This form contains 510 fields organized into 60 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Ability to Perform Repetitive Use Testing
RG_3B_Repetitive_use_RG_1.RG_3B_Repetitive_use_RG._1	RadioButton
Ability to Perform Repetitive Use Testing - Yes	Checkbox	Check this box if the Veteran is able to perform repetitive use testing with at least three repetitions.
Ability to Perform Repetitive Use Testing - No	Checkbox	Check this box if the Veteran is not able to perform repetitive use testing with at least three repetitions.
Active Range of Motion Values
Forward Flexion Endpoint	Number	Enter the active range of motion value for forward flexion endpoint in degrees. Max length: 9 characters
Extension Endpoint	Number	Enter the active range of motion value for extension endpoint in degrees. Max length: 9 characters
Right Lateral Flexion Endpoint	Number	Enter the active range of motion value for right lateral flexion endpoint in degrees. Max length: 9 characters
Left Lateral Flexion Endpoint	Number	Enter the active range of motion value for left lateral flexion endpoint in degrees. Max length: 9 characters
Right Lateral Rotation Endpoint	Number	Enter the active range of motion value for right lateral rotation endpoint in degrees. Max length: 9 characters
Left Lateral Rotation Endpoint	Number	Enter the active range of motion value for left lateral rotation endpoint in degrees. Max length: 9 characters
Additional Factors Contributing to Disability
checkbox_NOtdch_95e0	CheckBox
checkbox_hMgrEZ_668b	CheckBox
checkbox_0Htmpx_cfc0	CheckBox
checkbox_IJPIt8_dede	CheckBox
checkbox_uFYUXp_5ba0	CheckBox
checkbox_4hiMJ8_0bfb	CheckBox
checkbox_KHGZSm_c02c	CheckBox
checkbox_d75x9d_bf8a	CheckBox
checkbox_wtCIUM_c123	CheckBox
checkbox_9w9pPx_597a	CheckBox
checkbox_qY5Fc3_bd32	CheckBox
checkbox_ETyVVt_5a30	CheckBox
3F. Other Contributing Factor Description	Text	Enter a description for the 'Other' additional contributing factor of disability. Max length: 59 characters
Additional Loss of Function After Repetitions
RG_3B_RG2_1.RG_3B_RG2._1	RadioButton
Yes	Checkbox	Check this box if there is additional loss of function or range of motion after three repetitions.
No	Checkbox	Check this box if there is no additional loss of function or range of motion after three repetitions.
Ankylosis Details
Ankylosis Comments	Text	Provide any additional comments or details regarding ankylosis for this section. Max length: 101 characters
Yes, Ankylosis	Checkbox	Check this box if ankylosis of the spine is present.
Unfavorable Ankylosis of Entire Spine	Checkbox	Check this box if there is unfavorable ankylosis involving the entire spine.
No, Ankylosis	Checkbox	Check this box if ankylosis of the spine is not present.
Unfavorable Ankylosis of Entire Thoracolumbar Spine	Checkbox	Check this box if there is unfavorable ankylosis involving the entire thoracolumbar spine.
Favorable Ankylosis of Entire Thoracolumbar Spine	Checkbox	Check this box if there is favorable ankylosis involving the entire thoracolumbar spine.
Claimed Conditions for Questionnaire
Claimed Conditions 1A	Text	Enter the claimed condition(s) that pertain to this questionnaire. Max length: 101 characters
Degree Endpoint if Different Than Above
Forward Flexion Degree Endpoint	Number	Enter the degree endpoint for forward flexion if it is different than the previously noted value. Max length: 6 characters
Extension Degree Endpoint	Number	Enter the degree endpoint for extension if it is different than the previously noted value. Max length: 6 characters
Right Lateral Flexion Degree Endpoint	Number	Enter the degree endpoint for right lateral flexion if it is different than the previously noted value. Max length: 6 characters
Left Lateral Flexion Degree Endpoint	Number	Enter the degree endpoint for left lateral flexion if it is different than the previously noted value. Max length: 6 characters
Right Lateral Rotation Degree Endpoint	Number	Enter the degree endpoint for right lateral rotation if it is different than the previously noted value. Max length: 6 characters
Left Lateral Rotation Degree Endpoint	Number	Enter the degree endpoint for left lateral rotation if it is different than the previously noted value. Max length: 6 characters
Description of Additional Contributing Factors
Additional Contributing Factors Description	Text	Please provide a description of any additional contributing factors of disability.
Evidence for Flare-ups
Flare-ups Evidence	Text	Provide specific evidence related to flare-ups, discussing all procurable evidence.
Evidence for Repeated Use Over Time
Evidence Discussion	Text	Please cite and discuss evidence, which must be specific to the case and based on all procurable evidence.
Evidence of Functional Limits with Flare-ups
RG_3D_Does_procured_evidence_1.RG_3D_Does_procured_evidence._1	RadioButton
Flare-ups: Functional Limits with Evidence - Yes	Checkbox	Check this box if procured evidence, such as statements from the Veteran, suggests pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability during flare-ups.
Flare-ups: Functional Limits with Evidence - No	Checkbox	Check this box if procured evidence does not suggest pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability during flare-ups.
Evidence of Functional Limits with Repeated Use
RG_3C_Procured_evidence_1.RG_3C_Procured_evidence._1	RadioButton
Evidence Suggests Functional Limits with Repeated Use - Yes	Checkbox	Check this box if procured evidence suggests pain, fatigability, weakness, lack of endurance, or incoordination significantly limits functional ability with repeated use over time.
Evidence Suggests Functional Limits with Repeated Use - No	Checkbox	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
RG_Is_there_evidence_of_pain_1.RG_Is_there_evidence_of_pain._1	RadioButton
Pain on Rest/Non-movement	Checkbox	Check this box if pain is evidenced while at rest or during non-movement.
Pain on Passive motion	Checkbox	Check this box if pain is evidenced during passive motion.
Pain does not cause functional loss	Checkbox	Check this box if the pain does not result in or cause functional loss.
Pain on Active motion	Checkbox	Check this box if pain is evidenced during active motion.
Pain on Nonweight-bearing	Checkbox	Check this box if pain is evidenced during nonweight-bearing activities.
Pain on Weight-bearing	Checkbox	Check this box if pain is evidenced during weight-bearing activities.
Pain causes functional loss	Checkbox	Check this box if the pain causes functional loss, and describe it in the comments section below.
checkbox_I3x5Ry_4d31	CheckBox
No, evidence of pain	Checkbox	Check this box if there is no evidence of pain.
Evidence Review
RG_Evidence_reviewed2_1.RG_Evidence_reviewed2._1	RadioButton
No records were reviewed	Checkbox	Check this box if no evidence records were reviewed for the veteran's claim.
Records reviewed	Checkbox	Check this box if evidence records were reviewed for the veteran's claim.
Evidence Reviewed Details	Text	Provide details about the evidence reviewed, such as service treatment records, VA treatment records, private treatment records, and the date range.
Examination Details
RG_Examined_in_person_YN2_1.RG_Examined_in_person_YN2._1	RadioButton
Non-In-Person Examination Method	Text	Specify how the examination was conducted if the veteran was not examined in person.
Examined in Person No	Checkbox	Check this box if the Veteran was not examined in person.
Examined in Person Yes	Checkbox	Check this box if the Veteran was examined in person.
Explanation of Neurological Findings
Explanation of Neurological Findings	Text	Provide a detailed explanation of the likely cause for any abnormal or positive neurological findings identified in Sections 4-8. Max length: 101 characters
Factors Causing Functional Loss
Other Factor Causing Functional Loss	Text	Provide details of any other factor not listed that causes functional loss. Max length: 48 characters
N/A	Checkbox	Check this box if none of the other specified factors contribute to the functional loss.
Incoordination	Checkbox	Check this box if incoordination is a factor causing the functional loss.
Other	Checkbox	Check this box if an unlisted factor is causing the functional loss.
Pain	Checkbox	Check this box if pain is a factor causing the functional loss.
Fatigability	Checkbox	Check this box if fatigability is a factor causing the functional loss.
Weakness	Checkbox	Check this box if weakness is a factor causing the functional loss.
Lack of endurance	Checkbox	Check this box if lack of endurance is a factor causing the functional loss.
Factors Causing Functional Loss After Repeated Use
Other Factor Causing Functional Loss After Repeated Use	Text	Provide details for any other factor causing functional loss after repeated use that is not listed. Max length: 48 characters
Fatigability	Checkbox	Check this box if fatigability is a factor causing functional loss after repeated use.
Pain	Checkbox	Check this box if pain is a factor causing functional loss after repeated use.
N/A	Checkbox	Check this box if none of the specific factors (pain, fatigability, weakness, lack of endurance, or incoordination) are applicable or cannot be determined as causing functional loss after repeated use.
Incoordination	Checkbox	Check this box if incoordination is a factor causing functional loss after repeated use.
Other Factors	Checkbox	Check this box if there are other factors not listed that cause functional loss after repeated use.
Weakness	Checkbox	Check this box if weakness is a factor causing functional loss after repeated use.
Lack of endurance	Checkbox	Check this box if lack of endurance is a factor causing functional loss after repeated use.
Factors Causing Functional Loss During Flare-ups
Flare-ups Other Functional Loss Factor	Text	Enter any other factors causing functional loss during flare-ups not listed. Max length: 48 characters
Lack of endurance	Checkbox	Check this box if lack of endurance is a factor causing functional loss during flare-ups.
Weakness	Checkbox	Check this box if weakness is a factor causing functional loss during flare-ups.
Fatigability	Checkbox	Check this box if fatigability is a factor causing functional loss during flare-ups.
Pain	Checkbox	Check this box if pain is a factor causing functional loss during flare-ups.
Other Factors	Checkbox	Check this box if other unlisted factors cause functional loss during flare-ups.
Incoordination	Checkbox	Check this box if incoordination is a factor causing functional loss during flare-ups.
N/A	Checkbox	Check this box if none of the specified factors cause functional loss during flare-ups.
Femoral Nerve Roots Involvement
Involvement of L2/L3/L4 nerve roots (femoral nerve)	Checkbox	Check this box if there is an involvement of the L2, L3, or L4 nerve roots, also known as the femoral nerve.
Femoral Nerve Affected Right Side	Checkbox	Check this box if the involvement of the femoral nerve (L2/L3/L4 nerve roots) affects the right side.
Femoral Nerve Affected Left Side	Checkbox	Check this box if the involvement of the femoral nerve (L2/L3/L4 nerve roots) affects the left side.
Femoral Nerve Affected Both Sides	Checkbox	Check this box if the involvement of the femoral nerve (L2/L3/L4 nerve roots) affects both the right and left sides.
Flare-up Examination Status
RG_3B_RG3_1.RG_3B_RG3._1	RadioButton
Flare-up Yes	Checkbox	Check this box if the Veteran is being examined during a flare-up.
Flare-up No	Checkbox	Check this box if the Veteran is not being examined during a flare-up.
General
VA Healthcare Provider: No	Radiobutton	Check this box if you are not a VA Healthcare provider.
The Veteran does not have a current diagnosis associated with any claimed conditions listed above.	Checkbox	Check this box if the veteran does not have a current diagnosis related to the claimed conditions.
Ankylosing spondylitis	Checkbox	Check this box if the diagnosis is Ankylosing spondylitis.
Degenerative arthritis	Checkbox	Check this box if the diagnosis is Degenerative arthritis.
Degenerative disc disease other than intervertebral disc syndrome (IVDS)	Checkbox	Check this box if the diagnosis is Degenerative disc disease other than intervertebral disc syndrome (IVDS).
Lumbosacral strain	Checkbox	Check this box if the diagnosis is Lumbosacral strain.
Intervertebral disc syndrome (Note: See VA definition of IVDS in Section XI.)	Checkbox	Check this box if the diagnosis is Intervertebral disc syndrome.
Sacroiliac injury	Checkbox	Check this box if the diagnosis is Sacroiliac injury.
Sacroiliac weakness	Checkbox	Check this box if the diagnosis is Sacroiliac weakness.
Segmental instability	Checkbox	Check this box if the diagnosis is Segmental instability.
Spinal fusion	Checkbox	Check this box if the diagnosis is Spinal fusion.
Spinal stenosis	Checkbox	Check this box if the diagnosis is Spinal stenosis.
Spondylolisthesis	Checkbox	Check this box if the diagnosis is Spondylolisthesis.
Traumatic paralysis, complete	Checkbox	Check this box if the diagnosis is Traumatic paralysis, complete.
Vertebral dislocation	Checkbox	Check this box if the diagnosis is Vertebral dislocation.
Vertebral fracture	Checkbox	Check this box if the diagnosis is Vertebral fracture.
Other (specify)	Checkbox	Check this box if the diagnosis is not listed among the other options and then specify the diagnosis.
Additional Thoracolumbar Spine Conditions Diagnoses	Text	Enter any additional diagnoses pertaining to thoracolumbar spine conditions.
Veteran's Thoracolumbar Spine Condition History	Text	Provide a brief summary describing the history, including onset and course, of the Veteran's thoracolumbar spine condition.
Ankylosing Spondylitis ICD Code	Text	Enter the ICD code for Ankylosing spondylitis. Max length: 16 characters
Degenerative Arthritis ICD Code	Text	Enter the ICD code for Degenerative arthritis. Max length: 16 characters
Degenerative Disc Disease (Non-IVDS) ICD Code	Text	Enter the ICD code for Degenerative disc disease other than intervertebral disc syndrome (IVDS). Max length: 16 characters
Lumbosacral Strain ICD Code	Text	Enter the ICD code for Lumbosacral strain. Max length: 16 characters
Intervertebral Disc Syndrome ICD Code	Text	Enter the ICD code for Intervertebral disc syndrome. Max length: 16 characters
Sacroiliac Injury ICD Code	Text	Enter the ICD code for Sacroiliac injury. Max length: 16 characters
Sacroiliac Weakness ICD Code	Text	Enter the ICD code for Sacroiliac weakness. Max length: 16 characters
Segmental Instability ICD Code	Text	Enter the ICD code for Segmental instability. Max length: 16 characters
Spinal Fusion ICD Code	Text	Enter the ICD code for Spinal fusion. Max length: 16 characters
Spinal Stenosis ICD Code	Text	Enter the ICD code for Spinal stenosis. Max length: 16 characters
Spondylolisthesis ICD Code	Text	Enter the ICD code for Spondylolisthesis. Max length: 16 characters
Traumatic Paralysis Complete ICD Code	Text	Enter the ICD code for Traumatic paralysis, complete. Max length: 16 characters
Vertebral Dislocation ICD Code	Text	Enter the ICD code for Vertebral dislocation. Max length: 16 characters
Vertebral Fracture ICD Code	Text	Enter the ICD code for Vertebral fracture. Max length: 16 characters
Vertebral Fracture Date of Diagnosis	Date	Enter the date of diagnosis for Vertebral fracture. Max length: 11 characters
Vertebral Dislocation Date of Diagnosis	Date	Enter the date of diagnosis for Vertebral dislocation. Max length: 11 characters
Traumatic Paralysis Complete Date of Diagnosis	Date	Enter the date of diagnosis for Traumatic paralysis, complete. Max length: 11 characters
Spondylolisthesis Date of Diagnosis	Date	Enter the date of diagnosis for Spondylolisthesis. Max length: 11 characters
Spinal Stenosis Date of Diagnosis	Date	Enter the date of diagnosis for Spinal stenosis. Max length: 11 characters
Spinal Fusion Date of Diagnosis	Date	Enter the date of diagnosis for Spinal fusion. Max length: 11 characters
Segmental Instability Date of Diagnosis	Date	Enter the date of diagnosis for Segmental instability. Max length: 11 characters
Sacroiliac Weakness Date of Diagnosis	Date	Enter the date of diagnosis for Sacroiliac weakness. Max length: 11 characters
Sacroiliac Injury Date of Diagnosis	Date	Enter the date of diagnosis for Sacroiliac injury. Max length: 11 characters
Intervertebral Disc Syndrome Date of Diagnosis	Date	Enter the date of diagnosis for Intervertebral disc syndrome. Max length: 11 characters
Lumbosacral Strain Date of Diagnosis	Date	Enter the date of diagnosis for Lumbosacral strain. Max length: 11 characters
Degenerative Disc Disease (Non-IVDS) Date of Diagnosis	Date	Enter the date of diagnosis for Degenerative disc disease other than intervertebral disc syndrome (IVDS). Max length: 11 characters
Degenerative Arthritis Date of Diagnosis	Date	Enter the date of diagnosis for Degenerative arthritis. Max length: 11 characters
Ankylosing Spondylitis Date of Diagnosis	Date	Enter the date of diagnosis for Ankylosing spondylitis. Max length: 11 characters
Other Diagnosis #1 Date of Diagnosis	Date	Enter the date of diagnosis for Other diagnosis #1. Max length: 11 characters
Other Diagnosis #2 Date of Diagnosis	Date	Enter the date of diagnosis for Other diagnosis #2. Max length: 11 characters
Other Diagnosis #3 Date of Diagnosis	Date	Enter the date of diagnosis for Other diagnosis #3. Max length: 11 characters
Other Diagnosis #1 ICD Code	Text	Enter the ICD code for Other diagnosis #1. Max length: 16 characters
Other Diagnosis #2 ICD Code	Text	Enter the ICD code for Other diagnosis #2. Max length: 16 characters
Other Diagnosis #3 ICD Code	Text	Enter the ICD code for Other diagnosis #3. Max length: 16 characters
Other Diagnosis #1 Name	Text	Enter the name of Other diagnosis #1. Max length: 37 characters
Other Diagnosis #2 Name	Text	Enter the name of Other diagnosis #2. Max length: 37 characters
Other Diagnosis #3 Name	Text	Enter the name of Other diagnosis #3. Max length: 37 characters
RG_Yes_No_1.RG_Yes_No._1	RadioButton
RG_Yes_No2_1.RG_Yes_No2._1	RadioButton
RG_3ARG_1_1_1.RG_3ARG._1	RadioButton
RG_3A_ABNORMAL_1.RG_3A_ABNORMAL._1	RadioButton
Joint/Extremity Functional Loss Description	Text	Describe any functional loss or impairment of the joint or extremity, including that which occurs after repeated use over time, in the Veteran's own words.
Thoracolumbar Flare-ups Description	Text	Provide a detailed description of the Veteran's thoracolumbar spine flare-ups, including frequency, duration, characteristics, precipitating and alleviating factors, severity, and extent of functional impairment.
Initial ROM Measurement Explanation	Text	Explain why the initial range of motion (ROM) measurements were unable to be tested or why they were not indicated.
ROM Normal For Veteran Description	Text	Describe why the range of motion, although outside of the normal range, is considered normal for the Veteran due to reasons other than a back condition.
Abnormal ROM Functional Loss Explanation	Text	Explain why an abnormal range of motion itself contributes to a functional loss.
2B No	Checkbox	Check this box if the Veteran does not report flare-ups of the thoracolumbar spine.
2B Yes	Checkbox	Check this box if the Veteran reports flare-ups of the thoracolumbar spine.
2C Yes	Checkbox	Check this box if the Veteran reports having any functional loss or functional impairment of the joint or extremity being evaluated, including but not limited to after repeated use over time.
2C No	Checkbox	Check this box if the Veteran does not report having any functional loss or functional impairment of the joint or extremity being evaluated, including but not limited to after repeated use over time.
3A All Normal	Checkbox	Check this box if all initial Range of Motion (ROM) measurements are normal.
3A Not indicated	Checkbox	Check this box if initial Range of Motion (ROM) measurements are not indicated.
3A Abnormal or outside of normal range	Checkbox	Check this box if initial Range of Motion (ROM) measurements are abnormal or outside of the normal range.
3A Unable to test	Checkbox	Check this box if initial Range of Motion (ROM) measurements are unable to be tested.
ROM contributes to functional loss? Yes	Checkbox	Check this box if an abnormal range of motion itself contributes to a functional loss.
ROM contributes to functional loss? No	Checkbox	Check this box if an abnormal range of motion itself does not contribute to a functional loss.
No	Radiobutton	Check this box if the Veteran does not have localized tenderness, guarding, or muscle spasm of the thoracolumbar spine.
Localized Tenderness: Not resulting in abnormal gait or abnormal spinal contour	Radiobutton	Check this box if localized tenderness is present but does not result in an abnormal gait or abnormal spinal contour.
Muscle Spasm: Resulting in abnormal gait or abnormal spine contour	Radiobutton	Check this box if muscle spasm is present and results in an abnormal gait or abnormal spinal contour.
Guarding: Resulting in abnormal gait or abnormal spine contour	Radiobutton	Check this box if guarding is present and results in an abnormal gait or abnormal spinal contour.
RG_4B_Does_the_Veteran_have_muscle_atrophy_YN_1.RG_4B_Does_the_Veteran_have_muscle_atrophy_YN._1	RadioButton
RG_4C_If_yes_is_the_muscle_atrophy_due_to_YN_1.RG_4C_If_yes_is_the_muscle_atrophy_due_to_YN._1	RadioButton
RG_6A_Right_Upper_Thigh_1_1.RG_6A_Right_Upper_Thigh._1	RadioButton
RG_6A_Right_Thigh_1_1.RG_6A_Right_Thigh._1	RadioButton
RG_6A_Right_Leg_1_1.RG_6A_Right_Leg._1	RadioButton
RG_6A_Right_Foot_1_1.RG_6A_Right_Foot._1	RadioButton
Atrophy Rationale	Text	Provide a detailed rationale if muscle atrophy is not due to the claimed condition. Max length: 92 characters
Atrophy Location and Measurements	Text	Indicate the specific location of atrophy and provide measurements in centimeters of both normal and atrophied sides at maximum muscle bulk.
Does Veteran Have Muscle Atrophy - Yes	Checkbox	Check this box if the veteran has muscle atrophy.
Does Veteran Have Muscle Atrophy - No	Checkbox	Check this box if the veteran does not have muscle atrophy.
Muscle Atrophy Due To Claimed Condition - No	Checkbox	Check this box if the muscle atrophy is not due to the claimed condition in the diagnosis section.
Muscle Atrophy Due To Claimed Condition - Yes	Checkbox	Check this box if the muscle atrophy is due to the claimed condition in the diagnosis section.
checkbox_ZmdKYl_c829	CheckBox
checkbox_ygaRok_8bae	CheckBox
checkbox_JaB5zK_4333	CheckBox
checkbox_eXwetb_b717	CheckBox
checkbox_miZ6rx_a8ed	CheckBox
checkbox_p17lGJ_f4d1	CheckBox
checkbox_kaWzye_60d8	CheckBox
checkbox_i6C6gG_917f	CheckBox
checkbox_O3vwXZ_6708	CheckBox
checkbox_x0ZE9G_29c0	CheckBox
checkbox_NXDw7b_ccee	CheckBox
checkbox_oBARj9_b426	CheckBox
Normal Side Circumference	Number	Enter the circumference of the normal side in centimeters. Max length: 8 characters
Atrophied Side Circumference	Number	Enter the circumference of the atrophied side in centimeters. Max length: 8 characters
Right Knee DTR Rate	Text	Enter the rate for the deep tendon reflex of the right knee. Max length: 3 characters
Left Knee DTR Rate	Text	Enter the rate for the deep tendon reflex of the left knee. Max length: 3 characters
Right Ankle DTR Rate	Text	Enter the rate for the deep tendon reflex of the right ankle. Max length: 3 characters
Left Ankle DTR Rate	Text	Enter the rate for the deep tendon reflex of the left ankle. Max length: 3 characters
Right Hip Flexion Rate Strength	Text	Enter the rate strength for right hip flexion, on a scale of 0 to 5. Max length: 3 characters
Right Knee Extension Rate Strength	Text	Enter the rate strength for right knee extension, on a scale of 0 to 5. Max length: 3 characters
Right Ankle Plantar Flexion Rate Strength	Text	Enter the rate strength for right ankle plantar flexion, on a scale of 0 to 5. Max length: 3 characters
Right Great Toe Extension Rate Strength	Text	Enter the rate strength for right great toe extension, on a scale of 0 to 5. Max length: 3 characters
Right Ankle Dorsi-flexion Rate Strength	Text	Enter the rate strength for right ankle dorsi-flexion, on a scale of 0 to 5. Max length: 3 characters
Left Hip Flexion Rate Strength	Text	Enter the rate strength for left hip flexion, on a scale of 0 to 5. Max length: 3 characters
Left Knee Extension Rate Strength	Text	Enter the rate strength for left knee extension, on a scale of 0 to 5. Max length: 3 characters
Left Ankle Plantar Flexion Rate Strength	Text	Enter the rate strength for left ankle plantar flexion, on a scale of 0 to 5. Max length: 3 characters
Left Great Toe Extension Rate Strength	Text	Enter the rate strength for left great toe extension, on a scale of 0 to 5. Max length: 3 characters
Left Ankle Dorsi-flexion Rate Strength	Text	Enter the rate strength for left ankle dorsi-flexion, on a scale of 0 to 5. Max length: 3 characters
RG_6A_Left_Upper_Thigh_1_1.RG_6A_Left_Upper_Thigh._1	RadioButton
RG_6A_Left_Thigh_1_1.RG_6A_Left_Thigh._1	RadioButton
RG_6A_Left_Leg_1_1.RG_6A_Left_Leg._1	RadioButton
RG_6A_Left_Foot_1_1.RG_6A_Left_Foot._1	RadioButton
RG_7A_Right_NPU_1_1.RG_7A_Right_NPU._1	RadioButton
RG_7A_Left_NPU_1_1.RG_7A_Left_NPU._1	RadioButton
RG_8_YN_1.RG_8_YN._1	RadioButton
RG_8A_Constant_Right_NMMS_1_1_1.RG_8A_Constant_Right_NMMS._1	RadioButton
RG_8A_Constant_Left_NMMS_1_1_1.RG_8A_Constant_Left_NMMS._1	RadioButton
RG_8A_Inter_Right_NMMS_1_1_1.RG_8A_Inter_Right_NMMS._1	RadioButton
RG_8A_Inter_Left_NMMS_1_1_1.RG_8A_Inter_Left_NMMS._1	RadioButton
RG_8A_Pare_Right_NMMS_1_1_1.RG_8A_Pare_Right_NMMS._1	RadioButton
RG_8A_Pare_Left_NMMS_1_1_1.RG_8A_Pare_Left_NMMS._1	RadioButton
RG_8A_Numb_Right_NMMS_1_1_1.RG_8A_Numb_Right_NMMS._1	RadioButton
RG_8A_Numb_Left_NMMS_1_1_1.RG_8A_Numb_Left_NMMS._1	RadioButton
RG_YN8B_1.RG_YN8B._1	RadioButton
Unable to Perform Explanation	Text	Explain the reason why the Straight Leg Raising Test could not be performed.
Other Sensory Findings	Text	Provide any other sensory findings.
Other Radiculopathy Symptoms Description	Text	Describe any other signs or symptoms of radiculopathy.
Other Radiculopathy Symptoms No	Checkbox	Check this box if the Veteran does not have any other signs or symptoms of radiculopathy.
Other Radiculopathy Symptoms Yes	Checkbox	Check this box if the Veteran has any other signs or symptoms of radiculopathy.
Has Radicular Pain Yes	Checkbox	Check this box if the Veteran has radicular pain or any other signs or symptoms due to radiculopathy.
Constant Pain Right Lower Extremity None	Checkbox	Check this box if there is no constant pain in the right lower extremity.
Has Radicular Pain No	Checkbox	Check this box if the Veteran does not have radicular pain or any other signs or symptoms due to radiculopathy.
Constant Pain Left Lower Extremity None	Checkbox	Check this box if there is no constant pain in the left lower extremity.
Intermittent Pain Right Lower Extremity None	Checkbox	Check this box if there is no intermittent pain in the right lower extremity.
Intermittent Pain Left Lower Extremity None	Checkbox	Check this box if there is no intermittent pain in the left lower extremity.
Paresthesias/Dysesthesias Right Lower Extremity None	Checkbox	Check this box if there are no paresthesias or dysesthesias in the right lower extremity.
Paresthesias/Dysesthesias Left Lower Extremity None	Checkbox	Check this box if there are no paresthesias or dysesthesias in the left lower extremity.
Numbness Right Lower Extremity None	Checkbox	Check this box if there is no numbness in the right lower extremity.
Numbness Left Lower Extremity None	Checkbox	Check this box if there is no numbness in the left lower extremity.
Numbness Left Lower Extremity Mild	Checkbox	Check this box if there is mild numbness in the left lower extremity.
Numbness Right Lower Extremity Mild	Checkbox	Check this box if there is mild numbness in the right lower extremity.
Paresthesias/Dysesthesias Left Lower Extremity Mild	Checkbox	Check this box if there are mild paresthesias or dysesthesias in the left lower extremity.
Paresthesias/Dysesthesias Right Lower Extremity Mild	Checkbox	Check this box if there are mild paresthesias or dysesthesias in the right lower extremity.
Intermittent Pain Left Lower Extremity Mild	Checkbox	Check this box if there is mild intermittent pain in the left lower extremity.
Intermittent Pain Right Lower Extremity Mild	Checkbox	Check this box if there is mild intermittent pain in the right lower extremity.
Constant Pain Left Lower Extremity Mild	Checkbox	Check this box if there is mild constant pain in the left lower extremity.
Constant Pain Right Lower Extremity Mild	Checkbox	Check this box if there is mild constant pain in the right lower extremity.
Constant Pain Right Lower Extremity Moderate	Checkbox	Check this box if there is moderate constant pain in the right lower extremity.
Constant Pain Left Lower Extremity Moderate	Checkbox	Check this box if there is moderate constant pain in the left lower extremity.
Intermittent Pain Right Lower Extremity Moderate	Checkbox	Check this box if there is moderate intermittent pain in the right lower extremity.
Intermittent Pain Left Lower Extremity Moderate	Checkbox	Check this box if there is moderate intermittent pain in the left lower extremity.
Constant Pain Right Lower Extremity Severe	Checkbox	Check this box if there is severe constant pain in the right lower extremity.
Constant Pain Left Lower Extremity Severe	Checkbox	Check this box if there is severe constant pain in the left lower extremity.
Intermittent Pain Right Lower Extremity Severe	Checkbox	Check this box if there is severe intermittent pain in the right lower extremity.
Intermittent Pain Left Lower Extremity Severe	Checkbox	Check this box if there is severe intermittent pain in the left lower extremity.
Paresthesias/Dysesthesias Right Lower Extremity Severe	Checkbox	Check this box if there are severe paresthesias or dysesthesias in the right lower extremity.
Paresthesias/Dysesthesias Left Lower Extremity Severe	Checkbox	Check this box if there are severe paresthesias or dysesthesias in the left lower extremity.
Numbness Right Lower Extremity Severe	Checkbox	Check this box if there is severe numbness in the right lower extremity.
Numbness Left Lower Extremity Severe	Checkbox	Check this box if there is severe numbness in the left lower extremity.
Paresthesias/Dysesthesias Right Lower Extremity Moderate	Checkbox	Check this box if there are moderate paresthesias or dysesthesias in the right lower extremity.
Paresthesias/Dysesthesias Left Lower Extremity Moderate	Checkbox	Check this box if there are moderate paresthesias or dysesthesias in the left lower extremity.
Numbness Right Lower Extremity Moderate	Checkbox	Check this box if there is moderate numbness in the right lower extremity.
Numbness Left Lower Extremity Moderate	Checkbox	Check this box if there is moderate numbness in the left lower extremity.
Right Straight Leg Test Unable to Perform	Checkbox	Check this box if the straight leg raising test for the right leg was unable to be performed.
Left Straight Leg Test Unable to Perform	Checkbox	Check this box if the straight leg raising test for the left leg was unable to be performed.
Right Straight Leg Test Positive	Checkbox	Check this box if the straight leg raising test result for the right leg is positive.
Left Straight Leg Test Positive	Checkbox	Check this box if the straight leg raising test result for the left leg is positive.
Right Straight Leg Test Negative	Checkbox	Check this box if the straight leg raising test result for the right leg is negative.
Left Straight Leg Test Negative	Checkbox	Check this box if the straight leg raising test result for the left leg is negative.
Sensory Finding 1 Normal	Checkbox	Check this box if the first identified sensory finding is normal.
Sensory Finding 1 Decreased	Checkbox	Check this box if the first identified sensory finding is decreased.
Sensory Finding 1 Absent	Checkbox	Check this box if the first identified sensory finding is absent.
Sensory Finding 2 Normal	Checkbox	Check this box if the second identified sensory finding is normal.
Sensory Finding 2 Decreased	Checkbox	Check this box if the second identified sensory finding is decreased.
Sensory Finding 2 Absent	Checkbox	Check this box if the second identified sensory finding is absent.
Sensory Finding 3 Normal	Checkbox	Check this box if the third identified sensory finding is normal.
Sensory Finding 3 Decreased	Checkbox	Check this box if the third identified sensory finding is decreased.
Sensory Finding 3 Absent	Checkbox	Check this box if the third identified sensory finding is absent.
Sensory Finding 4 Normal	Checkbox	Check this box if the fourth identified sensory finding is normal.
Sensory Finding 4 Decreased	Checkbox	Check this box if the fourth identified sensory finding is decreased.
Sensory Finding 4 Absent	Checkbox	Check this box if the fourth identified sensory finding is absent.
L2/L3/L4 Nerve Roots Left	Radiobutton	Check this box if the left side is affected due to involvement of L2/L3/L4 nerve roots (femoral nerve).
L4/L5/S1/S2/S3 Nerve Roots Left	Radiobutton	Check this box if the left side is affected due to involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve).
Other Nerves Left	Radiobutton	Check this box if the left side is affected due to other specified nerve involvement.
Ankylosis of Spine No	Radiobutton	Check this box if there is no ankylosis of the spine.
Unfavorable Ankylosis Entire Thoracolumbar Spine	Radiobutton	Check this box if the severity of ankylosis is unfavorable in the entire thoracolumbar spine.
Other Neurologic Abnormalities No	Radiobutton	Check this box if the Veteran does not have any other neurologic abnormalities or findings related to a thoracolumbar spine condition.
IVDS of Thoracolumbar Spine No	Radiobutton	Check this box if the Veteran does not have IVDS of the thoracolumbar spine.
RG_11B_YN_1.RG_11B_YN._1	RadioButton
RG_11B_If_yes_RG_1_1_1.RG_11B_If_yes_RG._1	RadioButton
RG_12A_YN_1.RG_12A_YN._1	RadioButton
RG_12A_Wheel_1_1.RG_12A_Wheel._1	RadioButton
RG_12A_Brace_1_1.RG_12A_Brace._1	RadioButton
RG_12A_Crutch_1_1.RG_12A_Crutch._1	RadioButton
Veteran Described Medical History	Text	Enter the medical history as described by the Veteran only, without any supporting documentation. Max length: 92 characters
Individual Treatment Record Dates Reviewed	Text	Provide the individual date(s) of each treatment record reviewed, as shown and documented in the Veteran's file. Max length: 92 characters
Facility Provider	Text	Enter the name of the facility and/or provider associated with the treatment. Max length: 92 characters
Treatment Description	Text	Provide a description of the treatment received. Max length: 92 characters
Other Description	Text	Describe any other relevant information not covered by the previous fields. Max length: 92 characters
Medical history documented in Veteran's file	Checkbox	Check this box if the medical history supporting the 'yes' response to question 11B is shown and documented in the Veteran's file.
Medical history described by Veteran only	Checkbox	Check this box if the medical history supporting the 'yes' response to question 11B is described by the Veteran only, without documentation.
Other assistive device	Checkbox	Check this box if the Veteran uses an assistive device not listed, and describe it in the provided text field.
Wheelchair	Checkbox	Check this box if the Veteran uses a wheelchair as an assistive device.
Brace(s)	Checkbox	Check this box if the Veteran uses brace(s) as an assistive device.
Crutch(es)	Checkbox	Check this box if the Veteran uses crutch(es) as an assistive device.
Wheelchair - Occasional	Checkbox	Check this box if the Veteran uses a wheelchair occasionally.
Brace(s) - Occasional	Checkbox	Check this box if the Veteran uses brace(s) occasionally.
Crutch(es) - Occasional	Checkbox	Check this box if the Veteran uses crutch(es) occasionally.
Wheelchair - Regular	Checkbox	Check this box if the Veteran uses a wheelchair regularly.
Brace(s) - Regular	Checkbox	Check this box if the Veteran uses brace(s) regularly.
Crutch(es) - Regular	Checkbox	Check this box if the Veteran uses crutch(es) regularly.
Crutch(es) - Constant	Checkbox	Check this box if the Veteran uses crutch(es) constantly.
Brace(s) - Constant	Checkbox	Check this box if the Veteran uses brace(s) constantly.
Wheelchair - Constant	Checkbox	Check this box if the Veteran uses a wheelchair constantly.
12A No	Checkbox	Check this box if the Veteran does not use any assistive devices as a normal mode of locomotion.
12A Yes	Checkbox	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.
11B Yes	Checkbox	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 by a physician in the past 12 months.
11B No	Checkbox	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 by a physician in the past 12 months.
No episodes of bed rest	Checkbox	Check this box if the Veteran had no episodes of bed rest during the past 12 months related to IVDS.
Bed rest 2 to less than 4 weeks	Checkbox	Check this box if the Veteran had episodes of bed rest with a total duration of at least 2 weeks but less than 4 weeks during the past 12 months.
Bed rest 1 to less than 2 weeks	Checkbox	Check this box if the Veteran had episodes of bed rest with a total duration of at least 1 week but less than 2 weeks during the past 12 months.
Bed rest 4 to less than 6 weeks	Checkbox	Check this box if the Veteran had episodes of bed rest with a total duration of at least 4 weeks but less than 6 weeks during the past 12 months.
Bed rest at least 6 weeks	Checkbox	Check this box if the Veteran had episodes of bed rest with a total duration of at least 6 weeks during the past 12 months.
RG_12A_Cane_1_1.RG_12A_Cane._1	RadioButton
RG_12A_Walker_1_1.RG_12A_Walker._1	RadioButton
RG_12A_Other_1_1.RG_12A_Other._1	RadioButton
RG_13AYN_1.RG_13AYN._1	RadioButton
RG_14AYN_1.RG_14AYN._1	RadioButton
RG_14BYN_1.RG_14BYN._1	RadioButton
Assistive Devices Description	Text	Provide details about any assistive devices the Veteran uses, including the specific condition requiring the device, the affected side of the body, and the type of assistive device used for each condition. Max length: 101 characters
Extremity Functional Impairment Description	Text	For each selected extremity, describe the specific condition causing the loss of function, detail the loss of effective function, and provide brief examples to illustrate the impairment. Max length: 101 characters
Other Pertinent Physical Findings Summary	Text	Provide a brief summary of any other pertinent physical findings, complications, conditions, signs, or symptoms related to conditions listed in the diagnosis section. Max length: 101 characters
General Comments	Text	Enter any additional comments or relevant information. Max length: 101 characters
Right Lower Extremity - Diminished Function	Checkbox	Check this box if the right lower extremity has diminished functioning.
Left Lower Extremity - Diminished Function	Checkbox	Check this box if the left lower extremity has diminished functioning.
Right Upper Extremity - Diminished Function	Checkbox	Check this box if the right upper extremity has diminished functioning.
Left Upper Extremity - Diminished Function	Checkbox	Check this box if the left upper extremity has diminished functioning.
13A Yes - Functional Impairment	Checkbox	Check this box if the Veteran's functioning is so diminished that amputation with prosthesis would equally serve them due to the thoracolumbar spine condition.
13A No - Functional Impairment	Checkbox	Check this box if the Veteran's functioning is not so diminished that amputation with prosthesis would equally serve them due to the thoracolumbar spine condition.
14A Yes - Other Physical Findings	Checkbox	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.
14A No - Other Physical Findings	Checkbox	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.
14B No - Scars or Disfigurement	Checkbox	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.
14B Yes - Scars or Disfigurement	Checkbox	Check this box if the Veteran has any scars or other disfigurement of the skin related to any conditions or to the treatment of any conditions listed in the diagnosis section.
checkbox_iJOJQa_3d58	CheckBox
checkbox_ELBo3v_ba47	CheckBox
checkbox_d7j59i_b777	CheckBox
Cane(s) - Occasional Use	Checkbox	Check this box if the Veteran uses cane(s) occasionally.
Walker - Occasional Use	Checkbox	Check this box if the Veteran uses a walker occasionally.
Other Assistive Device - Occasional Use	Checkbox	Check this box if the Veteran uses an 'other' assistive device occasionally.
Cane(s) - Regular Use	Checkbox	Check this box if the Veteran uses cane(s) regularly.
Walker - Regular Use	Checkbox	Check this box if the Veteran uses a walker regularly.
Other Assistive Device - Regular Use	Checkbox	Check this box if the Veteran uses an 'other' assistive device regularly.
Other Assistive Device - Constant Use	Checkbox	Check this box if the Veteran uses an 'other' assistive device constantly.
Walker - Constant Use	Checkbox	Check this box if the Veteran uses a walker constantly.
Cane(s) - Constant Use	Checkbox	Check this box if the Veteran uses cane(s) constantly.
text_ngk1NK_bf9f	Text	Max length: 15 characters
RG_16AYN_1.RG_16AYN._1	RadioButton
Functional Impact Description	Text	Provide a detailed description of the functional impact of each condition, including one or more examples. Max length: 101 characters
Remarks	Text	Enter any remarks, identifying the section to which the remark pertains when appropriate. Max length: 101 characters
Examiner's Signature	Text	Provide the examiner's signature. Max length: 40 characters
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. Max length: 40 characters
Examiner's Address	Text	Enter the examiner's complete address. Max length: 102 characters
Examiner's Phone/Fax Numbers	Text	Enter the examiner's phone and/or fax numbers. Max length: 32 characters
National Provider Identifier (NPI) Number	Text	Enter the examiner's National Provider Identifier (NPI) number. Max length: 32 characters
Medical License Number and State	Text	Enter the examiner's medical license number and the state where it was issued. Max length: 32 characters
Examiner's Area of Practice/Specialty	Text	Enter the examiner's area of practice or specialty, such as Cardiology, Orthopedics, Psychology/Psychiatry, or General Practice. Max length: 76 characters
Date Signed	Date	Provide the date the form was signed. Max length: 23 characters
16A No	Checkbox	Check this box if the diagnosed conditions do not impact the Veteran's ability to perform occupational tasks.
16A Yes	Checkbox	Check this box if the diagnosed conditions impact the Veteran's ability to perform occupational tasks.
Guarding
Guarding Description and Etiology	Text	Provide a detailed description of guarding and its etiology.
Guarding None	Checkbox	Check this box if no guarding is present.
Guarding Resulting in abnormal gait or abnormal spine contour	Checkbox	Check this box if guarding is present and results in an abnormal gait or abnormal spinal contour.
Guarding Not resulting in abnormal gait or abnormal spine contour	Checkbox	Check this box if guarding is present but does not result in an abnormal gait or abnormal spinal contour.
Guarding Unable to evaluate	Checkbox	Check this box if guarding cannot be evaluated, and provide a description below.
Guarding and Muscle Spasm Presence
Guarding and Muscle Spasm Presence - Yes	Checkbox	Check this box if the Veteran has localized tenderness, guarding or muscle spasm of the thoracolumbar spine.
Guarding and Muscle Spasm Presence - No	Checkbox	Check this box if the Veteran does not have localized tenderness, guarding or muscle spasm of the thoracolumbar spine.
Imaging Studies for Arthritis Details
RG_15AYN_1.RG_15AYN._1	RadioButton
RG_15BYN_1.RG_15BYN._1	RadioButton
15C Imaging Studies for Arthritis Details	Text	Provide the type of test or procedure, date, and a brief summary of results for the imaging studies related to arthritis. Max length: 101 characters
15A. Imaging Studies Performed - Yes	Checkbox	Check this box if imaging studies have been performed in conjunction with this examination.
15B. Arthritis Documented - Yes	Checkbox	Check this box if degenerative or post-traumatic arthritis is documented based on the imaging studies.
15B. Arthritis Documented - No	Checkbox	Check this box if degenerative or post-traumatic arthritis is not documented based on the imaging studies.
15A. Imaging Studies Performed - No	Checkbox	Check this box if imaging studies have not been performed in conjunction with this examination.
Intervertebral Disc Syndrome Diagnosis
Yes	Checkbox	Check this box if the Veteran has Intervertebral Disc Syndrome (IVDS) of the thoracolumbar spine.
No	Checkbox	Check this box if the Veteran does not have Intervertebral Disc Syndrome (IVDS) of the thoracolumbar spine.
Left Lateral Endpoint (30 degrees)
Left Lateral Endpoint (30 degrees)	Number	Enter the left lateral endpoint measurement in degrees. Max length: 8 characters
Left Lateral Endpoint (30 degrees) - Same as active ROM	Checkbox	Check this box if the left lateral endpoint at 30 degrees is the same as the active Range of Motion (ROM).
Left Lateral Flexion Endpoint (30 degrees)
Left Lateral Flexion Endpoint	Number	Enter the measured left lateral flexion endpoint in degrees. Max length: 8 characters
Left Lateral Flexion Endpoint (30 degrees) - Same as active ROM	Checkbox	Check this box if the left lateral flexion endpoint (30 degrees) is the same as the active range of motion.
Limitation of Motion Description
Limitation of Motion Description	Text	Provide a description of the factors to which any limitation of motion is specifically attributable, including pain, weakness, fatigability, incoordination, or other.
Limitation of Motion Description and Endpoints
Limitation of Motion Description	Text	Provide a detailed description of any limitation of motion specifically attributable to pain, weakness, fatigability, incoordination, or other factors, including the degrees in which motion is limited. Max length: 101 characters
Left Lateral Flexion Endpoint Degree	Number	Enter the degree endpoint for left lateral flexion if it is different from the active range of motion value recorded above. Max length: 7 characters
Right Lateral Rotation Endpoint Degree	Number	Enter the degree endpoint for right lateral rotation if it is different from the active range of motion value recorded above. Max length: 7 characters
Left Lateral Rotation Endpoint Degree	Number	Enter the degree endpoint for left lateral rotation if it is different from the active range of motion value recorded above. Max length: 7 characters
Forward Flexion Endpoint Degree	Number	Enter the degree endpoint for forward flexion if it is different from the active range of motion value recorded above. Max length: 7 characters
Extension Endpoint Degree	Number	Enter the degree endpoint for extension if it is different from the active range of motion value recorded above. Max length: 7 characters
Right Lateral Flexion Endpoint Degree	Number	Enter the degree endpoint for right lateral flexion if it is different from the active range of motion value recorded above. Max length: 7 characters
Localized Tenderness
Localized Tenderness Description/Etiology	Text	Provide a description and/or etiology for the localized tenderness.
None	Checkbox	Check this box if there is no localized tenderness.
Not resulting in abnormal gait or abnormal spinal contour	Checkbox	Check this box if localized tenderness is present but does not result in an abnormal gait or an abnormal spinal contour.
Muscle Spasm
Muscle Spasm Description and Etiology	Text	Provide a description and/or etiology of the muscle spasm, especially if it was unable to be evaluated.
Muscle Spasm: None	Checkbox	Check this box if the veteran does not exhibit any muscle spasm in the thoracolumbar spine.
Muscle Spasm: Resulting in abnormal gait or abnormal spine contour	Checkbox	Check this box if the muscle spasm in the thoracolumbar spine results in an abnormal gait or an abnormal spinal contour.
Muscle Spasm: Not resulting in abnormal gait or abnormal spinal contour	Checkbox	Check this box if the muscle spasm in the thoracolumbar spine is present but does not result in an abnormal gait or an abnormal spinal contour.
Muscle Spasm: Unable to evaluate	Checkbox	Check this box if the muscle spasm in the thoracolumbar spine cannot be evaluated, and provide further details in the associated description field.
Objective Evidence of Crepitus
RG_Yes_No3_1.RG_Yes_No3._1	RadioButton
Crepitus Yes	Checkbox	Check this box if there is objective evidence of crepitus.
Crepitus No	Checkbox	Check this box if there is no objective evidence of crepitus.
Objective Evidence of Localized Tenderness or Pain
RG_Is_there_objective_evidence_of_localized_tenderness_or_pain_1.RG_Is_there_objective_evidence_of_localized_tenderness_or_pain._1	RadioButton
Objective Evidence of Localized Tenderness or Pain - Yes	Checkbox	Check this box if there is objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue.
Objective Evidence of Localized Tenderness or Pain - No	Checkbox	Check this box if there is no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue.
Other Nerves Involvement
Other Nerves	Checkbox	Check this box if the patient has involvement of nerves not listed in the preceding options.
Other Nerves - Right	Checkbox	Select this option if the 'Other Nerves' checkbox is checked and the right side is affected.
Other Nerves - Left	Checkbox	Select this option if the 'Other Nerves' checkbox is checked and the left side is affected.
Other Nerves - Both	Checkbox	Select this option if the 'Other Nerves' checkbox is checked and both the left and right sides are affected.
Other Neurologic Abnormalities
Other Neurologic Abnormalities Description	Text	Describe any other neurologic abnormalities or findings, not previously identified in Sections 4-8, and how they relate to a thoracolumbar spine condition. Max length: 101 characters
10A. No	Checkbox	Check this box if the Veteran does not have any other neurologic abnormalities or findings (other than those identified in Sections 4-8) related to a thoracolumbar spine condition (such as bowel or bladder problems/pathologic reflexes).
10A. Yes	Checkbox	Check this box if the Veteran has any other neurologic abnormalities or findings (other than those identified in Sections 4-8) related to a thoracolumbar spine condition (such as bowel or bladder problems/pathologic reflexes).
Other Significant Diagnostic Test Findings
RG_15EYN_1.RG_15EYN._1	RadioButton
15E. Other Significant Diagnostic Test Findings	Text	Provide the type of test or procedure, date, and a brief summary of the results for any other significant diagnostic test findings. Max length: 101 characters
15E No	Checkbox	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.
15E Yes	Checkbox	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.
Pain Comments
Pain Comments	Text	Provide comments related to pain, functional loss, or any other relevant observations.
Passive Range of Motion Testing Status and Explanation
RG_Was_passive_ROM_testing_performed_1.RG_Was_passive_ROM_testing_performed._1	RadioButton
Passive ROM Testing Explanation	Text	Enter a detailed explanation regarding the passive range of motion testing status, or why it was not performed. Max length: 101 characters
Passive ROM Testing Performed - No	Checkbox	Check this box if passive range of motion testing was not performed.
Passive ROM Testing Performed - Yes	Checkbox	Check this box if passive range of motion testing was performed.
Passive ROM Testing Not Performed - Medically Contraindicated	Checkbox	Check this box if passive range of motion testing was not performed because it was medically contraindicated, due to severe pain or risk of further injury.
Passive ROM Testing Not Performed - Testing Not Necessary	Checkbox	Check this box if passive range of motion testing was not performed because it was not necessary.
Passive ROM Testing Not Performed - Other Reason	Checkbox	Check this box if passive range of motion testing was not performed for an unspecified reason.
Passive ROM - Extension
Extension - Same as active ROM	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 Extension Endpoint	Number	Please enter the passive range of motion extension endpoint in degrees. Max length: 7 characters
Passive ROM - Forward Flexion
Forward Flexion - Same as active ROM	Checkbox	Check this box if the passive range of motion endpoint for forward flexion is the same as the active range of motion endpoint.
Passive ROM Forward Flexion Endpoint	Number	Enter the passive range of motion forward flexion endpoint in degrees. Max length: 7 characters
Passive ROM - Right Lateral Flexion
Right Lateral Flexion - Same as Active ROM	Checkbox	Check this box if the passive range of motion for right lateral flexion is the same as the active range of motion for right lateral flexion.
Passive ROM Right Lateral Flexion Endpoint	Number	Enter the passive range of motion endpoint in degrees for right lateral flexion. Max length: 7 characters
Passive ROM Pain Checklist
Left lateral rotation	Checkbox	Check this box if passive left lateral rotation exhibited pain during examination.
Right lateral rotation	Checkbox	Check this box if passive right lateral rotation exhibited pain during examination.
Right lateral flexion	Checkbox	Check this box if passive right lateral flexion exhibited pain during examination.
Left lateral flexion	Checkbox	Check this box if passive left lateral flexion exhibited pain during examination.
Extension	Checkbox	Check this box if passive extension exhibited pain during examination.
Forward flexion	Checkbox	Check this box if passive forward flexion exhibited pain during examination.
Patient Clinic Status
RG_Regularly_seen_at_clinic_YN2_1.RG_Regularly_seen_at_clinic_YN2._1	RadioButton
Yes	Checkbox	Check this box if the Veteran is regularly seen as a patient in your clinic.
No	Checkbox	Check this box if the Veteran is not regularly seen as a patient in your clinic.
Patient/Veteran Information
Patient/Veteran Name	Text	Enter the full name of the patient or veteran. Max length: 32 characters
Patient/Veteran Social Security Number	Text	Enter the Social Security Number of the patient or veteran. Max length: 32 characters
Date of Examination	Date	Enter the date when the examination took place. Max length: 32 characters
Post-Repetition Endpoints
Post-Repetition Forward Flexion Endpoint	Number	Enter the measured forward flexion endpoint in degrees after three repetitions. Max length: 8 characters
Post-Repetition Extension Endpoint	Number	Enter the measured extension endpoint in degrees after three repetitions. Max length: 8 characters
Post-Repetition Left Lateral Flexion Endpoint	Number	Enter the measured left lateral flexion endpoint in degrees after three repetitions. Max length: 8 characters
Post-Repetition Right Lateral Rotation Endpoint	Number	Enter the measured right lateral rotation endpoint in degrees after three repetitions. Max length: 8 characters
Questionnaire Requester
Requester Third Party Names	Text	Enter the name(s) of the organization(s) or individual(s) that requested the questionnaire, if a third party.
Requester Other Description	Text	Provide a description of the other party or reason that requested the completion of this questionnaire.
Veteran/Claimant	Checkbox	Check this box if the questionnaire is being completed at the request of the Veteran or Claimant.
Third party	Checkbox	Check this box if the questionnaire is being completed at the request of a third party, such as an organization or individual.
Other	Checkbox	Check this box if the questionnaire is being completed at the request of an entity or individual not otherwise specified, and provide a description.
Range of Motion After Repeated Use
text_uODVEc_f560	Text	Max length: 10 characters
text_ejC7qt_f0bb	Text	Max length: 10 characters
text_xmaFHa_c5c8	Text	Max length: 10 characters
text_uII3wm_9afd	Text	Max length: 10 characters
text_evXLv3_c2ae	Text	Max length: 10 characters
text_rOve71_1559	Text	Max length: 10 characters
Range of Motion During Flare-ups
Flare-ups Left Lateral Flexion Endpoint	Number	Enter the estimated left lateral flexion endpoint in degrees during flare-ups. Max length: 10 characters
Flare-ups Right Lateral Rotation Endpoint	Number	Enter the estimated right lateral rotation endpoint in degrees during flare-ups. Max length: 10 characters
Flare-ups Left Lateral Rotation Endpoint	Number	Enter the estimated left lateral rotation endpoint in degrees during flare-ups. Max length: 10 characters
Flare-ups Forward Flexion Endpoint	Number	Enter the estimated forward flexion endpoint in degrees during flare-ups. Max length: 10 characters
Flare-ups Extension Endpoint	Number	Enter the estimated extension endpoint in degrees during flare-ups. Max length: 10 characters
Flare-ups Right Lateral Flexion Endpoint	Number	Enter the estimated right lateral flexion endpoint in degrees during flare-ups. Max length: 10 characters
Range of Motion Endpoints
Left Lateral Rotation Endpoint	Number	Enter the left lateral rotation endpoint value. Max length: 10 characters
Right Lateral Flexion Endpoint	Number	Enter the right lateral flexion endpoint value. Max length: 10 characters
Relationship of Abnormal Findings to Diagnosed Conditions
Relationship of Abnormal Findings	Text	Provide information about the relationship of any abnormal test findings to diagnosed conditions. Max length: 101 characters
Repeated Use Over Time Examination Status
RG_3C_VETERAN_1.RG_3C_VETERAN._1	RadioButton
Repeated Use Over Time Examination Status No	Checkbox	Check this box if the Veteran is not being examined immediately after repeated use over time.
Repeated Use Over Time Examination Status Yes	Checkbox	Check this box if the Veteran is being examined immediately after repeated use over time.
Repetitive Use Testing Explanation
Repetitive Use Testing No Explanation	Text	Provide an explanation if the veteran is unable to perform repetitive use testing with at least three repetitions.
Right Lateral Rotation Endpoint (30 degrees)
Right Lateral Rotation Endpoint	Number	Enter the measured value in degrees for the right lateral rotation endpoint. Max length: 8 characters
Right Lateral Rotation Endpoint Same as active ROM	Checkbox	Check this box if the right lateral rotation endpoint (30 degrees) is the same as the active Range of Motion (ROM).
ROM Exhibiting Pain
Forward flexion	Checkbox	Check this box if forward flexion exhibited pain during the examination.
Extension	Checkbox	Check this box if extension exhibited pain during the examination.
Right lateral flexion	Checkbox	Check this box if right lateral flexion exhibited pain during the examination.
Left lateral flexion	Checkbox	Check this box if left lateral flexion exhibited pain during the examination.
Right lateral rotation	Checkbox	Check this box if right lateral rotation exhibited pain during the examination.
Left lateral rotation	Checkbox	Check this box if left lateral rotation exhibited pain during the examination.
Sciatic Nerve Roots Involvement
Involvement of L4/L5/S1/S2/S3 Nerve Roots (Sciatic Nerve)	Checkbox	Select this option if there is an involvement of the L4, L5, S1, S2, or S3 nerve roots, which together form the sciatic nerve.
Sciatic Nerve Involvement - Right Side	Checkbox	Check this box if the involvement of the L4/L5/S1/S2/S3 nerve roots (sciatic nerve) affects the right side.
Sciatic Nerve Involvement - Left Side	Checkbox	Check this box if the involvement of the L4/L5/S1/S2/S3 nerve roots (sciatic nerve) affects the left side.
Sciatic Nerve Involvement - Both Sides	Checkbox	Check this box if the involvement of the L4/L5/S1/S2/S3 nerve roots (sciatic nerve) affects both the right and left sides.
Tenderness or Pain Description
Tenderness or Pain Description	Text	Provide details on the location, severity, and relationship of the tenderness or pain to the condition(s).
Testing Performance Status
RG_3A_Can_testing_be_performed_1.RG_3A_Can_testing_be_performed._1	RadioButton
Testing Performance Status Explanation	Text	Provide a detailed explanation if testing cannot be performed or is medically contraindicated, or note any characteristics of pain observed during examination. Max length: 101 characters
Yes	Checkbox	Check this box if testing can be performed.
No	Checkbox	Check this box if testing cannot be performed or is medically contraindicated.
Thoracolumbar Vertebral Fracture Evidence
RG_15DYN_1.RG_15DYN._1	RadioButton
RG_15D2YN_1.RG_15D2YN._1	RadioButton
Thoracolumbar Vertebral Fracture Loss of Height Yes	Checkbox	Check this box if there is a loss of 50 percent or more of height due to the thoracolumbar vertebral fracture.
Thoracolumbar Vertebral Fracture Loss of Height No	Checkbox	Check this box if there is not a loss of 50 percent or more of height due to the thoracolumbar vertebral fracture.
checkbox_XlyR7s_325f	CheckBox
Thoracolumbar Vertebral Fracture Evidence No	Checkbox	Check this box if the Veteran does not have imaging evidence of a thoracolumbar vertebral fracture.
VA Healthcare Provider Status
_on	RadioButton
VA Healthcare Provider - Yes	Checkbox	Check this box if you are a VA Healthcare provider.
VA Healthcare Provider - No	Checkbox	Check this box if you are not a VA Healthcare provider.

Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire Instructions