Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire Instructions

Describe any other neurologic abnormalities or findings related to the thoracolumbar spine condition and explain how the condition is related. Fill only if '10A Other neurologic abnormalities - Yes' is 'Yes'.

Check this box if the Veteran does not have any other neurologic abnormalities or findings (other than those in Sections 4–8) related to a thoracolumbar spine condition.

Check this box if the Veteran has any other neurologic abnormalities or findings (other than those in Sections 4–8) related to a thoracolumbar spine condition.

Check this box if the Veteran has intervertebral disc syndrome (IVDS) of the thoracolumbar spine.

Check this box if the Veteran does not have intervertebral disc syndrome (IVDS) of the thoracolumbar spine.

Check this box if, in the past 12 months, 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. Fill only if '11A. Does the Veteran have IVDS of the thoracolumbar spine?' is 'Yes'.

Check this box if, in the past 12 months, 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. Fill only if '11A. Does the Veteran have IVDS of the thoracolumbar spine?' is 'Yes'.

Check this box if the Veteran has had no physician-prescribed bed rest for IVDS in the past 12 months. Fill only if '11B Yes' is 'Yes'.

Check this box if the Veteran’s total physician-prescribed bed rest for IVDS over the past 12 months is at least 2 weeks but less than 4 weeks. Fill only if '11B Yes' is 'Yes'.

Check this box if the Veteran’s total physician-prescribed bed rest for IVDS over the past 12 months is at least 1 week but less than 2 weeks. Fill only if '11B Yes' is 'Yes'.

Check this box if the Veteran’s total physician-prescribed bed rest for IVDS over the past 12 months is at least 4 weeks but less than 6 weeks. Fill only if '11B Yes' is 'Yes'.

Check this box if the Veteran’s total physician-prescribed bed rest for IVDS over the past 12 months is at least 6 weeks. Fill only if '11B Yes' is 'Yes'.

Enter the medical history as described by the Veteran only, without supporting documentation. Fill only if '11B Yes' is 'Yes'.

Check this box if the support for the “Yes” response in question 11B is based only on the Veteran’s described medical history and no additional documentation is provided.

Enter the individual date(s) for each treatment record that was reviewed in the Veteran’s file. Fill only if '11B Yes' is 'Yes'.

Enter the name of the medical facility and/or provider associated with the treatment records reviewed. Fill only if '11B Yes' is 'Yes'.

Describe the treatment documented in the Veteran’s file that supports the response to question 11B. Fill only if '11B Yes' is 'Yes'.

Check this box if the Veteran’s medical history is supported by records shown and documented in the Veteran’s file.

Describe any other documentation provided to support the yes response to question 11B. Fill only if '11C Other, describe' is 'Yes'.

Check this box if the supporting documentation is something other than the listed medical history options, and then provide the details in the adjacent “Other, describe” field.

Check this box if the Veteran does not use any assistive devices as a normal mode of locomotion.

Check this box if the Veteran uses any assistive devices as a normal mode of locomotion.

Enter the condition(s) requiring assistive devices, the affected side (if applicable), and the specific assistive device used for each condition. Fill only if 'Cane(s)', 'Walker', 'Other (specify) assistive device' is 'Yes' (any).

Check this box if the right lower extremity is affected by functional loss such that amputation with prosthesis would equally serve the Veteran. Fill only if '13A Functional impairment - Yes' is 'Yes'.

Check this box if the left lower extremity is affected by functional loss such that amputation with prosthesis would equally serve the Veteran. Fill only if '13A Functional impairment - Yes' is 'Yes'.

Check this box if the right upper extremity is affected by functional loss such that amputation with prosthesis would equally serve the Veteran. Fill only if '13A Functional impairment - Yes' is 'Yes'.

Check this box if the left upper extremity is affected by functional loss such that amputation with prosthesis would equally serve the Veteran. Fill only if '13A Functional impairment - Yes' is 'Yes'.

Check this box if the Veteran’s functioning is so diminished that amputation with prosthesis would equally serve the Veteran.

Check this box if the Veteran does not have functional impairment of an extremity to the extent that amputation with prosthesis would equally serve the Veteran.

For each affected extremity, enter the condition causing the loss of effective function and a brief description with specific examples of the functional loss. Fill only if '13A Right lower extremity', '13A Left lower extremity', '13A Right upper extremity', '13A Left upper extremity', '13A Functional impairment - Yes' is 'Yes' (all) and is 'Yes' (any).

Describe any other pertinent physical findings, complications, conditions, signs, or symptoms related to the conditions listed in the diagnosis section. Fill only if '14A Other Pertinent Physical Findings - Yes' is 'Yes'.

Check this box if the Veteran has any other pertinent physical findings, complications, conditions, signs, or symptoms related to the diagnosed conditions listed above.

Check this box if the Veteran does not have any other pertinent physical findings, complications, conditions, signs, or symptoms related to the diagnosed conditions listed above.

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.

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.

Enter any additional comments related to item 14C, if applicable.

Check this box if imaging studies were performed in conjunction with this examination.

Check this box if no imaging studies were performed in conjunction with this examination.

Check this box if degenerative or post-traumatic arthritis is documented (based on the imaging studies). Fill only if '15A Imaging studies performed - Yes' is 'Yes'.

Check this box if degenerative or post-traumatic arthritis is not documented (based on the imaging studies). Fill only if '15A Imaging studies performed - Yes' is 'Yes'.

Enter the type of imaging test or procedure performed, the date it was performed, and a brief summary of the results. Fill only if '15A Imaging studies performed - Yes' is 'Yes'.

Check this box if, given a thoracolumbar vertebral fracture, there is loss of 50 percent or more of vertebral height. Fill only if '15D Imaging evidence of thoracolumbar vertebral fracture - Yes' is 'Yes'.

Check this box if, given a thoracolumbar vertebral fracture, there is not loss of 50 percent or more of vertebral height. Fill only if '15D Imaging evidence of thoracolumbar vertebral fracture - Yes' is 'Yes'.

Check this box if imaging shows the Veteran has a thoracolumbar vertebral fracture.

Check this box if imaging does not show a thoracolumbar vertebral fracture.

Provide a brief summary of any other significant diagnostic test findings or results reviewed for the claimed condition(s), including the test/procedure type, date, and results. Fill only if '15E Other Significant Diagnostic Findings - Yes' is 'Yes'.

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 with this examination.

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 with this examination.

Describe how any abnormal diagnostic test results relate to the Veteran's diagnosed conditions.

Describe how the diagnosed condition(s) affect the Veteran’s ability to perform occupational tasks, providing one or more examples. Fill only if '16A Yes' is 'Yes'.

Check this box if the diagnosed condition(s) do not impact the Veteran’s ability to perform any type of occupational task.

Check this box if the diagnosed condition(s) impact the Veteran’s ability to perform any type of occupational task.

Enter any additional remarks or comments, identifying the section of the form the remark pertains to when appropriate.

Enter the examiner’s signature to certify the accuracy and completeness of the information provided.

Enter the examiner’s printed full name and professional title/credentials (e.g., MD, DO, NP, PA-C).

Enter the examiner’s complete mailing address.

Enter the examiner’s phone number and/or fax number.

Enter the examiner’s National Provider Identifier (NPI) number.

Enter the examiner’s medical license number and the state that issued the license.

Enter the examiner’s medical area of practice or specialty (e.g., Cardiology, Orthopedics, Psychology/Psychiatry).

Enter the date the examiner signed this certification.

Enter the Veteran's description of thoracolumbar spine flare-ups, including frequency, duration, characteristics, precipitating and alleviating factors, severity, and any functional impairment during flare-ups. Fill only if '2B Thoracolumbar Spine Flare-Ups - Yes' is 'Yes'.

Check this box if the Veteran does not report experiencing flare-ups of the thoracolumbar spine.

Check this box if the Veteran reports experiencing flare-ups of the thoracolumbar spine.

Enter the Veteran's description, in their own words, of any functional loss or functional impairment of the joint or extremity being evaluated (including after repeated use over time). Fill only if '2C Functional loss/impairment reported - Yes' is 'Yes'.

Check this box if the Veteran reports any functional loss or functional impairment of the joint or extremity being evaluated (including after repeated use over time).

Check this box if the Veteran does not report any functional loss or functional impairment of the joint or extremity being evaluated.

Check this box if the Veteran’s initial range of motion (ROM) measurements are all within normal limits.

Check this box if initial ROM measurements are not indicated for this evaluation (and provide an explanation in the space provided).

Check this box if any initial ROM measurement is abnormal or outside the normal range.

Check this box if initial ROM measurements could not be performed (and provide an explanation in the space provided).

Provide the explanation for why the Veteran's initial range of motion (ROM) measurements were unable to be tested or were not indicated. Fill only if '3A Initial ROM measurements - Not indicated', '3A Initial ROM measurements - Unable to test' is 'Yes' (any).

Provide an explanation of how the abnormal range of motion itself contributes to the Veteran’s functional loss. Fill only if '3A Initial ROM measurements - Abnormal or outside of normal range', '3A ROM Contributes to Functional Loss - Yes' is 'Yes' (all).

Check this box if the range of motion (ROM) abnormality itself contributes to a functional loss.

Check this box if the ROM abnormality does not itself contribute to a functional loss.

Describe why the Veteran’s range of motion is outside the normal range but is considered normal for the Veteran (e.g., due to age, body habitus, or neurologic disease rather than a back condition). Fill only if '3A Initial ROM measurements - Abnormal or outside of normal range' is 'Yes'.

Provide a detailed narrative citing and discussing the specific evidence used to support the repeated-use-over-time findings for this case. Fill only if '3C Examined immediately after repeated use over time - No' is 'Yes'.

Enter the estimated forward flexion range-of-motion endpoint immediately after repeated use over time. Fill only if '3C Examined immediately after repeated use over time - No' is 'Yes'.

Enter the estimated extension range-of-motion endpoint immediately after repeated use over time. Fill only if '3C Examined immediately after repeated use over time - No' is 'Yes'.

Enter the estimated right lateral flexion range-of-motion endpoint immediately after repeated use over time. Fill only if '3C Examined immediately after repeated use over time - No' is 'Yes'.

Enter the estimated left lateral flexion range-of-motion endpoint immediately after repeated use over time. Fill only if '3C Examined immediately after repeated use over time - No' is 'Yes'.

Enter the estimated right lateral rotation range-of-motion endpoint immediately after repeated use over time. Fill only if '3C Examined immediately after repeated use over time - No' is 'Yes'.

Enter the estimated left lateral rotation range-of-motion endpoint immediately after repeated use over time. Fill only if '3C Examined immediately after repeated use over time - No' is 'Yes'.

Check this box if procured evidence (including the Veteran’s statements) suggests pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability with repeated use over time.

Check this box if procured evidence (including the Veteran’s statements) does not suggest pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability with repeated use over time.

Check this box if the Veteran is not being examined immediately after repeated use over time.

Check this box if the Veteran is being examined immediately after repeated use over time.

Enter any other factor(s) causing functional loss with repeated use over time that are not listed (e.g., pain, fatigability, weakness, lack of endurance, or incoordination). Fill only if '3C Evidence Suggests Functional Limitation With Repeated Use Over Time - Yes', '3C Functional loss factor - Other' is 'Yes' and field 39 is 'Yes' (all fields).

Check this box if fatigability significantly limits functional ability with repeated use over time. Fill only if '3C Evidence Suggests Functional Limitation With Repeated Use Over Time - Yes' is 'Yes'.

Check this box if pain significantly limits functional ability with repeated use over time. Fill only if '3C Evidence Suggests Functional Limitation With Repeated Use Over Time - Yes' is 'Yes'.

Check this box if no factor applies (i.e., there is no additional functional loss with repeated use over time). Fill only if '3C Evidence Suggests Functional Limitation With Repeated Use Over Time - Yes' is 'Yes'.

Check this box if incoordination significantly limits functional ability with repeated use over time. Fill only if '3C Evidence Suggests Functional Limitation With Repeated Use Over Time - Yes' is 'Yes'.

Check this box if another factor (not listed) significantly limits functional ability with repeated use over time, and specify the factor in the space provided. Fill only if '3C Evidence Suggests Functional Limitation With Repeated Use Over Time - Yes' is 'Yes'.

Check this box if weakness significantly limits functional ability with repeated use over time. Fill only if '3C Evidence Suggests Functional Limitation With Repeated Use Over Time - Yes' is 'Yes'.

Check this box if lack of endurance significantly limits functional ability with repeated use over time. Fill only if '3C Evidence Suggests Functional Limitation With Repeated Use Over Time - Yes' is 'Yes'.

Provide a case-specific narrative citing and discussing all procurable evidence supporting the estimated functional loss and range-of-motion limitations during flare-ups. Fill only if '3D Flare-ups - Examined during a flare-up: No' is 'Yes'.

Enter the estimated endpoint of left lateral flexion during flare-ups, measured in degrees. Fill only if '3D Flare-ups - Examined during a flare-up: No' is 'Yes'.

Enter the estimated endpoint of right lateral rotation during flare-ups, measured in degrees. Fill only if '3D Flare-ups - Examined during a flare-up: No' is 'Yes'.

Enter the estimated endpoint of left lateral rotation during flare-ups, measured in degrees. Fill only if '3D Flare-ups - Examined during a flare-up: No' is 'Yes'.

Enter the estimated endpoint of forward flexion during flare-ups, measured in degrees. Fill only if '3D Flare-ups - Examined during a flare-up: No' is 'Yes'.

Enter the estimated endpoint of extension during flare-ups, measured in degrees. Fill only if '3D Flare-ups - Examined during a flare-up: No' is 'Yes'.

Enter the estimated endpoint of right lateral flexion during flare-ups, measured in degrees. Fill only if '3D Flare-ups - Examined during a flare-up: No' is 'Yes'.

Check this box if procured evidence (e.g., the Veteran’s statements) suggests pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability during flare-ups.

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.

Check this box if the Veteran is being examined during a flare-up.

Check this box if the Veteran is not being examined during a flare-up.

Enter any other factor(s) not listed that cause functional loss during flare-ups. Fill only if '3D Flare-ups - Other', '3D Flare-ups: Evidence suggests functional limitation (Yes)' is 'Yes' and field 46 is 'Yes' (all fields).

Check this box if lack of endurance causes functional loss during flare-ups. Fill only if '3D Flare-ups: Evidence suggests functional limitation (Yes)' is 'Yes'.

Check this box if weakness causes functional loss during flare-ups. Fill only if '3D Flare-ups: Evidence suggests functional limitation (Yes)' is 'Yes'.

Check this box if fatigability causes functional loss during flare-ups. Fill only if '3D Flare-ups: Evidence suggests functional limitation (Yes)' is 'Yes'.

Check this box if pain causes functional loss during flare-ups. Fill only if '3D Flare-ups: Evidence suggests functional limitation (Yes)' is 'Yes'.

Check this box if another factor not listed causes functional loss during flare-ups. Fill only if '3D Flare-ups: Evidence suggests functional limitation (Yes)' is 'Yes'.

Check this box if incoordination causes functional loss during flare-ups. Fill only if '3D Flare-ups: Evidence suggests functional limitation (Yes)' is 'Yes'.

Check this box if no listed factors cause functional loss during flare-ups. Fill only if '3D Flare-ups: Evidence suggests functional limitation (Yes)' is 'Yes'.

Check this box if the Veteran has no constant pain in the left lower extremity. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran’s constant pain in the left lower extremity is mild. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran’s constant pain in the left lower extremity is moderate. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran’s constant pain in the left lower extremity is severe. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran has no constant pain in the right lower extremity. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran’s constant pain in the right lower extremity is mild. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran’s constant pain in the right lower extremity is moderate. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran’s constant pain in the right lower extremity is severe. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran has no intermittent (usually dull) pain in the left lower extremity. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran’s intermittent (usually dull) pain in the left lower extremity is mild. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran’s intermittent (usually dull) pain in the left lower extremity is moderate. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran’s intermittent (usually dull) pain in the left lower extremity is severe. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran has no intermittent (usually dull) pain in the right lower extremity. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran’s intermittent (usually dull) pain in the right lower extremity is mild. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran’s intermittent (usually dull) pain in the right lower extremity is moderate. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran’s intermittent (usually dull) pain in the right lower extremity is severe. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran has no numbness in the left lower extremity. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran’s numbness in the left lower extremity is mild. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran’s numbness in the left lower extremity is severe. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran’s numbness in the left lower extremity is moderate. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran has no numbness in the right lower extremity. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran has mild numbness in the right lower extremity. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran has severe numbness in the right lower extremity. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran has moderate numbness in the right lower extremity. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran has no paresthesias and/or dysesthesias in the left lower extremity. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if paresthesias and/or dysesthesias in the left lower extremity are mild in severity. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if paresthesias and/or dysesthesias in the left lower extremity are severe in severity. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if paresthesias and/or dysesthesias in the left lower extremity are moderate in severity. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran has no paresthesias and/or dysesthesias in the right lower extremity. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran’s paresthesias and/or dysesthesias in the right lower extremity are mild. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran’s paresthesias and/or dysesthesias in the right lower extremity are severe. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran’s paresthesias and/or dysesthesias in the right lower extremity are moderate. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Describe any other signs or symptoms of radiculopathy the Veteran has, if applicable. Fill only if '8B Other signs/symptoms of radiculopathy - Yes' is 'Yes'.

Check this box if the Veteran does not have any other signs or symptoms of radiculopathy. Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the Veteran has any other signs or symptoms of radiculopathy (other than those already listed). Fill only if 'Radiculopathy present - Yes' is 'Yes'.

Check this box if the L2, L3, and/or L4 nerve roots (femoral nerve) are involved. Fill only if 'Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy?' is 'Yes'.

Check this box if the femoral nerve root involvement affects the right side. Fill only if '8C Involvement of L2/L3/L4 nerve roots (femoral nerve)' is 'Yes'.

Check this box if the femoral nerve root involvement affects the left side. Fill only if '8C Involvement of L2/L3/L4 nerve roots (femoral nerve)' is 'Yes'.

Check this box if the femoral nerve root involvement affects both sides. Fill only if '8C Involvement of L2/L3/L4 nerve roots (femoral nerve)' is 'Yes'.

Check this box if neurological involvement is due to nerves other than the listed nerve roots, and you will specify the nerve(s) and side(s) affected. Fill only if 'Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy?' is 'Yes'.

Check this box if the other nerve(s) involvement affects the right side. Fill only if '8C Other nerves involved' is 'Yes'.

Check this box if the other nerve(s) involvement affects the left side. Fill only if '8C Other nerves involved' is 'Yes'.

Check this box if the other nerve(s) involvement affects both sides. Fill only if '8C Other nerves involved' is 'Yes'.

Check this box if the neurological findings indicate involvement of the L4/L5/S1/S2/S3 nerve roots (sciatic nerve). Fill only if 'Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy?' is 'Yes'.

Check this box if L4/L5/S1/S2/S3 (sciatic nerve) nerve root involvement affects the right side. Fill only if '8C Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve)' is 'Yes'.

Check this box if L4/L5/S1/S2/S3 (sciatic nerve) nerve root involvement affects the left side. Fill only if '8C Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve)' is 'Yes'.

Check this box if L4/L5/S1/S2/S3 (sciatic nerve) nerve root involvement affects both sides. Fill only if '8C Involvement of L4/L5/S1/S2/S3 nerve roots (sciatic nerve)' is 'Yes'.

Explain the likely cause of any abnormal or positive neurological findings identified in Sections 4–8. Fill only if 'Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy?' is 'Yes'.

Check this box if there is ankylosis (fixation) of the spine.

Check this box if ankylosis is present and it is unfavorable ankylosis involving the entire spine. Fill only if '9A Ankylosis of the spine - Yes' is 'Yes'.

Check this box if there is no ankylosis (fixation) of the spine.

Check this box if ankylosis is present and it is unfavorable ankylosis involving the entire thoracolumbar spine. Fill only if '9A Ankylosis of the spine - Yes' is 'Yes'.

Check this box if ankylosis is present and it is favorable ankylosis involving the entire thoracolumbar spine. Fill only if '9A Ankylosis of the spine - Yes' is 'Yes'.

Enter any additional comments or clarifications regarding the presence, type, severity, or functional impact of ankylosis described in Section IX.

Enter the measured active range of motion endpoint for forward flexion in degrees.

Enter the measured active range of motion endpoint for extension in degrees.

Enter the measured active range of motion endpoint for right lateral flexion in degrees.

Enter the measured active range of motion endpoint for left lateral flexion in degrees.

Enter the measured active range of motion endpoint for right lateral rotation in degrees.

Enter the measured active range of motion endpoint for left lateral rotation in degrees.

Enter the degree endpoint for left lateral flexion that is specifically attributable to pain, weakness, fatigability, incoordination, or other factors (if different than the ROM values reported above).

Enter the degree endpoint for right lateral rotation that is specifically attributable to pain, weakness, fatigability, incoordination, or other factors (if different than the ROM values reported above).

Enter the degree endpoint for left lateral rotation that is specifically attributable to pain, weakness, fatigability, incoordination, or other factors (if different than the ROM values reported above).

Enter the degree endpoint for forward flexion that is specifically attributable to pain, weakness, fatigability, incoordination, or other factors (if different than the ROM values reported above).

Enter the degree endpoint for extension that is specifically attributable to pain, weakness, fatigability, incoordination, or other factors (if different than the ROM values reported above).

Enter the degree endpoint for right lateral flexion that is specifically attributable to pain, weakness, fatigability, incoordination, or other factors (if different than the ROM values reported above).

Describe any limitation of active range of motion that is specifically attributable to pain, weakness, fatigability, incoordination, or other factors, including the degree(s) at which the limitation occurs.

Check this box if active range of motion testing showed pain during forward flexion.

Check this box if active range of motion testing showed pain during extension.

Check this box if active range of motion testing showed pain during right lateral flexion.

Check this box if active range of motion testing showed pain during left lateral flexion.

Check this box if active range of motion testing showed pain during right lateral rotation.

Check this box if active range of motion testing showed pain during left lateral rotation.

Check this box if there is an additional contributing factor to the disability not listed above, and provide details in the description area.

Enter a description of any other additional contributing factor(s) to the disability that are not covered by the listed options. Fill only if 'Other (describe)' is 'Yes'.

Check this box if there are no additional contributing factors to the disability beyond those already addressed above.

Check this box if the disability causes a disturbance of locomotion (difficulty walking or moving about).

Check this box if the disability causes instability of station (unsteadiness while standing).

Check this box if the disability results in less movement than normal.

Check this box if the disability interferes with the Veteran’s ability to sit.

Check this box if the disability interferes with the Veteran’s ability to stand.

Check this box if the disability results in more movement than normal (e.g., excessive motion or instability).

Check this box if the disability results in weakened movement.

Check this box if swelling is an additional contributing factor of the disability.

Check this box if deformity is an additional contributing factor of the disability.

Check this box if there is atrophy due to disuse related to the disability.

Provide a narrative description of any additional factors contributing to the disability (including details for any items selected above).

Enter the forward flexion endpoint, in degrees, measured after completion of three repetitive-use repetitions. Fill only if 'Additional loss after three repetitions - Yes' is 'Yes'.

Enter the extension endpoint, in degrees, measured after completion of three repetitive-use repetitions. Fill only if 'Additional loss after three repetitions - Yes' is 'Yes'.

Enter the left lateral flexion endpoint, in degrees, measured after completion of three repetitive-use repetitions. Fill only if 'Additional loss after three repetitions - Yes' is 'Yes'.

Enter the right lateral rotation endpoint, in degrees, measured after completion of three repetitive-use repetitions. Fill only if 'Additional loss after three repetitions - Yes' is 'Yes'.

Check this box if there is additional loss of function or range of motion after three repetitions.

Check this box if there is no additional loss of function or range of motion after three repetitions.

Enter a narrative listing any additional thoracolumbar spine diagnoses not already captured above, using the same format (diagnosis, ICD code, and date of diagnosis if known).

Check this box if the Veteran has a current diagnosis of ankylosing spondylitis associated with the claimed condition(s).

Enter the ICD diagnosis code for ankylosing spondylitis. Fill only if 'Ankylosing spondylitis' is 'Yes'.

Enter the date when ankylosing spondylitis was diagnosed. Fill only if 'Ankylosing spondylitis' is 'Yes'.

Check this box if the Veteran uses a cane or canes as an assistive device. Fill only if '12A. Does the Veteran use any assistive devices as a normal mode of locomotion' is 'Yes'.

Check this box if the Veteran uses a cane/canes occasionally. Fill only if 'Cane(s)' is 'Yes'.

Check this box if the Veteran uses a cane/canes regularly. Fill only if 'Cane(s)' is 'Yes'.

Check this box if the Veteran uses a cane/canes constantly. Fill only if 'Cane(s)' is 'Yes'.

Check this box if the Veteran uses an assistive device other than the listed options and you will specify what it is. Fill only if '12A. Does the Veteran use any assistive devices as a normal mode of locomotion' is 'Yes'.

Check this box if the Veteran uses the specified other assistive device occasionally. Fill only if 'Other (specify) assistive device' is 'Yes'.

Check this box if the Veteran uses the specified other assistive device on a regular basis. Fill only if 'Other (specify) assistive device' is 'Yes'.

Check this box if the Veteran uses the specified other assistive device constantly. Fill only if 'Other (specify) assistive device' is 'Yes'.

Enter the other assistive device used if it is not a cane or walker. Fill only if 'Other (specify) assistive device' is 'Yes'.

Check this box if the Veteran uses a walker as an assistive device. Fill only if '12A. Does the Veteran use any assistive devices as a normal mode of locomotion' is 'Yes'.

Select this option if the Veteran uses a walker occasionally. Fill only if 'Walker' is 'Yes'.

Select this option if the Veteran uses a walker regularly. Fill only if 'Walker' is 'Yes'.

Select this option if the Veteran uses a walker constantly. Fill only if 'Walker' is 'Yes'.

Check this box if the Veteran uses a wheelchair as an assistive device for normal locomotion. Fill only if '12A Assistive devices used - Yes' is 'Yes'.

Check this box if the Veteran uses a wheelchair occasionally. Fill only if 'First Row - Wheelchair' is 'Yes'.

Check this box if the Veteran uses a wheelchair regularly. Fill only if 'First Row - Wheelchair' is 'Yes'.

Check this box if the Veteran uses a wheelchair constantly. Fill only if 'First Row - Wheelchair' is 'Yes'.

Check this box if the Veteran uses brace(s) as an assistive device for locomotion. Fill only if '12A Assistive devices used - Yes' is 'Yes'.

Check this box if the Veteran uses brace(s) occasionally. Fill only if 'Second Row - Brace(s)' is 'Yes'.

Check this box if the Veteran uses brace(s) regularly. Fill only if 'Second Row - Brace(s)' is 'Yes'.

Check this box if the Veteran uses brace(s) constantly. Fill only if 'Second Row - Brace(s)' is 'Yes'.

Check this box if the Veteran uses crutches as an assistive device for locomotion. Fill only if '12A Assistive devices used - Yes' is 'Yes'.

Check this box if the Veteran uses crutches occasionally. Fill only if 'Third Row - Crutch(es)' is 'Yes'.

Check this box if the Veteran uses crutches on a regular basis. Fill only if 'Third Row - Crutch(es)' is 'Yes'.

Check this box if the Veteran uses crutches constantly. Fill only if 'Third Row - Crutch(es)' is 'Yes'.

Check this box if testing can be performed.

Check this box if testing cannot be performed or is medically contraindicated.

Enter the claimed medical condition(s) that pertain to this thoracolumbar spine questionnaire.

Check this box if the Veteran has a diagnosis of degenerative arthritis associated with the claimed condition(s).

Enter the ICD diagnostic code corresponding to the diagnosis of degenerative arthritis. Fill only if 'Degenerative arthritis' is 'Yes'.

Enter the date when degenerative arthritis was diagnosed. Fill only if 'Degenerative arthritis' is 'Yes'.

Check this box when the veteran has a diagnosis of degenerative disc disease that is not intervertebral disc syndrome (IVDS), and you will provide the ICD code and date of diagnosis for this condition.

Enter the ICD diagnosis code for degenerative disc disease other than intervertebral disc syndrome (IVDS). Fill only if 'Degenerative disc disease other than intervertebral disc syndrome (IVDS)' is 'Yes'.

Enter the date this degenerative disc disease (other than IVDS) diagnosis was made. Fill only if 'Degenerative disc disease other than intervertebral disc syndrome (IVDS)' is 'Yes'.

Check this box if the pain is present at rest or with no movement. Fill only if 'Evidence of pain - Yes' is 'Yes'.

Check this box if the pain is present during passive motion (examiner moves the joint). Fill only if 'Evidence of pain - Yes' is 'Yes'.

Check this box if the pain does not result in or cause functional loss. Fill only if 'Evidence of pain - Yes' is 'Yes'.

Check this box if the pain is present during active motion (patient moves the joint). Fill only if 'Evidence of pain - Yes' is 'Yes'.

Check this box if the pain is present during nonweight-bearing activities. Fill only if 'Evidence of pain - Yes' is 'Yes'.

Check this box if the pain is present during weight-bearing activities. Fill only if 'Evidence of pain - Yes' is 'Yes'.

Check this box if the pain results in or causes functional loss (and describe it in the comments box). Fill only if 'Evidence of pain - Yes' is 'Yes'.

Check this box if there is evidence of pain.

Check this box if there is no evidence of pain.

Enter any comments describing the evidence of pain, including when it occurs and whether it results in functional loss. Fill only if 'Pain causes functional loss' is 'Yes'.

Check this box if you did not review any records/evidence when completing this questionnaire.

Check this box if you reviewed any records/evidence (e.g., service treatment records, VA treatment records, or private treatment records) when completing this questionnaire.

Describe the records or other evidence reviewed (e.g., service treatment records, VA treatment records, private treatment records) and specify the date range covered. Fill only if 'Records reviewed' is 'Yes'.

Check this box if you are not a VA Healthcare provider.

Enter a narrative description of the thoracolumbar spine guarding observed and/or the suspected cause (etiology). Fill only if 'Guarding: Unable to evaluate, describe below' is 'Yes'.

Check this box if there is no guarding of the thoracolumbar spine. Fill only if 'Thoracolumbar spine localized tenderness/guarding/muscle spasm - Yes' is 'Yes'.

Check this box if guarding is present and it results in an abnormal gait or abnormal spine contour. Fill only if 'Thoracolumbar spine localized tenderness/guarding/muscle spasm - Yes' is 'Yes'.

Check this box if guarding is present but it does not result in an abnormal gait or abnormal spinal contour. Fill only if 'Thoracolumbar spine localized tenderness/guarding/muscle spasm - Yes' is 'Yes'.

Check this box if guarding cannot be evaluated and you will describe the reason/details in the space below. Fill only if 'Thoracolumbar spine localized tenderness/guarding/muscle spasm - Yes' is 'Yes'.

Check this box if the Veteran has a current diagnosis of intervertebral disc syndrome (IVDS) associated with the claimed condition(s), and then provide the ICD code and date of diagnosis on the corresponding lines.

Enter the ICD diagnosis code corresponding to Intervertebral Disc Syndrome (IVDS). Fill only if 'Intervertebral disc syndrome (IVDS)' is 'Yes'.

Enter the date when Intervertebral Disc Syndrome (IVDS) was diagnosed. Fill only if 'Intervertebral disc syndrome (IVDS)' is 'Yes'.

Check this box if sensation in the left sensory exam Area 1 is normal.

Check this box if sensation in the left sensory exam Area 1 is decreased.

Check this box if sensation in the left sensory exam Area 1 is absent.

Check this box if left-sided sensation in Area 2 is normal.

Check this box if left-sided sensation in Area 2 is decreased (reduced compared to normal).

Check this box if left-sided sensation in Area 2 is absent (no sensation detected).

Check this box if sensation is normal in Left Sensory Exam Area 3.

Check this box if sensation is decreased (diminished) in Left Sensory Exam Area 3.

Check this box if sensation is absent in Left Sensory Exam Area 3.

Check this box if sensation in the left sensory exam Area 4 is normal.

Check this box if sensation in the left sensory exam Area 4 is decreased (diminished).

Check this box if sensation in the left sensory exam Area 4 is absent.

Enter a narrative description of the Veteran’s localized tenderness findings, including any suspected cause or etiology. Fill only if 'Thoracolumbar spine localized tenderness/guarding/muscle spasm - Yes', 'Localized tenderness: None' is 'Yes' and all fields selection.

Check this box if there is no localized tenderness of the thoracolumbar spine. Fill only if 'Thoracolumbar spine localized tenderness/guarding/muscle spasm - Yes' is 'Yes'.

Check this box if localized tenderness is present but it does not result in abnormal gait or abnormal spinal contour. Fill only if 'Thoracolumbar spine localized tenderness/guarding/muscle spasm - Yes' is 'Yes'.

Check this box if the Veteran has a current diagnosis of lumbosacral strain associated with the claimed condition(s).

Enter the ICD diagnosis code corresponding to the lumbosacral strain diagnosis. Fill only if 'Lumbosacral strain' is 'Yes'.

Enter the date on which lumbosacral strain was diagnosed. Fill only if 'Lumbosacral strain' is 'Yes'.

Enter a brief summary describing the history of the Veteran’s thoracolumbar spine condition, including onset and course over time.

Provide the rationale explaining why the Veteran’s muscle atrophy is not due to the claimed condition listed in the diagnosis section. Fill only if '4C. No' is 'Yes'.

Check this box if the Veteran’s muscle atrophy is not due to the claimed condition listed in the diagnosis section. Fill only if '4B Muscle atrophy present - Yes' is 'Yes'.

Check this box if the Veteran’s muscle atrophy is due to the claimed condition listed in the diagnosis section. Fill only if '4B Muscle atrophy present - Yes' is 'Yes'.

Describe the specific anatomical location of the muscle atrophy. Fill only if '4B Muscle atrophy present - Yes' is 'Yes'.

Enter the circumference measurement of the normal (unaffected) side taken at maximum muscle bulk. Fill only if '4B Muscle atrophy present - Yes' is 'Yes'.

Enter the circumference measurement of the atrophied (affected) side taken at maximum muscle bulk. Fill only if '4B Muscle atrophy present - Yes' is 'Yes'.

Check this box if the Veteran has muscle atrophy.

Check this box if the Veteran does not have muscle atrophy.

Enter a narrative description of the Veteran's thoracolumbar muscle spasm findings, including any relevant details and suspected cause (etiology). Fill only if 'Muscle spasm: Unable to evaluate' is 'Yes'.

Check this box if the Veteran has no muscle spasm of the thoracolumbar spine. Fill only if 'Thoracolumbar spine localized tenderness/guarding/muscle spasm - Yes' is 'Yes'.

Check this box if muscle spasm is present and it results in an abnormal gait or abnormal spine contour. Fill only if 'Thoracolumbar spine localized tenderness/guarding/muscle spasm - Yes' is 'Yes'.

Check this box if muscle spasm is present but it does not result in an abnormal gait or abnormal spinal contour. Fill only if 'Thoracolumbar spine localized tenderness/guarding/muscle spasm - Yes' is 'Yes'.

Check this box if you are unable to evaluate muscle spasm and will describe the reason/details in the space below. Fill only if 'Thoracolumbar spine localized tenderness/guarding/muscle spasm - Yes' is 'Yes'.

Enter the muscle strength rating (0/5 to 5/5) for right hip flexion.

Enter the muscle strength rating (0/5 to 5/5) for right ankle dorsiflexion.

Enter the muscle strength rating (0/5 to 5/5) for left hip flexion.

Enter the muscle strength rating (0/5 to 5/5) for left ankle dorsiflexion.

Enter the muscle strength grade (0/5 to 5/5) for right knee extension.

Enter the muscle strength grade (0/5 to 5/5) for right great toe extension.

Enter the muscle strength grade (0/5 to 5/5) for left knee extension.

Enter the muscle strength grade (0/5 to 5/5) for left great toe extension.

Enter the muscle strength rating for the right ankle plantar flexion movement on the 0–5 scale shown in the form.

Enter the muscle strength rating for the left ankle plantar flexion movement on the 0–5 scale shown in the form.

Check this box if the Veteran does not have a current diagnosis associated with any of the claimed conditions listed above.

Check this box if there is objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue.

Check this box if there is objective evidence of crepitus on examination.

Check this box if there is no objective evidence of crepitus on examination.

Check this box if there is no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue.

Describe the location, severity, and relationship to the condition(s) for any objective evidence of crepitus and/or localized tenderness or pain on palpation. Fill only if 'Objective evidence of localized tenderness/pain on palpation: Yes' is 'Yes'.

Check this box if the Veteran has another diagnosis associated with the claimed condition(s) that is not listed above, and then specify it in the “Other diagnosis” lines.

Enter the date when Other Diagnosis #1 was diagnosed. Fill only if 'Other (specify)' is 'Yes'.

Enter the ICD diagnosis code for Other Diagnosis #1. Fill only if 'Other (specify)' is 'Yes'.

Enter the description or name of the first additional diagnosis not listed elsewhere on the form. Fill only if 'Other (specify)' is 'Yes'.

Enter the date when Other Diagnosis #2 was diagnosed. Fill only if 'Other (specify)' is 'Yes'.

Enter the ICD diagnostic code for Other Diagnosis #2. Fill only if 'Other (specify)' is 'Yes'.

Enter the name or description of the second additional diagnosis not listed above. Fill only if 'Other (specify)' is 'Yes'.

Enter the date when Other Diagnosis #3 was diagnosed. Fill only if 'Other (specify)' is 'Yes'.

Enter the ICD diagnostic code associated with Other Diagnosis #3. Fill only if 'Other (specify)' is 'Yes'.

Enter the name/description of the third additional diagnosis (the condition specified for “Other diagnosis #3”). Fill only if 'Other (specify)' is 'Yes'.

Enter any additional sensory findings not captured elsewhere in the form.

Enter the degree at which forward flexion is limited due to pain, weakness, fatigability, incoordination, or other factors (if different than previously recorded). Fill only if 'Was passive range of motion testing performed?' is 'Yes'.

Enter the degree at which extension is limited due to pain, weakness, fatigability, incoordination, or other factors (if different than previously recorded). Fill only if 'Was passive range of motion testing performed?' is 'Yes'.

Enter the degree at which right lateral flexion is limited due to pain, weakness, fatigability, incoordination, or other factors (if different than previously recorded). Fill only if 'Was passive range of motion testing performed?' is 'Yes'.

Enter the degree at which left lateral flexion is limited due to pain, weakness, fatigability, incoordination, or other factors (if different than previously recorded). Fill only if 'Was passive range of motion testing performed?' is 'Yes'.

Enter the degree at which right lateral rotation is limited due to pain, weakness, fatigability, incoordination, or other factors (if different than previously recorded). Fill only if 'Was passive range of motion testing performed?' is 'Yes'.

Enter the degree at which left lateral rotation is limited due to pain, weakness, fatigability, incoordination, or other factors (if different than previously recorded). Fill only if 'Was passive range of motion testing performed?' is 'Yes'.

Describe any limitation of motion attributable to pain, weakness, fatigability, incoordination, or other factors, including the circumstances and findings. Fill only if 'Was passive range of motion testing performed?' is 'Yes'.

Check this box if the passive forward flexion endpoint degrees are the same as the active ROM forward flexion endpoint degrees.

Check this box if the passive extension endpoint degrees are the same as the active ROM extension endpoint degrees.

Check this box if the passive right lateral flexion endpoint degrees are the same as the active ROM right lateral flexion endpoint degrees.

Enter the passive range of motion endpoint measurement for forward flexion in degrees. Fill only if 'Passive ROM Forward Flexion Endpoint - Same as Active ROM' is 'No'.

Enter the passive range of motion endpoint measurement for extension in degrees. Fill only if 'Passive ROM Extension Endpoint - Same as Active ROM' is 'No'.

Enter the passive range of motion endpoint measurement for right lateral flexion in degrees. Fill only if 'Passive ROM Right Lateral Flexion Endpoint - Same as Active ROM' is 'No'.

Enter the passive range-of-motion endpoint for left lateral flexion in degrees. Fill only if 'Left lateral flexion endpoint — Same as active ROM' is 'No'.

Enter the passive range-of-motion endpoint for right lateral rotation in degrees. Fill only if 'Right lateral rotation endpoint — Same as active ROM' is 'No'.

Enter the passive range-of-motion endpoint for left lateral movement in degrees. Fill only if 'Left lateral endpoint — Same as active ROM' is 'No'.

Check this box if the passive left lateral endpoint is the same as the active ROM measurement. Fill only if 'Was passive range of motion testing performed?' is 'Yes'.

Check this box if the passive right lateral rotation endpoint is the same as the active ROM measurement. Fill only if 'Was passive range of motion testing performed?' is 'Yes'.

Check this box if the passive left lateral flexion endpoint is the same as the active ROM measurement. Fill only if 'Was passive range of motion testing performed?' is 'Yes'.

Provide the reason passive range of motion (ROM) testing was not performed (e.g., medically contraindicated, not necessary, or other) and any relevant details. Fill only if 'Passive ROM Testing Performed - No' is 'Yes'.

Check this box if passive range of motion (ROM) testing was not performed because it is medically contraindicated (e.g., could cause severe pain or risk further injury). Fill only if 'Passive ROM Testing Performed - No' is 'Yes'.

Check this box if passive range of motion (ROM) testing was not performed because the examiner determined the testing was not necessary. Fill only if 'Passive ROM Testing Performed - No' is 'Yes'.

Check this box if passive range of motion (ROM) testing was not performed for another reason not listed and you will provide an explanation. Fill only if 'Passive ROM Testing Performed - No' is 'Yes'.

Check this box if passive ROM testing produced pain during left lateral rotation. Fill only if 'Was passive range of motion testing performed?' is 'Yes'.

Check this box if passive ROM testing produced pain during right lateral rotation. Fill only if 'Was passive range of motion testing performed?' is 'Yes'.

Check this box if passive ROM testing produced pain during right lateral flexion. Fill only if 'Was passive range of motion testing performed?' is 'Yes'.

Check this box if passive ROM testing produced pain during left lateral flexion. Fill only if 'Was passive range of motion testing performed?' is 'Yes'.

Check this box if passive ROM testing produced pain during extension. Fill only if 'Was passive range of motion testing performed?' is 'Yes'.

Check this box if passive ROM testing produced pain during forward flexion. Fill only if 'Was passive range of motion testing performed?' is 'Yes'.

Check this box if passive range of motion (ROM) testing was not performed.

Check this box if passive range of motion (ROM) testing was performed.

Enter the full name of the patient/veteran.

Enter the patient/veteran's Social Security Number.

Enter the date the examination was performed.

Enter a description of any other factor causing functional loss that is not already listed (e.g., pain, fatigability, weakness, lack of endurance, or incoordination). Fill only if 'Other' is 'Yes'.

Check this box if none of the listed factors apply as causes of the functional loss. Fill only if 'Is there additional loss of function or range of motion after three repetitions?' is 'Yes'.

Check this box if incoordination contributes to the functional loss. Fill only if 'Is there additional loss of function or range of motion after three repetitions?' is 'Yes'.

Check this box if another factor not listed contributes to the functional loss and you will specify it in the provided line. Fill only if 'Is there additional loss of function or range of motion after three repetitions?' is 'Yes'.

Check this box if pain contributes to the functional loss. Fill only if 'Is there additional loss of function or range of motion after three repetitions?' is 'Yes'.

Check this box if fatigability (easy tiring) contributes to the functional loss. Fill only if 'Is there additional loss of function or range of motion after three repetitions?' is 'Yes'.

Check this box if weakness contributes to the functional loss. Fill only if 'Is there additional loss of function or range of motion after three repetitions?' is 'Yes'.

Check this box if lack of endurance contributes to the functional loss. Fill only if 'Is there additional loss of function or range of motion after three repetitions?' is 'Yes'.

Enter the prior section measured endpoint value for left lateral rotation (in degrees). Fill only if 'Is there additional loss of function or range of motion after three repetitions?' is 'Yes'.

Enter the prior section measured endpoint value for right lateral flexion (in degrees). Fill only if 'Is there additional loss of function or range of motion after three repetitions?' is 'Yes'.

Enter the name(s) of the third-party organization(s) or individual(s) requesting completion of this Disability Benefits Questionnaire. Fill only if 'Third party' is 'Yes'.

Describe who or what entity is requesting completion of this Disability Benefits Questionnaire if it is not the Veteran/Claimant or a third party. Fill only if 'Other (please describe)' is 'Yes'.

Check this box if the questionnaire is being completed at the request of the Veteran/claimant.

Check this box if the questionnaire is being completed at the request of a third party (an organization or individual).

Check this box if the questionnaire is being completed at the request of someone not listed above, and provide a description in the space provided.

Check this box if the Veteran has radicular pain or any other signs or symptoms due to radiculopathy.

Check this box if the Veteran does not have radicular pain or any other signs or symptoms due to radiculopathy.

Enter the deep tendon reflex (DTR) rating for the right knee.

Enter the deep tendon reflex (DTR) rating for the left knee.

Enter the deep tendon reflex (DTR) rating for the right ankle.

Enter the deep tendon reflex (DTR) rating for the left ankle.

Check this box if the Veteran is able to perform repetitive use testing with at least three repetitions.

Check this box if the Veteran is not able to perform repetitive use testing with at least three repetitions (and provide an explanation).

Provide an explanation for why the Veteran is not able to perform repetitive use testing with at least three repetitions. Fill only if '3B Repetitive use testing able (No)' is 'Yes'.

Check this box if the veteran is diagnosed with a sacroiliac injury as part of the claimed condition(s) being evaluated.

Enter the ICD diagnosis code corresponding to the sacroiliac injury. Fill only if 'Sacroiliac injury' is 'Yes'.

Provide the date when the sacroiliac injury was diagnosed. Fill only if 'Sacroiliac injury' is 'Yes'.

Check this box if the Veteran has a diagnosis of sacroiliac weakness associated with the claimed condition(s).

Enter the ICD diagnosis code corresponding to the selected condition of sacroiliac weakness. Fill only if 'Sacroiliac weakness' is 'Yes'.

Enter the date on which sacroiliac weakness was diagnosed. Fill only if 'Sacroiliac weakness' is 'Yes'.

Check this box if the Veteran has a current diagnosis of segmental instability associated with the claimed condition(s).

Enter the ICD diagnosis code corresponding to the Segmental instability diagnosis. Fill only if 'Segmental instability' is 'Yes'.

Provide the date on which Segmental instability was diagnosed. Fill only if 'Segmental instability' is 'Yes'.

Check this box if light-touch sensation testing for the right foot/toes (L5 dermatome) is normal.

Check this box if light-touch sensation testing for the right foot/toes (L5 dermatome) is decreased compared to normal.

Check this box if light-touch sensation testing for the right foot/toes (L5 dermatome) is absent.

Check this box if light-touch sensation is normal in the right lower leg/ankle dermatome area (L4/L5/S1).

Check this box if light-touch sensation is decreased (diminished) in the right lower leg/ankle dermatome area (L4/L5/S1).

Check this box if light-touch sensation is absent in the right lower leg/ankle dermatome area (L4/L5/S1).

Check this box if light-touch sensation is normal in the right thigh/knee (L3/4 dermatome) area.

Check this box if light-touch sensation is decreased (diminished) in the right thigh/knee (L3/4 dermatome) area.

Check this box if light-touch sensation is absent in the right thigh/knee (L3/4 dermatome) area.

Check this box if light touch sensation is normal on the right upper anterior thigh (L2 dermatome).

Check this box if light touch sensation is decreased on the right upper anterior thigh (L2 dermatome).

Check this box if light touch sensation is absent on the right upper anterior thigh (L2 dermatome).

Check this box if the Veteran has a diagnosis associated with spinal fusion for the claimed condition(s).

Enter the ICD diagnosis code associated with the Spinal fusion diagnosis. Fill only if 'Spinal fusion' is 'Yes'.

Enter the date the Spinal fusion diagnosis was made. Fill only if 'Spinal fusion' is 'Yes'.

Check this box if the Veteran has a diagnosis of spinal stenosis associated with the claimed condition(s).

Enter the ICD diagnosis code corresponding to the Veteran’s spinal stenosis. Fill only if 'Spinal stenosis' is 'Yes'.

Enter the date when spinal stenosis was first diagnosed. Fill only if 'Spinal stenosis' is 'Yes'.

Check this box if the Veteran has a current diagnosis of spondylolisthesis associated with the claimed condition(s).

Enter the ICD diagnosis code associated with the Spondylolisthesis diagnosis. Fill only if 'Spondylolisthesis' is 'Yes'.

Provide the date when Spondylolisthesis was diagnosed. Fill only if 'Spondylolisthesis' is 'Yes'.

Provide the reason the straight leg raising test could not be performed (for either the right, left, or both sides). Fill only if 'Right - Unable to perform', 'Left Straight Leg Raising Test Result - Unable to perform' is selected for any fields selection.

Check this box if the Straight Leg Raising test could not be performed on the left leg.

Check this box if the Straight Leg Raising test result for the left leg is positive.

Check this box if the Straight Leg Raising test result for the left leg is negative.

Check this box if you were unable to perform the straight leg raising test on the right leg.

Check this box if the straight leg raising test result for the right leg is positive.

Check this box if the straight leg raising test result for the right leg is negative.

Provide a detailed explanation of why the required testing could not be performed or was medically contraindicated. Fill only if 'Can testing be performed? No' is 'Yes'.

Check this box if the Veteran has localized tenderness, guarding, or muscle spasm of the thoracolumbar spine.

Check this box if the Veteran does not have localized tenderness, guarding, or muscle spasm of the thoracolumbar spine.

Check this box if the Veteran has a current diagnosis of complete traumatic paralysis associated with the claimed condition(s).

Enter the ICD diagnosis code for traumatic paralysis, complete. Fill only if 'Traumatic paralysis, complete' is 'Yes'.

Enter the date on which traumatic paralysis, complete was diagnosed. Fill only if 'Traumatic paralysis, complete' is 'Yes'.

Check this box if you are a VA Healthcare provider.

Check this box if you are not a VA Healthcare provider.

Check this box if the Veteran has a diagnosis of vertebral dislocation associated with the claimed condition(s).

Enter the ICD diagnostic code corresponding to the vertebral dislocation diagnosis. Fill only if 'Vertebral dislocation' is 'Yes'.

Enter the date when vertebral dislocation was diagnosed. Fill only if 'Vertebral dislocation' is 'Yes'.

Check this box if the Veteran has a diagnosis of a vertebral fracture associated with the claimed condition(s), and then provide the ICD code and date of diagnosis.

Enter the ICD diagnosis code for the vertebral fracture. Fill only if 'Vertebral fracture' is 'Yes'.

Enter the date when the vertebral fracture was diagnosed. Fill only if 'Vertebral fracture' is 'Yes'.

Provide details on how the Veteran's examination was conducted if it was not performed in person (e.g., telehealth, records review, or phone interview). Fill only if 'Was the Veteran examined in person? (No)' is 'Yes'.

Check this box if the Veteran was not examined in person (and then describe how the examination was conducted).

Check this box if the Veteran was examined in person.

Check this box if the Veteran is regularly seen as a patient in your clinic.

Check this box if the Veteran is not regularly seen as a patient in your clinic.