences mild intermittent pain in the right lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Moderate | Radiobutton |
Check this box if the veteran experiences moderate intermittent pain in the right lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Severe | Radiobutton |
Check this box if the veteran experiences severe intermittent pain in the right lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Intervertebral Disc Syndrome Diagnosis | ||
| Intervertebral disc syndrome | Checkbox |
Check this box if the veteran has been diagnosed with intervertebral disc syndrome.
|
| Intervertebral Disc Syndrome ICD Code | Text |
Provide the ICD (International Classification of Diseases) code for intervertebral disc syndrome. Fill only if 'Intervertebral disc syndrome' is 'Yes'.
Depends on:
Intervertebral disc syndrome
|
| Intervertebral Disc Syndrome Diagnosis Date | Date |
Enter the date when intervertebral disc syndrome was diagnosed. Fill only if 'Intervertebral disc syndrome' is 'Yes'.
Depends on:
Intervertebral disc syndrome
|
| IVDS of the Thoracolumbar Spine | ||
| Yes | Radiobutton |
Check this box if the Veteran has Intervertebral Disc Syndrome (IVDS) of the thoracolumbar spine.
|
| No | Radiobutton |
Check this box if the Veteran does not have Intervertebral Disc Syndrome (IVDS) of the thoracolumbar spine.
|
| Left Lateral Endpoint | ||
| Left Lateral Endpoint | Number |
Please provide the left lateral endpoint value in degrees.
|
| Same as active ROM | Checkbox |
Check this box if the left lateral endpoint (30 degrees) is the same as the active range of motion.
|
| Left Lateral Flexion Endpoint | ||
| Left Lateral Flexion Endpoint | Number |
Please enter the left lateral flexion endpoint in degrees.
|
| Same as active ROM | Checkbox |
Check this box if the left lateral flexion endpoint is the same as the active Range of Motion (ROM).
|
| Left Side Deep Tendon Reflexes | ||
| Left Knee DTR Rating | Text |
Enter the deep tendon reflex rating for the left knee according to the provided scale.
|
| Left Ankle DTR Rating | Text |
Enter the deep tendon reflex rating for the left ankle according to the provided scale.
|
| Left Side Muscle Strength Ratings | ||
| Left Hip Flexion Rate Strength | Text |
Enter the muscle strength rating for left hip flexion.
|
| Left Ankle Dorsi-flexion Rate Strength | Number |
Enter the muscle strength rating for left ankle dorsi-flexion.
|
| Left Knee Extension Rate Strength | Text |
Enter the muscle strength rating for left knee extension.
|
| Left Great Toe Extension Rate Strength | Text |
Enter the muscle strength rating for left great toe extension.
|
| Left Ankle Plantar Flexion Rate Strength | Text |
Enter the muscle strength rating for left ankle plantar flexion.
|
| Left Straight Leg Raising Test Results | ||
| Negative | Radiobutton |
Check this box if the straight leg raising test result for the left leg is negative.
|
| Positive | Radiobutton |
Check this box if the straight leg raising test result for the left leg is positive.
|
| Unable to perform | Radiobutton |
Check this box if the straight leg raising test for the left leg could not be performed.
|
| Limitation of Motion Degree Endpoints | ||
| Forward Flexion Degree Endpoint | Number |
Provide the degree endpoint for forward flexion, if this value differs from the active range of motion value provided above. Fill only if 'Forward Flexion Endpoint' is different than above.
Depends on:
Forward Flexion Endpoint
|
| Left Lateral Flexion Degree Endpoint | Number |
Provide the degree endpoint for left lateral flexion, if this value differs from the active range of motion value provided above. Fill only if 'Left Lateral Flexion Endpoint' is different than above.
Depends on:
Left Lateral Flexion Endpoint
|
| Extension Degree Endpoint | Number |
Provide the degree endpoint for extension, if this value differs from the active range of motion value provided above. Fill only if 'Extension Endpoint' is different than above.
Depends on:
Extension Endpoint
|
| Right Lateral Rotation Degree Endpoint | Number |
Provide the degree endpoint for right lateral rotation, if this value differs from the active range of motion value provided above. Fill only if 'Right Lateral Rotation Endpoint' is different than above.
Depends on:
Right Lateral Rotation Endpoint
|
| Right Lateral Flexion Degree Endpoint | Number |
Provide the degree endpoint for right lateral flexion, if this value differs from the active range of motion value provided above. Fill only if 'Right Lateral Flexion Endpoint' is different than above.
Depends on:
Right Lateral Flexion Endpoint
|
| Left Lateral Rotation Degree Endpoint | Number |
Provide the degree endpoint for left lateral rotation, if this value differs from the active range of motion value provided above. Fill only if 'Left Lateral Rotation Endpoint' is different than above.
Depends on:
Left Lateral Rotation Endpoint
|
| Limitation of Motion Description | ||
| Detailed Limitation Description | Text |
Provide a detailed explanation of any limitation of motion, specifying the degree(s) and the factors (e.g., pain, weakness, fatigability, incoordination) to which it is attributable.
|
| Localized tenderness | ||
| None | Radiobutton |
Check this box if the Veteran has no localized tenderness. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Not resulting in abnormal gait or abnormal spinal contour | Radiobutton |
Check this box if the Veteran has localized tenderness, but it does not result in an abnormal gait or an abnormal spinal contour. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Description and Etiology | Text |
Provide a description and/or etiology for the localized tenderness. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Location of Atrophy | ||
| Specific Location of Atrophy Details | Text |
Describe the specific location of muscle atrophy, providing measurements in centimeters of the normal side and the corresponding atrophied side, measured at maximum muscle bulk. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Lumbosacral Strain Diagnosis | ||
| Lumbosacral strain | Checkbox |
Check this box if the veteran has been diagnosed with lumbosacral strain associated with the claimed condition(s).
|
| Lumbosacral Strain ICD Code | Text |
Provide the ICD code for the lumbosacral strain diagnosis. Fill only if 'Lumbosacral strain' is 'Yes'.
Depends on:
Lumbosacral strain
|
| Lumbosacral Strain Date of Diagnosis | Date |
Provide the date when the lumbosacral strain was diagnosed. Fill only if 'Lumbosacral strain' is 'Yes'.
Depends on:
Lumbosacral strain
|
| Medical History (Veteran Description) | ||
| Medical history as described by the Veteran only, without documentation | Checkbox |
Check this box if the medical history provided to support the 'yes' response for question 11B is solely based on the Veteran's description and does not include other documentation. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Veteran's Medical History Description | Text |
Please provide the medical history as described by the veteran, without including any additional documentation. Fill only if 'Medical history as described by the Veteran only, without documentation' is checked.
Depends on:
Medical history as described by the Veteran only, without documentation
|
| Medical History Summary | ||
| Thoracolumbar Spine Condition History | Text |
Provide a brief summary describing the history, including the onset and course, of the Veteran's thoracolumbar spine condition.
|
| Motion Limitation Details | ||
| Forward Flexion Degree Endpoint | Number |
Enter the degree endpoint for forward flexion if it is different from the previously noted value.
|
| Left Lateral Flexion Degree Endpoint | Number |
Enter the degree endpoint for left lateral flexion if it is different from the previously noted value.
|
| Extension Degree Endpoint | Number |
Enter the degree endpoint for extension if it is different from the previously noted value.
|
| Right Lateral Rotation Degree Endpoint | Number |
Enter the degree endpoint for right lateral rotation if it is different from the previously noted value.
|
| Right Lateral Flexion Degree Endpoint | Number |
Enter the degree endpoint for right lateral flexion if it is different from the previously noted value.
|
| Left Lateral Rotation Degree Endpoint | Number |
Enter the degree endpoint for left lateral rotation if it is different from the previously noted value.
|
| Limitation of Motion Description | Text |
Describe any limitation of motion specifically attributable to pain, weakness, fatigability, incoordination, or other factors, including the degree(s) of limitation.
|
| Muscle Atrophy Cause and Rationale | ||
| Yes | Radiobutton |
Check this box if the muscle atrophy is due to the claimed condition in the diagnosis section. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if the muscle atrophy is NOT due to the claimed condition in the diagnosis section. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Muscle Atrophy Rationale | Text |
Please provide a detailed rationale explaining why the muscle atrophy is not due to the claimed condition in the diagnosis section. Fill only if 'No' is 'No'.
Depends on:
No
|
| Muscle Atrophy Presence | ||
| Yes | Radiobutton |
Check this box if the veteran has muscle atrophy.
|
| No | Radiobutton |
Check this box if the veteran does not have muscle atrophy.
|
| Muscle spasm | ||
| None | Radiobutton |
Check this box if there is no muscle spasm present. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Resulting in abnormal gait or abnormal spine contour | Radiobutton |
Check this box if the muscle spasm results in abnormal gait or abnormal spine contour. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Not resulting in abnormal gait or abnormal spinal contour | Radiobutton |
Check this box if the muscle spasm is present but does not result in abnormal gait or abnormal spine contour. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Unable to evaluate, describe below | Radiobutton |
Check this box if muscle spasm is unable to be evaluated, and provide a description in the space provided. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Muscle Spasm Description and Etiology | Text |
Provide a detailed description and/or etiology for the muscle spasm. Fill only if 'Yes', 'Unable to evaluate, describe below' is 'Yes' and checkbox 9 is selected.
Depends on:
Yes, Unable to evaluate, describe below
|
| No Current Diagnosis | ||
| No current diagnosis associated with claimed conditions | Checkbox |
Check this box if the veteran does not have a current diagnosis associated with any of the claimed conditions listed above.
|
| Numbness Severity - Left Lower Extremity | ||
| None | Radiobutton |
Check this box if the veteran experiences no numbness in the left lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Mild | Radiobutton |
Check this box if the veteran experiences mild numbness in the left lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Moderate | Radiobutton |
Check this box if the veteran experiences moderate numbness in the left lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Severe | Radiobutton |
Check this box if the veteran experiences severe numbness in the left lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Numbness Severity - Right Lower Extremity | ||
| None | Radiobutton |
Check this box if the veteran experiences no numbness in their right lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Mild | Radiobutton |
Check this box if the veteran experiences mild numbness in their right lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Moderate | Radiobutton |
Check this box if the veteran experiences moderate numbness in their right lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Severe | Radiobutton |
Check this box if the veteran experiences severe numbness in their right lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Assistive Device | ||
| Other Assistive Device | Checkbox |
Check this box if the veteran uses an assistive device other than a cane or walker.
|
| Other Assistive Device | Text |
Please specify the type of other assistive device used. Fill only if 'Other Assistive Device' is 'Yes'.
Depends on:
Other Assistive Device
|
| Occasional Use | Radiobutton |
Check this box if the 'Other Assistive Device' is used occasionally.
|
| Regular Use | Radiobutton |
Check this box if the 'Other Assistive Device' is used regularly.
|
| Constant Use | Radiobutton |
Check this box if the 'Other Assistive Device' is used constantly.
|
| Other Diagnosis Row 1 | ||
| Other (specify) | Checkbox |
Check this box if the diagnosis is not listed among the other options provided.
|
| Other Diagnosis 1 Description | Text |
Please enter the description for the first other diagnosis. Fill only if 'Other (specify)' is 'Yes'.
Depends on:
Other (specify)
|
| Other Diagnosis 1 ICD Code | Text |
Please enter the ICD Code for the first other diagnosis. Fill only if 'Other (specify)' is 'Yes'.
Depends on:
Other (specify)
|
| Other Diagnosis 1 Date of Diagnosis | Date |
Please enter the date when the first other diagnosis was made. Fill only if 'Other (specify)' is 'Yes'.
Depends on:
Other (specify)
|
| Other Diagnosis Row 2 | ||
| Other Diagnosis 2 Name | Text |
Provide the name or description of the second other diagnosis. Fill only if 'Other (specify)' is 'Yes'.
Depends on:
Other (specify)
|
| Other Diagnosis 2 ICD Code | Text |
Enter the ICD code for the second other diagnosis. Fill only if 'Other (specify)' is 'Yes'.
Depends on:
Other (specify)
|
| Other Diagnosis 2 Date of Diagnosis | Date |
Provide the date when the second other diagnosis was determined. Fill only if 'Other (specify)' is 'Yes'.
Depends on:
Other (specify)
|
| Other Diagnosis Row 3 | ||
| Other Diagnosis 3 Description | Text |
Please provide the description for the third other diagnosis. Fill only if 'Other (specify)' is 'Yes'.
Depends on:
Other (specify)
|
| Other Diagnosis 3 ICD Code | Text |
Please enter the ICD code for the third other diagnosis. Fill only if 'Other (specify)' is 'Yes'.
Depends on:
Other (specify)
|
| Other Diagnosis 3 Date of Diagnosis | Date |
Please provide the date when the third other diagnosis was made. Fill only if 'Other (specify)' is 'Yes'.
Depends on:
Other (specify)
|
| Other Documentation Description | ||
| Other, describe | Checkbox |
Check this box if you need to provide additional documentation details not covered by the preceding options. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Documentation Description | Text |
Provide a detailed description of other documentation not covered by previous options. Fill only if 'Other, describe' is checked.
Depends on:
Other, describe
|
| Other Nerves Affected | ||
| Other nerves | Checkbox |
Check this box if nerves other than the L2/L3/L4 (femoral nerve) or L4/L5/S1/S2/S3 (sciatic nerve) are affected.
|
| Right | Radiobutton |
Check this box to indicate the right side is affected by the "Other nerves" involvement. Fill only if 'Other nerves' is filled.
Depends on:
Other nerves
|
| Left | Radiobutton |
Check this box to indicate the left side is affected by the "Other nerves" involvement. Fill only if 'Other nerves' is filled.
Depends on:
Other nerves
|
| Both | Radiobutton |
Check this box to indicate both sides are affected by the "Other nerves" involvement. Fill only if 'Other nerves' is filled.
Depends on:
Other nerves
|
| Other Pertinent Physical Findings | ||
| Yes | Radiobutton |
Check this box if the Veteran has any other pertinent physical findings, complications, conditions, signs, or symptoms related to any conditions listed in the diagnosis section above.
|
| No | Radiobutton |
Check this box if the Veteran does not have any other pertinent physical findings, complications, conditions, signs, or symptoms related to any conditions listed in the diagnosis section above.
|
| Pertinent Findings Summary | Text |
Please provide a brief summary describing any other pertinent physical findings, complications, conditions, signs, or symptoms, if applicable. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other sensory findings | ||
| Other Sensory Findings | Text |
Enter any other sensory findings observed.
|
| Other Significant Diagnostic Test Findings | ||
| Yes | Radiobutton |
Check this box if there are other significant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es) that were reviewed in conjunction with this examination.
|
| No | Radiobutton |
Check this box if there are no other significant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es) that were reviewed in conjunction with this examination.
|
| Other Signs or Symptoms of Radiculopathy | ||
| Yes | Radiobutton |
Check this box if the veteran has other signs or symptoms of radiculopathy. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if the veteran does not have any other signs or symptoms of radiculopathy. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Test Details | ||
| Other Test Details Summary | Text |
Provide a brief summary of the type of test or procedure performed, the date of the test, and the results. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Pain Details and Comments | ||
| Weight-bearing | Checkbox |
Check this box if pain is experienced during weight-bearing activities. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Nonweight-bearing | Checkbox |
Check this box if pain is experienced during nonweight-bearing activities. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Active motion | Checkbox |
Check this box if pain is experienced during active motion. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Passive motion | Checkbox |
Check this box if pain is experienced during passive motion. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| On rest/non-movement | Checkbox |
Check this box if pain is experienced while at rest or during non-movement. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Causes functional loss | Checkbox |
Check this box if the pain causes functional loss, and describe it in the comments box below. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Does not result in/cause functional loss | Checkbox |
Check this box if the pain does not result in or cause functional loss. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Comments | Text |
Provide any additional comments or details, particularly regarding functional loss if applicable. Fill only if 'Causes functional loss' is checked.
Depends on:
Causes functional loss
|
| Paresthesias and/or Dysesthesias Severity - Left Lower Extremity | ||
| None | Radiobutton |
The user should check this box if the veteran experiences no paresthesias and/or dysesthesias in the left lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Mild | Radiobutton |
The user should check this box if the veteran experiences mild paresthesias and/or dysesthesias in the left lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Moderate | Radiobutton |
The user should check this box if the veteran experiences moderate paresthesias and/or dysesthesias in the left lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Severe | Radiobutton |
The user should check this box if the veteran experiences severe paresthesias and/or dysesthesias in the left lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Paresthesias and/or Dysesthesias Severity - Right Lower Extremity | ||
| None | Radiobutton |
Check this box if the patient experiences no paresthesias or dysesthesias in the right lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Mild | Radiobutton |
Check this box if the patient experiences mild paresthesias or dysesthesias in the right lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Moderate | Radiobutton |
Check this box if the patient experiences moderate paresthesias or dysesthesias in the right lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Severe | Radiobutton |
Check this box if the patient experiences severe paresthesias or dysesthesias in the right lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Passive Range of Motion Testing Confirmation | ||
| Yes | Radiobutton |
Check this box if passive range of motion testing was performed.
|
| No | Radiobutton |
Check this box if passive range of motion testing was not performed.
|
| Passive ROM Extension Endpoint | ||
| Passive Extension Endpoint | Number |
Provide the passive range of motion extension endpoint. Fill only if 'Yes', 'Same as active ROM (Extension Endpoint)' is selected and Same as active ROM is not checked, all.
Depends on:
Yes, Same as active ROM (Extension Endpoint)
|
| Same as active ROM (Extension Endpoint) | Checkbox |
Check this box if the passive range of motion for the extension endpoint is the same as the active range of motion for the extension endpoint.
|
| Passive ROM Forward Flexion Endpoint | ||
| Forward Flexion Endpoint | Number |
Enter the passive forward flexion endpoint in degrees. Fill only if 'Yes', 'Same as active ROM' is selected and Same as active ROM is not checked, all.
Depends on:
Yes, Same as active ROM
|
| Same as active ROM | Checkbox |
Check this box if the passive range of motion for forward flexion endpoint is identical to the active range of motion for forward flexion.
|
| Passive ROM Pain Areas | ||
| Forward flexion | Checkbox |
Check this box if forward flexion passive range of motion exhibited pain during the examination.
|
| Right lateral flexion | Checkbox |
Check this box if right lateral flexion passive range of motion exhibited pain during the examination.
|
| Right lateral rotation | Checkbox |
Check this box if right lateral rotation passive range of motion exhibited pain during the examination.
|
| Extension | Checkbox |
Check this box if extension passive range of motion exhibited pain during the examination.
|
| Left lateral flexion | Checkbox |
Check this box if left lateral flexion passive range of motion exhibited pain during the examination.
|
| Left lateral rotation | Checkbox |
Check this box if left lateral rotation passive range of motion exhibited pain during the examination.
|
| Passive ROM Right Lateral Flexion Endpoint | ||
| Passive Right Lateral Flexion Endpoint | Number |
Enter the passive range of motion endpoint for right lateral flexion. Fill only if 'Yes', 'Same as active ROM' is selected and Same as active ROM is not checked, all.
Depends on:
Yes, Same as active ROM
|
| Same as active ROM | Checkbox |
Check this box if the passive right lateral flexion endpoint is the same as the active right lateral flexion endpoint.
|
| Patient Information | ||
| Patient/Veteran Name | Text |
Please provide the full name of the patient or veteran.
|
| Social Security Number | Text |
Please provide the Social Security Number of the patient or veteran.
|
| Date of Examination | Date |
Please provide the date when the examination was conducted.
|
| Questionnaire Requester Information | ||
| Veteran/Claimant | Checkbox |
Check this box if you are completing the questionnaire at the request of the Veteran or Claimant themselves.
|
| Third party | Checkbox |
Check this box if you are completing the questionnaire at the request of a third party, such as an organization or another individual.
|
| Third Party Names | Text |
Please list the name(s) of the organization(s) or individual(s) at whose request this questionnaire is being completed, if applicable. Fill only if 'Third party' is 'Yes'.
Depends on:
Third party
|
| Other | Checkbox |
Check this box if you are completing the questionnaire at the request of someone not covered by the Veteran/Claimant or a specific third party, and provide a description.
|
| Other Requester Description | Text |
Please provide a description of the other party or reason at whose request this questionnaire is being completed. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Radicular Pain or Symptoms Presence | ||
| Yes | Radiobutton |
Check this box if the Veteran has radicular pain or any other signs or symptoms due to radiculopathy.
|
| No | Radiobutton |
Check this box if the Veteran does not have radicular pain or any other signs or symptoms due to radiculopathy.
|
| Range of Motion After Repeated Use | ||
| Forward Flexion Endpoint (90 Degrees) | Number |
Enter the estimated forward flexion endpoint for this joint after repeated use. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Left Lateral Flexion Endpoint (30 Degrees) | Number |
Enter the estimated left lateral flexion endpoint for this joint after repeated use. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Extension Endpoint (30 Degrees) | Number |
Enter the estimated extension endpoint for this joint after repeated use. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Right Lateral Rotation Endpoint (30 Degrees) | Number |
Enter the estimated right lateral rotation endpoint for this joint after repeated use. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Right Lateral Flexion Endpoint (30 Degrees) | Number |
Enter the estimated right lateral flexion endpoint for this joint after repeated use. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Left Lateral Rotation Endpoint (30 Degrees) | Number |
Enter the estimated left lateral rotation endpoint for this joint after repeated use. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Range of motion contribution to functional loss | ||
| Yes | Radiobutton |
Check this box if an abnormal range of motion contributes to a functional loss.
|
| No | Radiobutton |
Check this box if an abnormal range of motion does not contribute to a functional loss.
|
| Range of Motion During Flare-ups | ||
| Forward Flexion Endpoint During Flare-up | Number |
Enter the estimated forward flexion endpoint in degrees during flare-ups. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Left Lateral Flexion Endpoint During Flare-up | Number |
Enter the estimated left lateral flexion endpoint in degrees during flare-ups. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Extension Endpoint During Flare-up | Number |
Enter the estimated extension endpoint in degrees during flare-ups. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Right Lateral Rotation Endpoint During Flare-up | Number |
Enter the estimated right lateral rotation endpoint in degrees during flare-ups. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Right Lateral Flexion Endpoint During Flare-up | Number |
Enter the estimated right lateral flexion endpoint in degrees during flare-ups. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Left Lateral Rotation Endpoint During Flare-up | Number |
Enter the estimated left lateral rotation endpoint in degrees during flare-ups. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Reason for Not Performing Passive ROM Testing | ||
| Medically contraindicated | Checkbox |
Check this box if passive range of motion testing was not performed because it is medically contraindicated or could cause severe pain/injury to the Veteran. Fill only if 'No' is selected.
Depends on:
No
|
| Testing not necessary | Checkbox |
Check this box if passive range of motion testing was not performed because it was deemed not necessary. Fill only if 'No' is selected.
Depends on:
No
|
| Other reason | Checkbox |
Check this box if passive range of motion testing was not performed for a reason not listed in the other options. Fill only if 'No' is selected.
Depends on:
No
|
| Explanation | Text |
Provide a detailed explanation for why passive range of motion testing was not performed. Fill only if 'Medically contraindicated', 'Testing not necessary', 'Other reason' is checked, any.
Depends on:
Medically contraindicated, Testing not necessary, Other reason
|
| Regular Patient Status | ||
| Yes | Radiobutton |
Check this box if the Veteran is regularly seen as a patient in your clinic.
|
| No | Radiobutton |
Check this box if the Veteran is not regularly seen as a patient in your clinic.
|
| Relationship of Abnormal Findings to Diagnosed Conditions | ||
| Relationship of Abnormal Findings | Text |
Please describe the relationship between any abnormal test results and the diagnosed conditions. Fill only if 'Yes' is 'Yes' and results are other than normal.
Depends on:
Yes
|
| Remaining Effective Function of the Extremities | ||
| Yes, functioning diminished to amputation level | Radiobutton |
Check this box if the Veteran's extremity functioning is so diminished that an amputation with a prosthesis would equally serve them.
|
| No, functioning not diminished to amputation level | Radiobutton |
Check this box if the Veteran's extremity functioning is not so diminished that an amputation with a prosthesis would equally serve them.
|
| Right lower extremity | Checkbox |
Check this box if the right lower extremity has functional impairment where amputation with prosthesis would equally serve the Veteran. Fill only if 'Yes, functioning diminished to amputation level' is 'Yes'.
Depends on:
Yes, functioning diminished to amputation level
|
| Left lower extremity | Checkbox |
Check this box if the left lower extremity has functional impairment where amputation with prosthesis would equally serve the Veteran. Fill only if 'Yes, functioning diminished to amputation level' is 'Yes'.
Depends on:
Yes, functioning diminished to amputation level
|
| Right upper extremity | Checkbox |
Check this box if the right upper extremity has functional impairment where amputation with prosthesis would equally serve the Veteran. Fill only if 'Yes, functioning diminished to amputation level' is 'Yes'.
Depends on:
Yes, functioning diminished to amputation level
|
| Left upper extremity | Checkbox |
Check this box if the left upper extremity has functional impairment where amputation with prosthesis would equally serve the Veteran. Fill only if 'Yes, functioning diminished to amputation level' is 'Yes'.
Depends on:
Yes, functioning diminished to amputation level
|
| Loss of Function Description | Text |
Provide a brief summary identifying the condition causing loss of function, describing the loss of effective function, and giving specific examples for each checked extremity. Fill only if 'Yes, functioning diminished to amputation level' is 'Yes'.
Depends on:
Yes, functioning diminished to amputation level
|
| Remarks | ||
| Remarks | Text |
Provide any additional remarks, identifying the section to which the remark pertains when appropriate.
|
| Repetitive Use Testing Capability and Explanation | ||
| Yes | Radiobutton |
Check this box if the Veteran is able to perform repetitive use testing with at least three repetitions.
|
| No | Radiobutton |
Check this box if the Veteran is not able to perform repetitive use testing with at least three repetitions.
|
| Repetitive Use Testing Inability Explanation | Text |
Provide a detailed explanation if the Veteran is unable to perform repetitive use testing with at least three repetitions. Fill only if 'No' is 'No'.
Depends on:
No
|
| Right Foot/Toes Sensation | ||
| Normal | Radiobutton |
Check this box if the sensation in the right foot/toes is normal.
|
| Decreased | Radiobutton |
Check this box if the sensation in the right foot/toes is decreased.
|
| Absent | Radiobutton |
Check this box if the sensation in the right foot/toes is absent.
|
| Right Lateral Rotation Endpoint | ||
| Right Lateral Rotation Endpoint | Number |
Please enter the right lateral rotation endpoint value.
|
| Same as active ROM | Checkbox |
Check this box if the right lateral rotation endpoint is the same as the active Range of Motion (ROM).
|
| Right Lower Leg/Ankle Sensation | ||
| Right Lower Leg/Ankle Sensation Normal | Radiobutton |
Check this box if sensation to light touch in the right lower leg/ankle (L4/L5/S1) is normal.
|
| Right Lower Leg/Ankle Sensation Decreased | Radiobutton |
Check this box if sensation to light touch in the right lower leg/ankle (L4/L5/S1) is decreased.
|
| Right Lower Leg/Ankle Sensation Absent | Radiobutton |
Check this box if sensation to light touch in the right lower leg/ankle (L4/L5/S1) is absent.
|
| Right Side Deep Tendon Reflexes | ||
| Right Knee DTR Rating | Text |
Enter the deep tendon reflex rating for the right knee based on the provided scale.
|
| Right Ankle DTR Rating | Text |
Enter the deep tendon reflex rating for the right ankle based on the provided scale.
|
| Right Side Muscle Strength Ratings | ||
| Right Hip Flexion Strength | Text |
Enter the muscle strength rating for the right hip flexion.
|
| Right Ankle Dorsiflexion Strength | Number |
Enter the muscle strength rating for the right ankle dorsiflexion.
|
| Right Knee Extension Strength | Text |
Enter the muscle strength rating for the right knee extension.
|
| Right Great Toe Extension Strength | Text |
Enter the muscle strength rating for the right great toe extension.
|
| Right Ankle Plantar Flexion Strength | Text |
Enter the muscle strength rating for the right ankle plantar flexion.
|
| Right Straight Leg Raising Test Results | ||
| Straight Leg Raise Outcome – Right: Negative | Radiobutton |
Check this box if the straight leg raise test result on the right leg is negative.
|
| Straight Leg Raise Outcome – Right: Positive | Radiobutton |
Check this box if the straight leg raise test result on the right leg is positive.
|
| Straight Leg Raise Outcome – Right: Unable to perform | Radiobutton |
Check this box if you were unable to perform the straight leg raise test on the right leg.
|
| Right Thigh/Knee Sensation | ||
| Normal | Radiobutton |
Check this box if the sensation to light touch in the right thigh/knee (L3/4 dermatome) is normal.
|
| Decreased | Radiobutton |
Check this box if the sensation to light touch in the right thigh/knee (L3/4 dermatome) is decreased.
|
| Absent | Radiobutton |
Check this box if the sensation to light touch in the right thigh/knee (L3/4 dermatome) is absent.
|
| Right Upper Anterior Thigh Sensation | ||
| Normal | Radiobutton |
Check this box if the sensation in the right upper anterior thigh (L2 dermatome) is normal.
|
| Decreased | Radiobutton |
Check this box if the sensation in the right upper anterior thigh (L2 dermatome) is decreased.
|
| Absent | Radiobutton |
Check this box if the sensation in the right upper anterior thigh (L2 dermatome) is absent.
|
| ROM Exhibited Pain | ||
| Forward flexion | Checkbox |
Check this box if the examination noted pain during forward flexion.
|
| Right lateral flexion | Checkbox |
Check this box if the examination noted pain during right lateral flexion.
|
| Right lateral rotation | Checkbox |
Check this box if the examination noted pain during right lateral rotation.
|
| Extension | Checkbox |
Check this box if the examination noted pain during extension.
|
| Left lateral flexion | Checkbox |
Check this box if the examination noted pain during left lateral flexion.
|
| Left lateral rotation | Checkbox |
Check this box if the examination noted pain during left lateral rotation.
|
| ROM outside normal range description | ||
| Normal ROM Justification | Text |
Provide a description explaining why the Range of Motion (ROM) is considered normal for the Veteran, even if it falls outside the typical normal range, considering factors such as age, body habitus, or neurologic disease, but not a back condition. Fill only if 'Abnormal or outside of normal range' is 'Yes'.
Depends on:
Abnormal or outside of normal range
|
| Sacroiliac Injury Diagnosis | ||
| Sacroiliac injury | Checkbox |
Check this box if the claimed condition includes a sacroiliac injury.
|
| Sacroiliac Injury ICD Code | Text |
Please provide the ICD code for the sacroiliac injury. Fill only if 'Sacroiliac injury' is 'Yes'.
Depends on:
Sacroiliac injury
|
| Sacroiliac Injury Diagnosis Date | Date |
Please enter the date when the sacroiliac injury was diagnosed. Fill only if 'Sacroiliac injury' is 'Yes'.
Depends on:
Sacroiliac injury
|
| Sacroiliac Weakness Diagnosis | ||
| Sacroiliac weakness | Checkbox |
Check this box if Sacroiliac weakness is a diagnosis associated with the claimed condition(s).
|
| Sacroiliac Weakness ICD Code | Text |
Please provide the ICD Code for the Sacroiliac Weakness diagnosis. Fill only if 'Sacroiliac weakness' is 'Yes'.
Depends on:
Sacroiliac weakness
|
| Sacroiliac Weakness Date of Diagnosis | Date |
Please provide the date when the Sacroiliac Weakness was diagnosed. Fill only if 'Sacroiliac weakness' is 'Yes'.
Depends on:
Sacroiliac weakness
|
| Scars or Skin Disfigurement | ||
| Yes | Radiobutton |
Check this box if the Veteran has scars or other disfigurement of the skin related to any conditions or to the treatment of any conditions listed in the diagnosis section.
|
| No | Radiobutton |
Check this box if the Veteran does not have any scars or other disfigurement of the skin related to any conditions or to the treatment of any conditions listed in the diagnosis section.
|
| Sciatic Nerve Involvement | ||
| Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve) | Checkbox |
Check this box if there is involvement of the L4/L5/S1/S2/S3 nerve roots, which are collectively known as the sciatic nerve.
|
| Right | Radiobutton |
Check this box if the sciatic nerve involvement affects the right side. Fill only if 'Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve)' is 'Yes'.
Depends on:
Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve)
|
| Left | Radiobutton |
Check this box if the sciatic nerve involvement affects the left side. Fill only if 'Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve)' is 'Yes'.
Depends on:
Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve)
|
| Both | Radiobutton |
Check this box if the sciatic nerve involvement affects both the right and left sides. Fill only if 'Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve)' is 'Yes'.
Depends on:
Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve)
|
| SECTION X - OTHER NEUROLOGIC ABNORMALITIES | ||
| Yes | Radiobutton |
Check this box if the Veteran has other neurologic abnormalities or findings (such as bowel or bladder problems/pathologic reflexes) related to a thoracolumbar spine condition.
|
| No | Radiobutton |
Check this box if the Veteran does not have any other neurologic abnormalities or findings related to a thoracolumbar spine condition.
|
| Other Neurologic Abnormalities Description | Text |
Provide a detailed description of any other neurologic abnormalities or findings, including how they are related to a thoracolumbar spine condition. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Segmental Instability Diagnosis | ||
| Segmental instability | Checkbox |
Check this box if the veteran has been diagnosed with segmental instability.
|
| Segmental Instability ICD Code | Text |
Please provide the International Classification of Diseases (ICD) code for Segmental Instability. Fill only if 'Segmental instability' is 'Yes'.
Depends on:
Segmental instability
|
| Segmental Instability Diagnosis Date | Date |
Please provide the date when Segmental Instability was diagnosed. Fill only if 'Segmental instability' is 'Yes'.
Depends on:
Segmental instability
|
| Sensory Findings - First Column | ||
| Normal | Radiobutton |
Check this box if the sensory finding for the left side is normal.
|
| Decreased | Radiobutton |
Check this box if the sensory finding for the left side is decreased.
|
| Absent | Radiobutton |
Check this box if the sensory finding for the left side is absent.
|
| Sensory Findings - Fourth Column | ||
| Normal | Radiobutton |
Check this box if the sensory findings are normal.
|
| Decreased | Radiobutton |
Check this box if the sensory findings are decreased.
|
| Absent | Radiobutton |
Check this box if the sensory findings are absent.
|
| Sensory Findings - Second Column | ||
| Normal | Radiobutton |
Check this box if the sensory findings are normal.
|
| Decreased | Radiobutton |
Check this box if the sensory findings are decreased.
|
| Absent | Radiobutton |
Check this box if the sensory findings are absent.
|
| Sensory Findings - Third Column | ||
| Normal | Radiobutton |
Check this box if the sensory findings are normal.
|
| Decreased | Radiobutton |
Check this box if the sensory findings are decreased.
|
| Absent | Radiobutton |
Check this box if the sensory findings are absent.
|
| Severity of Ankylosis | ||
| Unfavorable ankylosis of the entire spine | Radiobutton |
Check this box if there is unfavorable ankylosis affecting the entire spine, characterized by fixation in flexion or extension resulting in one or more severe limitations as described in the note. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Unfavorable ankylosis of the entire thoracolumbar spine | Radiobutton |
Check this box if there is unfavorable ankylosis affecting the entire thoracolumbar spine, characterized by fixation in flexion or extension resulting in one or more severe limitations as described in the note. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Favorable ankylosis of the entire thoracolumbar spine | Radiobutton |
Check this box if there is favorable ankylosis of the entire thoracolumbar spine, meaning fixation of spinal segments in a neutral (zero degrees) position. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Spinal Fusion Diagnosis | ||
| Spinal fusion | Checkbox |
Check this box if spinal fusion is a diagnosis associated with the claimed condition(s).
|
| Spinal Fusion ICD Code | Text |
Please provide the ICD Code for the Spinal fusion diagnosis. Fill only if 'Spinal fusion' is 'Yes'.
Depends on:
Spinal fusion
|
| Spinal Fusion Date of Diagnosis | Date |
Please provide the date of diagnosis for Spinal fusion. Fill only if 'Spinal fusion' is 'Yes'.
Depends on:
Spinal fusion
|
| Spinal Stenosis Diagnosis | ||
| Spinal stenosis | Checkbox |
Check this box if spinal stenosis is a diagnosis associated with the claimed condition(s).
|
| Spinal Stenosis ICD Code | Text |
Please enter the International Classification of Diseases (ICD) code for spinal stenosis. Fill only if 'Spinal stenosis' is 'Yes'.
Depends on:
Spinal stenosis
|
| Spinal Stenosis Diagnosis Date | Date |
Please provide the date when spinal stenosis was diagnosed. Fill only if 'Spinal stenosis' is 'Yes'.
Depends on:
Spinal stenosis
|
| Spondylolisthesis Diagnosis | ||
| Spondylolisthesis | Checkbox |
Check this box if Spondylolisthesis is an associated diagnosis for the claimed condition(s).
|
| Spondylolisthesis ICD Code | Text |
Provide the International Classification of Diseases (ICD) code for the Spondylolisthesis diagnosis. Fill only if 'Spondylolisthesis' is 'Yes'.
Depends on:
Spondylolisthesis
|
| Spondylolisthesis Date of Diagnosis | Date |
Provide the date when the Spondylolisthesis diagnosis was made. Fill only if 'Spondylolisthesis' is 'Yes'.
Depends on:
Spondylolisthesis
|
| Testing Performance Confirmation | ||
| Yes | Radiobutton |
Check this box if testing can be performed.
|
| No | Radiobutton |
Check this box if testing cannot be performed or is medically contraindicated, and provide an explanation in the space below.
|
| Explanation for Not Performing Testing | Text |
Provide a detailed explanation if testing cannot be performed or is medically contraindicated. Fill only if 'No' is selected.
Depends on:
No
|
| Thoracolumbar Vertebral Fracture Evidence | ||
| Yes | Radiobutton |
Check this box if the Veteran has imaging evidence of a thoracolumbar vertebral fracture.
|
| No | Radiobutton |
Check this box if the Veteran does not have imaging evidence of a thoracolumbar vertebral fracture.
|
| Total Duration of Bed Rest | ||
| No episodes of bed rest | Radiobutton |
Check this box if the veteran had no episodes of bed rest during the past 12 months. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Bed rest 1 to 2 weeks | Radiobutton |
Check this box if the veteran had episodes of bed rest totaling at least 1 week but less than 2 weeks during the past 12 months. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Bed rest 2 to 4 weeks | Radiobutton |
Check this box if the veteran had episodes of bed rest totaling at least 2 weeks but less than 4 weeks during the past 12 months. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Bed rest 4 to 6 weeks | Radiobutton |
Check this box if the veteran had episodes of bed rest totaling at least 4 weeks but less than 6 weeks during the past 12 months. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Bed rest 6 weeks or more | Radiobutton |
Check this box if the veteran had episodes of bed rest totaling at least 6 weeks during the past 12 months. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Traumatic Paralysis, Complete Diagnosis | ||
| Traumatic paralysis, complete | Checkbox |
Check this box if the veteran has a complete traumatic paralysis diagnosis associated with the claimed condition.
|
| Traumatic Paralysis Complete ICD Code | Text |
Provide the ICD Code for the diagnosis of traumatic paralysis. Fill only if 'Traumatic paralysis, complete' is 'Yes'.
Depends on:
Traumatic paralysis, complete
|
| Traumatic Paralysis Complete Date of Diagnosis | Date |
Provide the date of diagnosis for traumatic paralysis. Fill only if 'Traumatic paralysis, complete' is 'Yes'.
Depends on:
Traumatic paralysis, complete
|
| VA Healthcare Provider Status | ||
| Yes | Radiobutton |
Check this box if you are a VA Healthcare provider.
|
| No | Radiobutton |
Check this box if you are not a VA Healthcare provider.
|
| Vertebral Dislocation Diagnosis | ||
| Vertebral dislocation | Checkbox |
Check this box if the current diagnosis is vertebral dislocation.
|
| Vertebral Dislocation ICD Code | Text |
Enter the International Classification of Diseases (ICD) code for vertebral dislocation. Fill only if 'Vertebral dislocation' is 'Yes'.
Depends on:
Vertebral dislocation
|
| Vertebral Dislocation Diagnosis Date | Date |
Provide the date when the vertebral dislocation was diagnosed. Fill only if 'Vertebral dislocation' is 'Yes'.
Depends on:
Vertebral dislocation
|
| Vertebral Fracture Diagnosis | ||
| Vertebral fracture | Checkbox |
Check this box if the veteran has been diagnosed with a vertebral fracture.
|
| Vertebral Fracture ICD Code | Text |
Provide the ICD code for the vertebral fracture diagnosis. Fill only if 'Vertebral fracture' is 'Yes'.
Depends on:
Vertebral fracture
|
| Vertebral Fracture Date of Diagnosis | Date |
Provide the date of diagnosis for the vertebral fracture. Fill only if 'Vertebral fracture' is 'Yes'.
Depends on:
Vertebral fracture
|
| Walker Assistive Device | ||
| Walker | Checkbox |
Check this box if the veteran uses a walker as an assistive device.
|
| Occasional | Radiobutton |
Check this box if the veteran uses the walker occasionally.
|
| Regular | Radiobutton |
Check this box if the veteran uses the walker regularly.
|
| Constant | Radiobutton |
Check this box if the veteran uses the walker constantly.
|
| Wheelchair Details | ||
| Wheelchair | Checkbox |
Check this box if the Veteran uses a wheelchair as an assistive device. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Wheelchair - Occasional | Radiobutton |
Check this box if the Veteran uses a wheelchair occasionally. Fill only if 'Yes', 'Wheelchair' is 'Yes' and Wheelchair is 'Yes' for all.
Depends on:
Yes, Wheelchair
|
| Wheelchair - Regular | Radiobutton |
Check this box if the Veteran uses a wheelchair regularly. Fill only if 'Yes', 'Wheelchair' is 'Yes' and Wheelchair is 'Yes' for all.
Depends on:
Yes, Wheelchair
|
| Wheelchair - Constant | Radiobutton |
Check this box if the Veteran uses a wheelchair constantly. Fill only if 'Yes', 'Wheelchair' is 'Yes' and Wheelchair is 'Yes' for all.
Depends on:
Yes, Wheelchair
|