This form contains 491 fields organized into 109 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
3F Diaphragm rupture with herniation (Yes/No)
Yes	Radiobutton	Check this box if the veteran has a history of rupture of the diaphragm with herniation.
No	Radiobutton	Check this box if the veteran does not have a history of rupture of the diaphragm with herniation.
3G Extensive muscle hernia history (Yes/No) and details
Yes	Radiobutton	Check this box if the veteran has a history of an extensive muscle hernia of any muscle, without other injury to the muscle.
No	Radiobutton	Check this box if the veteran does not have a history of an extensive muscle hernia of any muscle without other injury to the muscle.
Extensive Muscle Hernia Details	Text	If the veteran has a history of an extensive muscle hernia, enter the name of the affected muscle and describe the current residuals. Fill only if 'Yes' is 'Yes'. Depends on: Yes
3H Facial muscle injury history (Yes/No)
Yes	Radiobutton	Check this box if the veteran has a history of injury to the facial muscles.
No	Radiobutton	Check this box if the veteran does not have a history of injury to the facial muscles.
3H Mastication interference extent (Yes/No)
Yes	Radiobutton	Check this box if the veteran’s facial muscle injury interferes with mastication (chewing) to any extent. Fill only if 'Yes' is 'Yes'. Depends on: Yes
No	Radiobutton	Check this box if the veteran’s facial muscle injury does not interfere with mastication (chewing). Fill only if 'Yes' is 'Yes'. Depends on: Yes
3I Rhabdomyolysis history (Yes/No)
Yes	Radiobutton	Check this box if the Veteran has a history of rhabdomyolysis.
No	Radiobutton	Check this box if the Veteran does not have a history of rhabdomyolysis.
3J Compartment syndrome history (Yes/No)
Yes	Radiobutton	Check this box if the Veteran has a history of compartment syndrome.
No	Radiobutton	Check this box if the Veteran does not have a history of compartment syndrome.
4A Scars Associated With Muscle Injury (Presence, Severity/Types, Description)
Yes	Radiobutton	Check this box if the veteran has any scar(s) associated with a muscle injury.
No	Radiobutton	Check this box if the veteran does not have any scar(s) associated with a muscle injury.
Minimal scar(s)	Checkbox	Check this box if the scar(s) from the muscle injury are minimal. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Entrance/exit scars small or linear (short missile track through muscle tissue)	Checkbox	Check this box if entrance and (if present) exit scars are small or linear, indicating a short track of a missile through muscle tissue. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Entrance/exit scars indicate track through one or more muscle groups	Checkbox	Check this box if entrance and (if present) exit scars indicate the track of a missile through one or more muscle groups. Fill only if 'Yes' is 'Yes'. Depends on: Yes
4A. DOES THE VETERAN HAVE ANY SCAR(S) ASSOCIATED WITH A MUSCLE INJURY? If yes, indicate severity of scars(s) caused by the muscle injury(ies). Check all that apply if there is more than one area or type of scarring.: Ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track	CheckBox	Depends on: Yes
4A. DOES THE VETERAN HAVE ANY SCAR(S) ASSOCIATED WITH A MUSCLE INJURY? If yes, indicate severity of scars(s) caused by the muscle injury(ies). Check all that apply if there is more than one area or type of scarring.: Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle	CheckBox	Depends on: Yes
4A. DOES THE VETERAN HAVE ANY SCAR(S) ASSOCIATED WITH A MUSCLE INJURY? If yes, indicate severity of scars(s) caused by the muscle injury(ies). Check all that apply if there is more than one area or type of scarring.: Other (including surgical scars related to muscle injuries shown above, ALSO complete Scars/Disfigurement questionnaire)	CheckBox	Depends on: Yes
Scars Associated With Muscle Injury Description	Text	Provide a detailed description of any scars associated with the muscle injury, including presence and the severity/type of scarring. Fill only if 'Yes' is 'Yes'. Depends on: Yes
4B Fascial Defects Associated With Muscle Injuries (Presence, Findings, Other Description)
Yes	Radiobutton	Check this box if the Veteran has any known fascial defects or evidence of fascial defects associated with any muscle injuries.
No	Radiobutton	Check this box if the Veteran does not have any known fascial defects or evidence of fascial defects associated with any muscle injuries.
Some loss of deep fascia	Checkbox	Check this box if the muscle injury involves some loss of deep fascia. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Palpation shows loss of deep fascia	Checkbox	Check this box if palpation demonstrates loss of deep fascia due to the muscle injury. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other (describe)	Checkbox	Check this box if there is another type or finding of fascial defect not listed, and provide details in the description area. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Fascial Defects Findings / Other Description	Text	Provide details about any known fascial defects associated with the veteran’s muscle injury(ies), including relevant findings, severity, location, and any other descriptive information. Fill only if 'Other (describe)' is 'Yes'. Depends on: Other (describe)
4C Muscle Injury Effects on Muscle Substance/Function (Presence, Symptoms/Findings, Other Description)
Yes	Radiobutton	Check this box if the veteran's muscle injury(ies) affect muscle substance or function.
No	Radiobutton	Check this box if the veteran's muscle injury(ies) do not affect muscle substance or function.
Some impairment of muscle tonus	Checkbox	Check this box if the muscle injury causes some impairment of muscle tonus. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Some loss of muscle substance	Checkbox	Check this box if there is some loss of muscle substance due to the muscle injury. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Soft flabby muscles in wound area	Checkbox	Check this box if the muscles in the wound area are soft and flabby. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Muscles swell and harden abnormally in contraction	Checkbox	Check this box if the affected muscles swell and harden abnormally when contracting. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Induration or atrophy of an entire muscle following history of simple piercing by a projectile	Checkbox	Check this box if there is induration or atrophy of an entire muscle with a history of simple piercing by a projectile. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Adaptive contraction of an opposing group of muscles	Checkbox	Check this box if there is adaptive contraction of an opposing muscle group related to the injury. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Visible or measurable atrophy	Checkbox	Check this box if there is visible or measurable muscle atrophy. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Ragged, depressed and adherent scars indicating wide damage to muscle groups in missile track	Checkbox	Check this box if the veteran has ragged, depressed, and adherent scars that indicate wide damage to muscle groups along a missile track. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Adhesion of scar to long bone/scapula/pelvic bones/sacrum/vertebrae with epithelial sealing over bone	Checkbox	Check this box if there is adhesion of a scar to a long bone, scapula, pelvic bones, sacrum, or vertebrae with epithelial sealing over bone rather than true skin covering in an area normally protected by muscle. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other scars (including surgical scars related to muscle injuries shown above)	Checkbox	Check this box if there are other relevant scars (including surgical scars) related to the muscle injuries, and complete the Scars/Disfigurement questionnaire as indicated. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Muscle Injury Effects Description	Text	Enter a detailed narrative describing the effects of the muscle injury on muscle substance and function, including presence, symptoms/findings, and any other relevant details. Fill only if 'Other scars (including surgical scars related to muscle injuries shown above)' is 'Yes'. Depends on: Other scars (including surgical scars related to muscle injuries shown above)
6A Condition and loss of effective function description
Condition and Loss of Effective Function Summary	Text	For each affected extremity, describe the condition causing loss of function, explain the loss of effective function, and provide specific examples in a brief summary. Fill only if 'Right upper', 'Left upper', 'Right lower', 'Left lower' is 'Yes' (any). Depends on: Right upper, Left upper, Right lower, Left lower
6A Extremity(es) affected (if Yes)
Right upper	Checkbox	Check this box if the Veteran’s right upper extremity is affected (i.e., has functional impairment such that no effective function remains) and the answer to 6A is Yes. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left upper	Checkbox	Check this box if the Veteran’s left upper extremity is affected (i.e., has functional impairment such that no effective function remains) and the answer to 6A is Yes. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right lower	Checkbox	Check this box if the Veteran’s right lower extremity is affected (i.e., has functional impairment such that no effective function remains) and the answer to 6A is Yes. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left lower	Checkbox	Check this box if the Veteran’s left lower extremity is affected (i.e., has functional impairment such that no effective function remains) and the answer to 6A is Yes. Fill only if 'Yes' is 'Yes'. Depends on: Yes
6A Functional impairment equivalent to amputation with prosthesis (Yes/No)
Yes	Radiobutton	Check this box if the Veteran has functional impairment of an extremity such that no effective function remains and an amputation with prosthesis would equally serve the Veteran.
No	Radiobutton	Check this box if the Veteran does not have functional impairment of an extremity that would be equally well served by an amputation with prosthesis.
7A Neoplasm or Metastases Present (Yes/No)
Yes	Radiobutton	Check this box if the Veteran currently has, or has had, a benign or malignant neoplasm or metastases related to any condition in the diagnosis section.
No	Radiobutton	Check this box if the Veteran does not currently have and has not had a benign or malignant neoplasm or metastases related to any condition in the diagnosis section.
7B Neoplasm Type and Status
Benign	Radiobutton	Check this box if the Veteran’s neoplasm is benign (non-cancerous). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Malignant	Radiobutton	Check this box if the Veteran’s neoplasm is malignant (cancerous). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Active	Radiobutton	Check this box if the malignant neoplasm is currently active. Fill only if 'Malignant' is 'Yes'. Depends on: Malignant
In remission	Radiobutton	Check this box if the malignant neoplasm is in remission. Fill only if 'Malignant' is 'Yes'. Depends on: Malignant
Primary	Radiobutton	Check this box if the malignant neoplasm is a primary cancer at its original site. Fill only if 'Malignant' is 'Yes'. Depends on: Malignant
Secondary (metastatic)	Radiobutton	Check this box if the malignant neoplasm is secondary/metastatic (spread from a primary site). Fill only if 'Malignant' is 'Yes'. Depends on: Malignant
Primary Site (if Secondary/Metastatic)	Text	Enter the primary tumor site (origin) if the neoplasm is secondary (metastatic) and the primary site is known. Fill only if 'Malignant', 'Secondary (metastatic)' is 'Yes' (all). Depends on: Malignant, Secondary (metastatic)
7C Treatment Completed or Undergoing Treatment (Yes/No)
Yes	Radiobutton	Check this box if the Veteran has completed treatment or is currently undergoing treatment for a benign or malignant neoplasm or metastases. Fill only if 'Yes' is 'Yes'. Depends on: Yes
No; watchful waiting	Radiobutton	Check this box if the Veteran has not completed and is not currently undergoing treatment and is being managed with watchful waiting for the neoplasm or metastases. Fill only if 'Yes' is 'Yes'. Depends on: Yes
7C Treatment Type - Antineoplastic Chemotherapy Dates
Antineoplastic chemotherapy	Checkbox	Check this box if the patient received antineoplastic chemotherapy, and then provide the date of the most recent treatment and the completion or anticipated completion date. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Most Recent Chemotherapy Date	Date	Enter the date the most recent antineoplastic chemotherapy treatment was given. Fill only if 'Antineoplastic chemotherapy' is 'Yes'. Depends on: Antineoplastic chemotherapy
Chemotherapy Completion Date	Date	Enter the date antineoplastic chemotherapy was completed or the anticipated completion date if treatment is ongoing. Fill only if 'Antineoplastic chemotherapy' is 'Yes'. Depends on: Antineoplastic chemotherapy
7C Treatment Type - Other Therapeutic Procedure Details
Other therapeutic procedure	Checkbox	Check this box if the patient received an other therapeutic procedure (not antineoplastic chemotherapy), and then provide the procedure description and date of most recent procedure. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other Therapeutic Procedure Description	Text	Describe the other therapeutic procedure performed. Fill only if 'Other therapeutic procedure' is 'Yes'. Depends on: Other therapeutic procedure
Date of Most Recent Other Therapeutic Procedure	Date	Enter the date when the most recent other therapeutic procedure was performed. Fill only if 'Other therapeutic procedure' is 'Yes'. Depends on: Other therapeutic procedure
7C Treatment Type - Other Therapeutic Treatment Details
Other therapeutic treatment	Checkbox	Check this box if the patient received another type of therapeutic treatment not otherwise listed, and then provide the treatment details on the lines provided. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other Therapeutic Treatment Description	Text	Describe the other therapeutic treatment provided if the 'Other therapeutic treatment' option is selected. Fill only if 'Other therapeutic treatment' is 'Yes'. Depends on: Other therapeutic treatment
Treatment Completion or Anticipated Completion Date	Date	Enter the date the other therapeutic treatment was completed or the anticipated completion date. Fill only if 'Other therapeutic treatment' is 'Yes'. Depends on: Other therapeutic treatment
7C Treatment Type - Radiation Therapy Dates
Radiation therapy	Checkbox	Check this box if the Veteran is currently undergoing or has completed radiation therapy for the benign or malignant neoplasm or metastases, and then provide the date of most recent treatment and the completion/anticipated completion date. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Radiation Therapy Most Recent Treatment Date	Date	Enter the date of the Veteran’s most recent radiation therapy treatment. Fill only if 'Radiation therapy' is 'Yes'. Depends on: Radiation therapy
Radiation Therapy Completion Date	Date	Enter the date radiation therapy was completed, or the anticipated completion date if treatment is ongoing. Fill only if 'Radiation therapy' is 'Yes'. Depends on: Radiation therapy
7C Treatment Type - Surgery Details
Surgery	Checkbox	Check this box if the Veteran has completed or is currently undergoing surgery as treatment for the benign or malignant neoplasm or metastases. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Surgery Description	Text	Provide a brief description of the surgery performed or being performed as treatment for the neoplasm/metastases. Fill only if 'Surgery' is 'Yes'. Depends on: Surgery
Surgery Date(s)	Text	Enter the date or dates when the surgery was performed (or is scheduled), if applicable. Fill only if 'Surgery' is 'Yes'. Depends on: Surgery
7C Treatment Type - Treatment Completed
Treatment completed	Checkbox	Check this box if the Veteran has completed treatment for the benign or malignant neoplasm or metastases. Fill only if 'Yes' is 'Yes'. Depends on: Yes
7D Residuals or Complications Present (Yes/No)
Yes	Radiobutton	Check this box if the Veteran currently has any residuals or complications due to the neoplasm (including metastases) or its treatment that are not already documented above. Fill only if 'Yes' is 'Yes'. Depends on: Yes
No	Radiobutton	Check this box if the Veteran currently has no residuals or complications due to the neoplasm (including metastases) or its treatment other than those already documented above. Fill only if 'Yes' is 'Yes'. Depends on: Yes
7D Residuals/Complications Summary
Residuals/Complications Summary	Text	Provide a brief summary listing any current residuals or complications due to the neoplasm (including metastases) or its treatment that are not already documented above. Fill only if 'Yes' is 'Yes'. Depends on: Yes
7E Additional Neoplasms or Metastases Description
Additional Neoplasms or Metastases Description	Text	Describe any additional benign or malignant neoplasms or metastases related to the diagnoses listed above, using the same format as the prior entries.
9A Imaging Studies Performed and Results
Yes	Radiobutton	Check this box if imaging studies have been performed in conjunction with this examination.
No	Radiobutton	Check this box if no imaging studies have been performed in conjunction with this examination.
Imaging studies performed (type, date, and results)	Text	Enter the type of imaging test or procedure performed in conjunction with this examination, along with the date performed and the results. Fill only if 'Yes' is 'Yes'. Depends on: Yes
9B Retained Shell Fragments/Shrapnel Details
X-ray evidence of retained shell fragment(s) and/or shrapnel	Checkbox	Check this box if X-ray imaging shows retained shell fragment(s) and/or shrapnel in any muscle group. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Retained Fragment Location (Muscle Group)	Text	Enter the location of the retained shell fragments/shrapnel, specifying the affected muscle group (I–XXIII) if possible. Fill only if 'X-ray evidence of retained shell fragment(s) and/or shrapnel' is 'Yes'. Depends on: X-ray evidence of retained shell fragment(s) and/or shrapnel
Side affected: Right	Radiobutton	Check this box if the retained shell fragment(s)/shrapnel are on the right side. Fill only if 'X-ray evidence of retained shell fragment(s) and/or shrapnel' is 'Yes'. Depends on: X-ray evidence of retained shell fragment(s) and/or shrapnel
Side affected: Left	Radiobutton	Check this box if the retained shell fragment(s)/shrapnel are on the left side. Fill only if 'X-ray evidence of retained shell fragment(s) and/or shrapnel' is 'Yes'. Depends on: X-ray evidence of retained shell fragment(s) and/or shrapnel
Side affected: Both	Radiobutton	Check this box if the retained shell fragment(s)/shrapnel affect both the right and left sides. Fill only if 'X-ray evidence of retained shell fragment(s) and/or shrapnel' is 'Yes'. Depends on: X-ray evidence of retained shell fragment(s) and/or shrapnel
9B Scattered Foreign Bodies (Intermuscular Trauma) Details
X-ray evidence of minute multiple scattered foreign bodies (intermuscular trauma/explosive effect)	Checkbox	Check this box if imaging shows minute multiple scattered foreign bodies consistent with intermuscular trauma and an explosive effect of the missile. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Scattered foreign bodies location (muscle group)	Text	Enter the location of the minute multiple scattered foreign bodies, specifying the affected muscle group(s) (I–XXIII) if possible. Fill only if 'X-ray evidence of minute multiple scattered foreign bodies (intermuscular trauma/explosive effect)' is 'Yes'. Depends on: X-ray evidence of minute multiple scattered foreign bodies (intermuscular trauma/explosive effect)
Side affected: Right	Radiobutton	Check this box if the scattered foreign bodies/intermuscular trauma finding affects the right side. Fill only if 'X-ray evidence of minute multiple scattered foreign bodies (intermuscular trauma/explosive effect)' is 'Yes'. Depends on: X-ray evidence of minute multiple scattered foreign bodies (intermuscular trauma/explosive effect)
Side affected: Left	Radiobutton	Check this box if the scattered foreign bodies/intermuscular trauma finding affects the left side. Fill only if 'X-ray evidence of minute multiple scattered foreign bodies (intermuscular trauma/explosive effect)' is 'Yes'. Depends on: X-ray evidence of minute multiple scattered foreign bodies (intermuscular trauma/explosive effect)
Side affected: Both	Radiobutton	Check this box if the scattered foreign bodies/intermuscular trauma finding affects both sides. Fill only if 'X-ray evidence of minute multiple scattered foreign bodies (intermuscular trauma/explosive effect)' is 'Yes'. Depends on: X-ray evidence of minute multiple scattered foreign bodies (intermuscular trauma/explosive effect)
9B X-ray Evidence of Retained Metallic Fragments (Yes/No)
Yes	Radiobutton	Check this box if there is X-ray evidence of retained metallic fragments (such as shell fragments or shrapnel) in any muscle group.
No	Radiobutton	Check this box if there is no X-ray evidence of retained metallic fragments (such as shell fragments or shrapnel) in any muscle group.
9C Electrodiagnostic Tests (Performed, Findings, Affected Muscles)
Electrodiagnostic tests done: Yes	Radiobutton	Check this box if electrodiagnostic tests were performed as part of this examination.
Electrodiagnostic tests done: No	Radiobutton	Check this box if no electrodiagnostic tests were performed as part of this examination.
Diminished muscle excitability to pulsed electrical current: Yes	Radiobutton	Check this box if electrodiagnostic testing showed diminished muscle excitability to pulsed electrical current. Fill only if 'Electrodiagnostic tests done: Yes' is 'Yes'. Depends on: Electrodiagnostic tests done: Yes
Diminished muscle excitability to pulsed electrical current: No	Radiobutton	Check this box if electrodiagnostic testing did not show diminished muscle excitability to pulsed electrical current. Fill only if 'Electrodiagnostic tests done: Yes' is 'Yes'. Depends on: Electrodiagnostic tests done: Yes
Affected Muscles (Electrodiagnostic Tests)	Text	Enter the names of the muscle(s) found to be affected based on the electrodiagnostic testing performed. Fill only if 'Electrodiagnostic tests done: Yes', 'Diminished muscle excitability to pulsed electrical current: Yes' is 'Yes' all. Depends on: Diminished muscle excitability to pulsed electrical current: Yes, Electrodiagnostic tests done: Yes
9D Other Diagnostic Test Findings/Results and Summary
Yes	Radiobutton	Check this box if there are other diagnostic test findings and/or results related to the claimed condition(s) and/or diagnosis(es) that were reviewed in conjunction with this examination.
No	Radiobutton	Check this box if there are no other diagnostic test findings and/or results related to the claimed condition(s) and/or diagnosis(es) that were reviewed in conjunction with this examination.
Other Diagnostic Test Findings/Results Summary	Text	Enter a brief summary of any other diagnostic tests or procedures reviewed for the claimed condition(s), including the test type, date, and relevant results. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Additional Muscle Injury Diagnoses (Free Text)
Additional Muscle Injury Diagnoses	Text	List any additional diagnoses related to muscle injuries using the same diagnosis format shown above on the form.
Ankle Dorsiflexion Strength Ratings (Right & Left)
Right ankle dorsiflexion strength: 5/5	Radiobutton	Check this box if right ankle dorsiflexion strength is normal (5/5). Fill only if '3C. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?' is 'Yes'. Depends on: Yes
Right ankle dorsiflexion strength: 4/5	Radiobutton	Check this box if right ankle dorsiflexion strength is less than normal (4/5). Fill only if '3C. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?' is 'Yes'. Depends on: Yes
Right ankle dorsiflexion strength: 3/5	Radiobutton	Check this box if right ankle dorsiflexion has no movement against resistance (3/5). Fill only if '3C. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?' is 'Yes'. Depends on: Yes
Right ankle dorsiflexion strength: 2/5	Radiobutton	Check this box if right ankle dorsiflexion has no movement against gravity (2/5). Fill only if '3C. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?' is 'Yes'. Depends on: Yes
Right ankle dorsiflexion strength: 1/5	Radiobutton	Check this box if there is visible right ankle dorsiflexion muscle movement but no joint movement (1/5). Fill only if '3C. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?' is 'Yes'. Depends on: Yes
Right ankle dorsiflexion strength: 0/5	Radiobutton	Check this box if there is no right ankle dorsiflexion muscle movement (0/5). Fill only if '3C. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?' is 'Yes'. Depends on: Yes
Left ankle dorsiflexion strength: 5/5	Radiobutton	Check this box if left ankle dorsiflexion strength is normal (5/5). Fill only if '3C. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?' is 'Yes'. Depends on: Yes
Left ankle dorsiflexion strength: 4/5	Radiobutton	Check this box if left ankle dorsiflexion strength is less than normal (4/5). Fill only if '3C. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?' is 'Yes'. Depends on: Yes
Left ankle dorsiflexion strength: 3/5	Radiobutton	Check this box if left ankle dorsiflexion has no movement against resistance (3/5). Fill only if '3C. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?' is 'Yes'. Depends on: Yes
Left ankle dorsiflexion strength: 2/5	Radiobutton	Check this box if left ankle dorsiflexion has no movement against gravity (2/5). Fill only if '3C. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?' is 'Yes'. Depends on: Yes
Left ankle dorsiflexion strength: 1/5	Radiobutton	Check this box if there is visible left ankle dorsiflexion muscle movement but no joint movement (1/5). Fill only if '3C. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?' is 'Yes'. Depends on: Yes
Left ankle dorsiflexion strength: 0/5	Radiobutton	Check this box if there is no left ankle dorsiflexion muscle movement (0/5). Fill only if '3C. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?' is 'Yes'. Depends on: Yes
Ankle Plantar Flexion Strength Ratings (Right & Left)
Right ankle plantar flexion strength: 5/5	Radiobutton	Check this box if the right ankle plantar flexion strength is normal (5/5). Fill only if '3C. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?' is 'Yes'. Depends on: Yes
Right ankle plantar flexion strength: 4/5	Radiobutton	Check this box if the right ankle plantar flexion strength is less than normal (4/5). Fill only if '3C. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?' is 'Yes'. Depends on: Yes
Right ankle plantar flexion strength: 3/5	Radiobutton	Check this box if the right ankle plantar flexion moves against gravity but not against resistance (3/5). Fill only if '3C. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?' is 'Yes'. Depends on: Yes
Right ankle plantar flexion strength: 2/5	Radiobutton	Check this box if the right ankle plantar flexion shows movement but not against gravity (2/5). Fill only if '3C. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?' is 'Yes'. Depends on: Yes
Right ankle plantar flexion strength: 1/5	Radiobutton	Check this box if there is visible muscle movement on the right but no joint movement (1/5). Fill only if '3C. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?' is 'Yes'. Depends on: Yes
Right ankle plantar flexion strength: 0/5	Radiobutton	Check this box if there is no right ankle plantar flexion muscle movement (0/5). Fill only if '3C. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?' is 'Yes'. Depends on: Yes
Left ankle plantar flexion strength: 5/5	Radiobutton	Check this box if the left ankle plantar flexion strength is normal (5/5). Fill only if '3C. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?' is 'Yes'. Depends on: Yes
Left ankle plantar flexion strength: 4/5	Radiobutton	Check this box if the left ankle plantar flexion strength is less than normal (4/5). Fill only if '3C. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?' is 'Yes'. Depends on: Yes
Left ankle plantar flexion strength: 3/5	Radiobutton	Check this box if the left ankle plantar flexion moves against gravity but not against resistance (3/5). Fill only if '3C. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?' is 'Yes'. Depends on: Yes
Left ankle plantar flexion strength: 2/5	Radiobutton	Check this box if the left ankle plantar flexion shows movement but not against gravity (2/5). Fill only if '3C. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?' is 'Yes'. Depends on: Yes
Left ankle plantar flexion strength: 1/5	Radiobutton	Check this box if there is visible muscle movement on the left but no joint movement (1/5). Fill only if '3C. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?' is 'Yes'. Depends on: Yes
Left ankle plantar flexion strength: 0/5	Radiobutton	Check this box if there is no left ankle plantar flexion muscle movement (0/5). Fill only if '3C. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOOT OR LEG?' is 'Yes'. Depends on: Yes
Any Cardinal Signs or Symptoms Attributable to Muscle Injuries (Yes/No)
Yes	Radiobutton	Check this box if the veteran has any signs and/or symptoms attributable to any muscle injuries.
No	Radiobutton	Check this box if the veteran does not have any signs and/or symptoms attributable to any muscle injuries.
Assistive Devices Details by Condition (Narrative)
Assistive Devices by Condition (Narrative)	Text	Describe each medical condition for which the veteran uses an assistive device and identify the specific assistive device used for that condition. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Assistive Devices Used (Yes/No)
Yes	Radiobutton	Check this box if the veteran uses any assistive devices as a normal mode of locomotion (even if other methods are occasionally possible).
No	Radiobutton	Check this box if the veteran does not use any assistive devices as a normal mode of locomotion.
Braces Use and Frequency
Brace(s)	Checkbox	Check this box if the veteran uses a brace as an assistive device for locomotion.
Brace(s) frequency: Occasional	Radiobutton	Check this box if the veteran uses brace(s) occasionally as a normal mode of locomotion. Fill only if 'Brace(s)' is 'Yes'. Depends on: Brace(s)
Brace(s) frequency: Regular	Radiobutton	Check this box if the veteran uses brace(s) regularly as a normal mode of locomotion. Fill only if 'Brace(s)' is 'Yes'. Depends on: Brace(s)
Brace(s) frequency: Constant	Radiobutton	Check this box if the veteran uses brace(s) constantly as a normal mode of locomotion. Fill only if 'Brace(s)' is 'Yes'. Depends on: Brace(s)
Canes Use and Frequency
Cane(s)	Checkbox	Check this box if the veteran uses a cane (or canes) as an assistive device for locomotion.
Cane(s) - Frequency of use: Occasional	Radiobutton	Check this box if the veteran uses a cane only occasionally (not regularly or constantly). Fill only if 'Cane(s)' is 'Yes'. Depends on: Cane(s)
Cane(s) - Frequency of use: Regular	Radiobutton	Check this box if the veteran uses a cane on a regular basis, but not constantly. Fill only if 'Cane(s)' is 'Yes'. Depends on: Cane(s)
Cane(s) - Frequency of use: Constant	Radiobutton	Check this box if the veteran uses a cane constantly as a normal mode of locomotion. Fill only if 'Cane(s)' is 'Yes'. Depends on: Cane(s)
Clarification for Multiple Muscle Group Injuries
Multiple Muscle Injury Clarification	Text	Describe which clinical findings, signs, and/or symptoms are attributable to each injured muscle group when multiple muscle groups are involved.
Crutches Use and Frequency
Crutch(es)	Checkbox	Check this box if the veteran uses crutches as an assistive device for locomotion.
Crutch(es) frequency: Occasional	Radiobutton	Check this box if the veteran uses crutches occasionally. Fill only if 'Crutch(es)' is 'Yes'. Depends on: Crutch(es)
Crutch(es) frequency: Regular	Radiobutton	Check this box if the veteran uses crutches regularly. Fill only if 'Crutch(es)' is 'Yes'. Depends on: Crutch(es)
Crutch(es) frequency: Constant	Radiobutton	Check this box if the veteran uses crutches constantly. Fill only if 'Crutch(es)' is 'Yes'. Depends on: Crutch(es)
Currently Diagnosed Muscle Injury (Yes/No)
Yes	Radiobutton	Check this box if the veteran currently has a diagnosed muscle injury.
No	Radiobutton	Check this box if the veteran does not currently have a diagnosed muscle injury.
Dominant Hand
Right	Radiobutton	Check this box if the patient/veteran’s dominant hand is the right hand.
Left	Radiobutton	Check this box if the patient/veteran’s dominant hand is the left hand.
Ambidextrous	Radiobutton	Check this box if the patient/veteran uses both hands equally as the dominant hand.
Elbow Extension Strength Ratings (Right & Left)
Right elbow extension strength: 5/5	Radiobutton	Check this box if the patient’s RIGHT elbow extension strength is rated 5/5 (normal strength). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Right elbow extension strength: 4/5	Radiobutton	Check this box if the patient’s RIGHT elbow extension strength is rated 4/5 (less than normal strength). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Right elbow extension strength: 3/5	Radiobutton	Check this box if the patient’s RIGHT elbow extension strength is rated 3/5 (no movement against resistance). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Right elbow extension strength: 2/5	Radiobutton	Check this box if the patient’s RIGHT elbow extension strength is rated 2/5 (no movement against gravity). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Right elbow extension strength: 1/5	Radiobutton	Check this box if the patient’s RIGHT elbow extension strength is rated 1/5 (visible muscle movement but no joint movement). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Right elbow extension strength: 0/5	Radiobutton	Check this box if the patient’s RIGHT elbow extension strength is rated 0/5 (no muscle movement). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Left elbow extension strength: 5/5	Radiobutton	Check this box if the patient’s LEFT elbow extension strength is rated 5/5 (normal strength). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Left elbow extension strength: 4/5	Radiobutton	Check this box if the patient’s LEFT elbow extension strength is rated 4/5 (less than normal strength). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Left elbow extension strength: 3/5	Radiobutton	Check this box if the patient’s LEFT elbow extension strength is rated 3/5 (no movement against resistance). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Left elbow extension strength: 2/5	Radiobutton	Check this box if the patient’s LEFT elbow extension strength is rated 2/5 (no movement against gravity). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Left elbow extension strength: 1/5	Radiobutton	Check this box if the patient’s LEFT elbow extension strength is rated 1/5 (visible muscle movement but no joint movement). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Left elbow extension strength: 0/5	Radiobutton	Check this box if the patient’s LEFT elbow extension strength is rated 0/5 (no muscle movement). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Elbow Flexion Strength Ratings (Right & Left)
Elbow flexion (Right) – 5/5	Radiobutton	Check this box if right elbow flexion strength is normal (5/5). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Elbow flexion (Right) – 4/5	Radiobutton	Check this box if right elbow flexion strength is less than normal (4/5). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Elbow flexion (Right) – 3/5	Radiobutton	Check this box if right elbow flexion has no movement against resistance (3/5). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Elbow flexion (Right) – 2/5	Radiobutton	Check this box if right elbow flexion has no movement against gravity (2/5). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Elbow flexion (Right) – 1/5	Radiobutton	Check this box if right elbow flexion shows visible muscle movement but no joint movement (1/5). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Elbow flexion (Right) – 0/5	Radiobutton	Check this box if there is no muscle movement for right elbow flexion (0/5). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Elbow flexion (Left) – 5/5	Radiobutton	Check this box if left elbow flexion strength is normal (5/5). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Elbow flexion (Left) – 4/5	Radiobutton	Check this box if left elbow flexion strength is less than normal (4/5). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Elbow flexion (Left) – 3/5	Radiobutton	Check this box if left elbow flexion has no movement against resistance (3/5). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Elbow flexion (Left) – 2/5	Radiobutton	Check this box if left elbow flexion has no movement against gravity (2/5). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Elbow flexion (Left) – 1/5	Radiobutton	Check this box if left elbow flexion shows visible muscle movement but no joint movement (1/5). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Elbow flexion (Left) – 0/5	Radiobutton	Check this box if there is no muscle movement for left elbow flexion (0/5). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
EVIDENCE REVIEW
No records were reviewed	Radiobutton	Check this box if you did not review any medical or other records as part of completing this questionnaire.
Records reviewed	Radiobutton	Check this box if you reviewed any records (e.g., service treatment records, VA treatment records, or private treatment records) when completing this questionnaire.
Evidence Reviewed and Date Range	Text	List the evidence/records reviewed (e.g., service treatment records, VA treatment records, private treatment records) and the applicable date range covered. Fill only if 'Records reviewed' is 'Yes'. Depends on: Records reviewed
Examiner Contact Information
Examiner Phone/Fax Number(s)	Text	Enter the examiner’s phone number and/or fax number(s) where they can be reached.
Examiner Address	Text	Enter the examiner’s full mailing address (street, city, state, and ZIP code).
Examiner Name and Professional Credentials
Examiner Printed Name and Title	Text	Enter the examiner’s printed full name and professional title/credentials (e.g., MD, DO, NP, PA-C).
Examiner Area of Practice/Specialty	Text	Enter the examiner’s medical area of practice or specialty (e.g., Cardiology, Orthopedics, Psychiatry, General Practice).
National Provider Identifier (NPI) Number	Text	Enter the examiner’s National Provider Identifier (NPI) number.
Medical License Number and State	Text	Enter the examiner’s medical license number and the issuing state.
Examiner Signature and Date Signed
Examiner Signature	Text	Enter the examiner’s signature.
Date Signed	Date	Enter the date the examiner signed this form.
Fatigue and/or Pain (Side, Muscle Group, Frequency/Severity)
Fatigue and/or pain	Checkbox	Check this box if the veteran has fatigue and/or pain attributable to a muscle injury. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right (side affected)	Radiobutton	Check this box if the fatigue and/or pain affects the right side. Fill only if 'Fatigue and/or pain' is 'Yes'. Depends on: Fatigue and/or pain
Left (side affected)	Radiobutton	Check this box if the fatigue and/or pain affects the left side. Fill only if 'Fatigue and/or pain' is 'Yes'. Depends on: Fatigue and/or pain
Both (sides affected)	Radiobutton	Check this box if the fatigue and/or pain affects both sides. Fill only if 'Fatigue and/or pain' is 'Yes'. Depends on: Fatigue and/or pain
Muscle group(s) affected	Text	Enter the muscle group or groups affected by the veteran’s fatigue and/or pain (e.g., I–XXIII, if possible). Fill only if 'Fatigue and/or pain' is 'Yes'. Depends on: Fatigue and/or pain
Occasional (frequency/severity)	Radiobutton	Check this box if the fatigue and/or pain occurs occasionally. Fill only if 'Fatigue and/or pain' is 'Yes'. Depends on: Fatigue and/or pain
Consistent (frequency/severity)	Radiobutton	Check this box if the fatigue and/or pain is consistent. Fill only if 'Fatigue and/or pain' is 'Yes'. Depends on: Fatigue and/or pain
Consistent at a more severe level (frequency/severity)	Radiobutton	Check this box if the fatigue and/or pain is consistent and occurs at a more severe level. Fill only if 'Fatigue and/or pain' is 'Yes'. Depends on: Fatigue and/or pain
First Muscle Injury Diagnosis
Diagnosis #1	Text	Enter the first diagnosed muscle injury condition. Fill only if 'Yes' is 'Yes'. Depends on: Yes
ICD Code (Diagnosis #1)	Text	Enter the ICD diagnostic code corresponding to the first muscle injury diagnosis. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Date of Diagnosis (Diagnosis #1)	Date	Enter the date when the first muscle injury diagnosis was made. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected (Diagnosis #1): Right	Radiobutton	Check this box if the first listed muscle injury diagnosis affects the right side. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected (Diagnosis #1): Left	Radiobutton	Check this box if the first listed muscle injury diagnosis affects the left side. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected (Diagnosis #1): Both	Radiobutton	Check this box if the first listed muscle injury diagnosis affects both the right and left sides. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Foot and Leg Injury (3C) Yes/No
Yes	Radiobutton	Check this box if the veteran now has or has ever had an injury to a muscle group of the foot or leg.
No	Radiobutton	Check this box if the veteran does not now have and has never had an injury to a muscle group of the foot or leg.
Foot and Leg Muscle Group X (Selected + Side Affected)
Group X (Foot muscles)	Checkbox	Check this box if the veteran has (now or ever had) an injury to Muscle Group X (muscles of the foot). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected: Right	Radiobutton	Check this box if the Muscle Group X injury affects the right foot/leg. Fill only if 'Yes', 'Group X (Foot muscles)' is 'Yes' (all). Depends on: Yes, Group X (Foot muscles)
Side affected: Left	Radiobutton	Check this box if the Muscle Group X injury affects the left foot/leg. Fill only if 'Yes', 'Group X (Foot muscles)' is 'Yes' (all). Depends on: Yes, Group X (Foot muscles)
Side affected: Both	Radiobutton	Check this box if the Muscle Group X injury affects both the right and left foot/leg. Fill only if 'Yes', 'Group X (Foot muscles)' is 'Yes' (all). Depends on: Yes, Group X (Foot muscles)
Foot and Leg Muscle Group XI (Selected + Side Affected)
Group XI (Foot/ankle/calf muscles)	Checkbox	Check this box if the veteran has (now or ever had) an injury to Muscle Group XI (foot, ankle and calf muscles). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected: Right (Group XI)	Radiobutton	Check this box if the Group XI muscle injury affects the right side only. Fill only if 'Yes', 'Group XI (Foot/ankle/calf muscles)' is 'Yes' (all). Depends on: Yes, Group XI (Foot/ankle/calf muscles)
Side affected: Left (Group XI)	Radiobutton	Check this box if the Group XI muscle injury affects the left side only. Fill only if 'Yes', 'Group XI (Foot/ankle/calf muscles)' is 'Yes' (all). Depends on: Yes, Group XI (Foot/ankle/calf muscles)
Side affected: Both (Group XI)	Radiobutton	Check this box if the Group XI muscle injury affects both the right and left sides. Fill only if 'Yes', 'Group XI (Foot/ankle/calf muscles)' is 'Yes' (all). Depends on: Yes, Group XI (Foot/ankle/calf muscles)
Foot and Leg Muscle Group XII (Selected + Side Affected)
Group XII	Checkbox	Check this box if the veteran has (now or ever had) an injury to Muscle Group XII (anterior muscles of the leg). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected: Right	Radiobutton	Check this box if the Muscle Group XII injury affects the right foot/leg. Fill only if 'Yes', 'Group XII' is 'Yes' (all). Depends on: Yes, Group XII
Side affected: Left	Radiobutton	Check this box if the Muscle Group XII injury affects the left foot/leg. Fill only if 'Yes', 'Group XII' is 'Yes' (all). Depends on: Yes, Group XII
Side affected: Both	Radiobutton	Check this box if the Muscle Group XII injury affects both the right and left foot/leg. Fill only if 'Yes', 'Group XII' is 'Yes' (all). Depends on: Yes, Group XII
Forearm/Hand Injury Question (Yes/No)
Yes	Radiobutton	Check this box if the veteran now has or has ever had an injury to a muscle group of the forearm or hand.
No	Radiobutton	Check this box if the veteran does not now have and has never had an injury to a muscle group of the forearm or hand.
Group XIX (Abdominal Wall) - Selected and Side Affected
Group XIX (abdominal wall muscles)	Checkbox	Check this box if the veteran has (or has ever had) an injury affecting Muscle Group XIX (abdominal wall muscles such as rectus abdominis, obliques, transversalis, or quadratus lumborum). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected: Right	Radiobutton	Check this box if the Group XIX injury affects the right side. Fill only if 'Yes', 'Group XIX (abdominal wall muscles)', 'Group XX: Spinal muscles (sacrospinalis/erector spinae)' is 'Yes' and any is selected. Depends on: Yes, Group XIX (abdominal wall muscles), Group XX: Spinal muscles (sacrospinalis/erector spinae)
Side affected: Left	Radiobutton	Check this box if the Group XIX injury affects the left side. Fill only if 'Yes', 'Group XIX (abdominal wall muscles)', 'Group XX: Spinal muscles (sacrospinalis/erector spinae)' is 'Yes' and any is selected. Depends on: Yes, Group XIX (abdominal wall muscles), Group XX: Spinal muscles (sacrospinalis/erector spinae)
Side affected: Both	Radiobutton	Check this box if the Group XIX injury affects both the right and left sides. Fill only if 'Yes', 'Group XIX (abdominal wall muscles)', 'Group XX: Spinal muscles (sacrospinalis/erector spinae)' is 'Yes' and any is selected. Depends on: Yes, Group XIX (abdominal wall muscles), Group XX: Spinal muscles (sacrospinalis/erector spinae)
Group XX (Spinal Muscles) - Selected and Region Affected
Group XX: Spinal muscles (sacrospinalis/erector spinae)	Checkbox	Check this box if the veteran has (now or ever had) an injury to Muscle Group XX spinal muscles. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Cervical	Radiobutton	Check this box if the Muscle Group XX injury affects the cervical (neck) region of the spine. Fill only if 'Group XX: Spinal muscles (sacrospinalis/erector spinae)' is selected. Depends on: Group XX: Spinal muscles (sacrospinalis/erector spinae)
Thoracic	Radiobutton	Check this box if the Muscle Group XX injury affects the thoracic (upper/mid-back) region of the spine. Fill only if 'Group XX: Spinal muscles (sacrospinalis/erector spinae)' is selected. Depends on: Group XX: Spinal muscles (sacrospinalis/erector spinae)
Lumbar	Radiobutton	Check this box if the Muscle Group XX injury affects the lumbar (lower back) region of the spine. Fill only if 'Group XX: Spinal muscles (sacrospinalis/erector spinae)' is selected. Depends on: Group XX: Spinal muscles (sacrospinalis/erector spinae)
Group XXI (Respiration/Thoracic Muscle Group) - Selected and Side Affected
Group XXI: Muscles of respiration (thoracic muscle group)	Checkbox	Check this box if Group XXI (thoracic muscles of respiration) is being selected as an involved/affected muscle group for this evaluation.
Right	Radiobutton	Check this box if the Group XXI condition affects the right side. Fill only if 'Group XXI: Muscles of respiration (thoracic muscle group)' is selected. Depends on: Group XXI: Muscles of respiration (thoracic muscle group)
Left	Radiobutton	Check this box if the Group XXI condition affects the left side. Fill only if 'Group XXI: Muscles of respiration (thoracic muscle group)' is selected. Depends on: Group XXI: Muscles of respiration (thoracic muscle group)
Both	Radiobutton	Check this box if the Group XXI condition affects both the right and left sides. Fill only if 'Group XXI: Muscles of respiration (thoracic muscle group)' is selected. Depends on: Group XXI: Muscles of respiration (thoracic muscle group)
Group XXII (Front of Neck Muscles) - Selected and Side Affected
Group XXII selected (Front of neck muscles)	Checkbox	Check this box if Group XXII (muscles of the front of the neck) is being reported as affected/abnormal.
Right side affected	Radiobutton	Check this box if the Group XXII (front of neck muscles) finding affects the right side. Fill only if 'Group XXII selected (Front of neck muscles)' is selected. Depends on: Group XXII selected (Front of neck muscles)
Left side affected	Radiobutton	Check this box if the Group XXII (front of neck muscles) finding affects the left side. Fill only if 'Group XXII selected (Front of neck muscles)' is selected. Depends on: Group XXII selected (Front of neck muscles)
Both sides affected	Radiobutton	Check this box if the Group XXII (front of neck muscles) finding affects both sides. Fill only if 'Group XXII selected (Front of neck muscles)' is selected. Depends on: Group XXII selected (Front of neck muscles)
Group XXIII (Side/Back of Neck Muscles) - Selected and Side Affected
Group XXIII selected (side/back of neck muscles)	Checkbox	Check this box if the condition or injury involves Group XXIII muscles of the side and back of the neck (suboccipital, lateral vertebral, and anterior vertebral muscles).
Side affected: Right	Radiobutton	Check this box if the Group XXIII muscle condition affects the right side. Fill only if 'Group XXIII selected (side/back of neck muscles)' is selected. Depends on: Group XXIII selected (side/back of neck muscles)
Side affected: Left	Radiobutton	Check this box if the Group XXIII muscle condition affects the left side. Fill only if 'Group XXIII selected (side/back of neck muscles)' is selected. Depends on: Group XXIII selected (side/back of neck muscles)
Side affected: Both	Radiobutton	Check this box if the Group XXIII muscle condition affects both sides. Fill only if 'Group XXIII selected (side/back of neck muscles)' is selected. Depends on: Group XXIII selected (side/back of neck muscles)
Hip Flexion Strength Ratings (Right & Left)
Hip flexion (Right) - 5/5	Radiobutton	Check this box if the patient's right hip flexion strength is rated 5/5 (normal strength). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Hip flexion (Right) - 4/5	Radiobutton	Check this box if the patient's right hip flexion strength is rated 4/5 (less than normal strength). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Hip flexion (Right) - 3/5	Radiobutton	Check this box if the patient's right hip flexion strength is rated 3/5 (no movement against resistance). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Hip flexion (Right) - 2/5	Radiobutton	Check this box if the patient's right hip flexion strength is rated 2/5 (no movement against gravity). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Hip flexion (Right) - 1/5	Radiobutton	Check this box if the patient's right hip flexion strength is rated 1/5 (visible muscle movement, but no joint movement). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Hip flexion (Right) - 0/5	Radiobutton	Check this box if the patient's right hip flexion strength is rated 0/5 (no muscle movement). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Hip flexion (Left) - 5/5	Radiobutton	Check this box if the patient's left hip flexion strength is rated 5/5 (normal strength). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Hip flexion (Left) - 4/5	Radiobutton	Check this box if the patient's left hip flexion strength is rated 4/5 (less than normal strength). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Hip flexion (Left) - 3/5	Radiobutton	Check this box if the patient's left hip flexion strength is rated 3/5 (no movement against resistance). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Hip flexion (Left) - 2/5	Radiobutton	Check this box if the patient's left hip flexion strength is rated 2/5 (no movement against gravity). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Hip flexion (Left) - 1/5	Radiobutton	Check this box if the patient's left hip flexion strength is rated 1/5 (visible muscle movement, but no joint movement). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Hip flexion (Left) - 0/5	Radiobutton	Check this box if the patient's left hip flexion strength is rated 0/5 (no muscle movement). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Impairment of Coordination (Side, Muscle Group, Frequency/Severity)
Impairment of coordination	Checkbox	Check this box if the veteran has impairment of coordination attributable to a muscle injury. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right (side affected)	Radiobutton	Select this option if the impairment of coordination affects the right side. Fill only if 'Impairment of coordination' is 'Yes'. Depends on: Impairment of coordination
Left (side affected)	Radiobutton	Select this option if the impairment of coordination affects the left side. Fill only if 'Impairment of coordination' is 'Yes'. Depends on: Impairment of coordination
Both (sides affected)	Radiobutton	Select this option if the impairment of coordination affects both sides. Fill only if 'Impairment of coordination' is 'Yes'. Depends on: Impairment of coordination
Impairment of coordination – Muscle group(s) affected	Text	Enter the muscle group number(s) and/or name(s) (I–XXIII) affected by the veteran’s impairment of coordination. Fill only if 'Impairment of coordination' is 'Yes'. Depends on: Impairment of coordination
Occasional (frequency/severity)	Radiobutton	Select this option if the impairment of coordination occurs occasionally. Fill only if 'Impairment of coordination' is 'Yes'. Depends on: Impairment of coordination
Consistent (frequency/severity)	Radiobutton	Select this option if the impairment of coordination is consistent. Fill only if 'Impairment of coordination' is 'Yes'. Depends on: Impairment of coordination
Consistent at a more severe level (frequency/severity)	Radiobutton	Select this option if the impairment of coordination is consistent and occurs at a more severe level. Fill only if 'Impairment of coordination' is 'Yes'. Depends on: Impairment of coordination
In-Person Examination and If-Not Method
Examined in person - Yes	Radiobutton	Check this box if the Veteran was examined in person (face-to-face) for this evaluation.
Examined in person - No	Radiobutton	Check this box if the Veteran was not examined in person, and the examination was conducted by another method.
Examination Method if Not In Person	Text	Describe how the examination was conducted if the Veteran was not examined in person (e.g., telehealth, records review, phone interview). Fill only if 'Examined in person - No' is 'Yes'. Depends on: Examined in person - No
Knee Extension Strength Ratings (Right & Left)
Knee extension strength (Right) – 5/5	Radiobutton	Check this box if right knee extension strength is normal (5/5). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Knee extension strength (Right) – 4/5	Radiobutton	Check this box if right knee extension strength is less than normal (4/5). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Knee extension strength (Right) – 3/5	Radiobutton	Check this box if right knee extension can move against gravity but not against resistance (3/5). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Knee extension strength (Right) – 2/5	Radiobutton	Check this box if right knee extension cannot move against gravity (2/5). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Knee extension strength (Right) – 1/5	Radiobutton	Check this box if there is visible right knee extensor muscle movement but no joint movement (1/5). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Knee extension strength (Right) – 0/5	Radiobutton	Check this box if there is no right knee extensor muscle movement (0/5). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Knee extension strength (Left) – 5/5	Radiobutton	Check this box if left knee extension strength is normal (5/5). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Knee extension strength (Left) – 4/5	Radiobutton	Check this box if left knee extension strength is less than normal (4/5). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Knee extension strength (Left) – 3/5	Radiobutton	Check this box if left knee extension can move against gravity but not against resistance (3/5). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Knee extension strength (Left) – 2/5	Radiobutton	Check this box if left knee extension cannot move against gravity (2/5). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Knee extension strength (Left) – 1/5	Radiobutton	Check this box if there is visible left knee extensor muscle movement but no joint movement (1/5). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Knee extension strength (Left) – 0/5	Radiobutton	Check this box if there is no left knee extensor muscle movement (0/5). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Knee Flexion Strength Ratings (Right & Left)
Knee flexion (Right) - 5/5	Radiobutton	Check this box if right knee flexion strength is normal (5/5). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Knee flexion (Right) - 4/5	Radiobutton	Check this box if right knee flexion strength is less than normal (4/5). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Knee flexion (Right) - 3/5	Radiobutton	Check this box if right knee flexion has no movement against resistance (3/5). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Knee flexion (Right) - 2/5	Radiobutton	Check this box if right knee flexion has no movement against gravity (2/5). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Knee flexion (Right) - 1/5	Radiobutton	Check this box if right knee flexion shows visible muscle movement but no joint movement (1/5). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Knee flexion (Right) - 0/5	Radiobutton	Check this box if there is no right knee flexion muscle movement (0/5). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Knee flexion (Left) - 5/5	Radiobutton	Check this box if left knee flexion strength is normal (5/5). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Knee flexion (Left) - 4/5	Radiobutton	Check this box if left knee flexion strength is less than normal (4/5). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Knee flexion (Left) - 3/5	Radiobutton	Check this box if left knee flexion has no movement against resistance (3/5). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Knee flexion (Left) - 2/5	Radiobutton	Check this box if left knee flexion has no movement against gravity (2/5). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Knee flexion (Left) - 1/5	Radiobutton	Check this box if left knee flexion shows visible muscle movement but no joint movement (1/5). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Knee flexion (Left) - 0/5	Radiobutton	Check this box if there is no left knee flexion muscle movement (0/5). Fill only if '3D. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE PELVIC GIRDLE OR THIGH?' is 'Yes'. Depends on: Yes
Loss of Power (Side, Muscle Group, Frequency/Severity)
Loss of power	Checkbox	Check this box if the veteran has loss of power attributable to a muscle injury. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Loss of power - Right side	Radiobutton	Check this box if the loss of power affects the right side. Fill only if 'Loss of power' is 'Yes'. Depends on: Loss of power
Loss of power - Left side	Radiobutton	Check this box if the loss of power affects the left side. Fill only if 'Loss of power' is 'Yes'. Depends on: Loss of power
Loss of power - Both sides	Radiobutton	Check this box if the loss of power affects both sides. Fill only if 'Loss of power' is 'Yes'. Depends on: Loss of power
Loss of Power - Muscle Group(s) Affected	Text	Enter the muscle group number(s) affected by loss of power (e.g., I–XXIII), if known. Fill only if 'Loss of power' is 'Yes'. Depends on: Loss of power
Loss of power frequency/severity - Occasional	Radiobutton	Check this box if the loss of power occurs occasionally. Fill only if 'Loss of power' is 'Yes'. Depends on: Loss of power
Loss of power frequency/severity - Consistent	Radiobutton	Check this box if the loss of power is consistent. Fill only if 'Loss of power' is 'Yes'. Depends on: Loss of power
Loss of power frequency/severity - Consistent at a more severe level	Radiobutton	Check this box if the loss of power is consistent and occurs at a more severe level. Fill only if 'Loss of power' is 'Yes'. Depends on: Loss of power
Lowered Threshold of Fatigue (Side, Muscle Group, Frequency/Severity)
Lowered threshold of fatigue	Checkbox	Check this box if the veteran has a lowered threshold of fatigue attributable to a muscle injury. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected: Right	Radiobutton	Check this box if the lowered threshold of fatigue affects the right side. Fill only if 'Lowered threshold of fatigue' is 'Yes'. Depends on: Lowered threshold of fatigue
Side affected: Left	Radiobutton	Check this box if the lowered threshold of fatigue affects the left side. Fill only if 'Lowered threshold of fatigue' is 'Yes'. Depends on: Lowered threshold of fatigue
Side affected: Both	Radiobutton	Check this box if the lowered threshold of fatigue affects both sides. Fill only if 'Lowered threshold of fatigue' is 'Yes'. Depends on: Lowered threshold of fatigue
Lowered Threshold of Fatigue - Muscle Group(s) Affected	Text	Enter the muscle group number(s) or name(s) (I–XXIII, if possible) affected by the veteran’s lowered threshold of fatigue. Fill only if 'Lowered threshold of fatigue' is 'Yes'. Depends on: Lowered threshold of fatigue
Frequency/Severity: Occasional	Radiobutton	Check this box if the lowered threshold of fatigue occurs occasionally. Fill only if 'Lowered threshold of fatigue' is 'Yes'. Depends on: Lowered threshold of fatigue
Frequency/Severity: Consistent	Radiobutton	Check this box if the lowered threshold of fatigue is consistent. Fill only if 'Lowered threshold of fatigue' is 'Yes'. Depends on: Lowered threshold of fatigue
Frequency/Severity: Consistent at a more severe level	Radiobutton	Check this box if the lowered threshold of fatigue is consistent and occurs at a more severe level. Fill only if 'Lowered threshold of fatigue' is 'Yes'. Depends on: Lowered threshold of fatigue
Muscle Atrophy Details (Location, Side, Groups, Measurements, Notes)
Muscle Atrophy Location	Text	Enter the anatomical location where muscle atrophy is present (e.g., calf, thigh, forearm, upper arm). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right	Radiobutton	Check this box if the muscle atrophy is present on the right side. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left	Radiobutton	Check this box if the muscle atrophy is present on the left side. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Both	Radiobutton	Check this box if the muscle atrophy is present on both the right and left sides. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Affected Muscle Group(s)	Text	Specify the affected muscle group number(s) (I–XXIII) if known. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Normal Side Circumference (cm)	Number	Provide the circumference measurement of the normal (unaffected) side at maximum muscle bulk. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Atrophied Side Circumference (cm)	Number	Provide the circumference measurement of the atrophied (affected) side at maximum muscle bulk. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Additional Atrophy Locations and Measurements	Text	If muscle atrophy affects more than one muscle group, describe each additional location and include the normal-side and atrophied-side measurements using the same format as above. Fill only if 'Yes' is 'Yes' and affects more than one muscle group. Depends on: Yes
Muscle Atrophy Present (Yes/No)
Yes	Radiobutton	Check this box if the veteran has muscle atrophy of the injured muscle group.
No	Radiobutton	Check this box if the veteran does not have muscle atrophy of the injured muscle group.
Muscle Group I Selection and Side Affected
Group I (Shoulder girdle and arm)	Checkbox	Check this box if the Veteran has an injury involving Muscle Group I (extrinsic muscles of the shoulder girdle, e.g., trapezius/levator scapulae/serratus magnus). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected: Right	Radiobutton	Check this box if the Veteran’s Muscle Group I injury affects the right side. Fill only if 'Group I (Shoulder girdle and arm)' is 'Yes'. Depends on: Group I (Shoulder girdle and arm)
Side affected: Left	Radiobutton	Check this box if the Veteran’s Muscle Group I injury affects the left side. Fill only if 'Group I (Shoulder girdle and arm)' is 'Yes'. Depends on: Group I (Shoulder girdle and arm)
Side affected: Both	Radiobutton	Check this box if the Veteran’s Muscle Group I injury affects both sides. Fill only if 'Group I (Shoulder girdle and arm)' is 'Yes'. Depends on: Group I (Shoulder girdle and arm)
Muscle Group II Selection and Side Affected
Group II (Shoulder girdle muscles)	Checkbox	Check this box if the Veteran has or has had an injury involving Muscle Group II (muscles of the shoulder girdle, e.g., pectoralis major/minor, latissimus dorsi, teres major, rhomboid). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected: Right (Group II)	Radiobutton	Check this box if the Muscle Group II injury affects the right side. Fill only if 'Group II (Shoulder girdle muscles)' is 'Yes'. Depends on: Group II (Shoulder girdle muscles)
Side affected: Left (Group II)	Radiobutton	Check this box if the Muscle Group II injury affects the left side. Fill only if 'Group II (Shoulder girdle muscles)' is 'Yes'. Depends on: Group II (Shoulder girdle muscles)
Side affected: Both (Group II)	Radiobutton	Check this box if the Muscle Group II injury affects both sides. Fill only if 'Group II (Shoulder girdle muscles)' is 'Yes'. Depends on: Group II (Shoulder girdle muscles)
Muscle Group III Selection and Side Affected
Group III (Intrinsic muscles of shoulder girdle)	Checkbox	Check this box if the Veteran has (now or ever had) an injury involving Muscle Group III (pectoralis major, deltoid) of the shoulder girdle. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected: Right	Radiobutton	Check this box if the Muscle Group III injury affects the right side. Fill only if 'Group III (Intrinsic muscles of shoulder girdle)' is 'Yes'. Depends on: Group III (Intrinsic muscles of shoulder girdle)
Side affected: Left	Radiobutton	Check this box if the Muscle Group III injury affects the left side. Fill only if 'Group III (Intrinsic muscles of shoulder girdle)' is 'Yes'. Depends on: Group III (Intrinsic muscles of shoulder girdle)
Side affected: Both	Radiobutton	Check this box if the Muscle Group III injury affects both the right and left sides. Fill only if 'Group III (Intrinsic muscles of shoulder girdle)' is 'Yes'. Depends on: Group III (Intrinsic muscles of shoulder girdle)
Muscle Group IV Selection and Side Affected
Group IV (Shoulder girdle muscles)	Checkbox	Check this box if the Veteran’s muscle injury involves Muscle Group IV (shoulder girdle muscles such as supraspinatus, infraspinatus/teres minor, subscapularis, or coracobrachialis). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Group IV side affected: Right	Radiobutton	Check this box if the Muscle Group IV injury affects the right side. Fill only if 'Group IV (Shoulder girdle muscles)' is 'Yes'. Depends on: Group IV (Shoulder girdle muscles)
Group IV side affected: Left	Radiobutton	Check this box if the Muscle Group IV injury affects the left side. Fill only if 'Group IV (Shoulder girdle muscles)' is 'Yes'. Depends on: Group IV (Shoulder girdle muscles)
Group IV side affected: Both	Radiobutton	Check this box if the Muscle Group IV injury affects both sides. Fill only if 'Group IV (Shoulder girdle muscles)' is 'Yes'. Depends on: Group IV (Shoulder girdle muscles)
Muscle Group IX Selection and Side Affected
Group IX (Intrinsic muscles of hand)	Checkbox	Check this box if the veteran has (now or ever had) an injury affecting Muscle Group IX (intrinsic muscles of the hand). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected: Right	Radiobutton	Check this box if the Muscle Group IX injury affects the right hand/forearm. Fill only if 'Yes', 'Group IX (Intrinsic muscles of hand)' is 'Yes' (all). Depends on: Yes, Group IX (Intrinsic muscles of hand)
Side affected: Left	Radiobutton	Check this box if the Muscle Group IX injury affects the left hand/forearm. Fill only if 'Yes', 'Group IX (Intrinsic muscles of hand)' is 'Yes' (all). Depends on: Yes, Group IX (Intrinsic muscles of hand)
Side affected: Both	Radiobutton	Check this box if the Muscle Group IX injury affects both the right and left hands/forearms. Fill only if 'Yes', 'Group IX (Intrinsic muscles of hand)' is 'Yes' (all). Depends on: Yes, Group IX (Intrinsic muscles of hand)
Muscle Group V Selection and Side Affected
Group V (Flexor muscles of elbow)	Checkbox	Check this box if the Veteran has (now or ever had) an injury involving Muscle Group V (flexor muscles of the elbow, e.g., biceps/brachialis/brachioradialis). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected: Right (Group V)	Radiobutton	Check this box if the Muscle Group V injury affects the right side. Fill only if 'Group V (Flexor muscles of elbow)' is 'Yes'. Depends on: Group V (Flexor muscles of elbow)
Side affected: Left (Group V)	Radiobutton	Check this box if the Muscle Group V injury affects the left side. Fill only if 'Group V (Flexor muscles of elbow)' is 'Yes'. Depends on: Group V (Flexor muscles of elbow)
Side affected: Both (Group V)	Radiobutton	Check this box if the Muscle Group V injury affects both the right and left sides. Fill only if 'Group V (Flexor muscles of elbow)' is 'Yes'. Depends on: Group V (Flexor muscles of elbow)
Muscle Group VI Selection and Side Affected
Group VI (Extensor muscles of elbow: triceps)	Checkbox	Check this box if the Veteran has a current or past muscle injury involving Muscle Group VI (extensor muscles of the elbow/triceps). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected: Right	Radiobutton	Check this box if the Muscle Group VI injury affects the right side only. Fill only if 'Group VI (Extensor muscles of elbow: triceps)' is 'Yes'. Depends on: Group VI (Extensor muscles of elbow: triceps)
Side affected: Left	Radiobutton	Check this box if the Muscle Group VI injury affects the left side only. Fill only if 'Group VI (Extensor muscles of elbow: triceps)' is 'Yes'. Depends on: Group VI (Extensor muscles of elbow: triceps)
Side affected: Both	Radiobutton	Check this box if the Muscle Group VI injury affects both the right and left sides. Fill only if 'Group VI (Extensor muscles of elbow: triceps)' is 'Yes'. Depends on: Group VI (Extensor muscles of elbow: triceps)
Muscle Group VII Selection and Side Affected
Group VII (forearm flexors)	Checkbox	Check this box if the veteran has (now or ever had) an injury involving Muscle Group VII (forearm muscles responsible for flexion of the wrist, fingers, and thumb). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected: Right	Radiobutton	Check this box if the Muscle Group VII injury affects the right side. Fill only if 'Yes', 'Group VII (forearm flexors)' is 'Yes' (all). Depends on: Yes, Group VII (forearm flexors)
Side affected: Left	Radiobutton	Check this box if the Muscle Group VII injury affects the left side. Fill only if 'Yes', 'Group VII (forearm flexors)' is 'Yes' (all). Depends on: Yes, Group VII (forearm flexors)
Side affected: Both	Radiobutton	Check this box if the Muscle Group VII injury affects both the right and left sides. Fill only if 'Yes', 'Group VII (forearm flexors)' is 'Yes' (all). Depends on: Yes, Group VII (forearm flexors)
Muscle Group VIII Selection and Side Affected
Group VIII (extensors of the wrist, fingers and thumb)	Checkbox	Check this box if the veteran has (or has ever had) an injury involving Muscle Group VIII (wrist/finger/thumb extensors). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected: Right (Group VIII)	Radiobutton	Check this box if the Muscle Group VIII injury affects the right forearm/hand. Fill only if 'Yes', 'Group VIII (extensors of the wrist, fingers and thumb)' is 'Yes' (all). Depends on: Yes, Group VIII (extensors of the wrist, fingers and thumb)
Side affected: Left (Group VIII)	Radiobutton	Check this box if the Muscle Group VIII injury affects the left forearm/hand. Fill only if 'Yes', 'Group VIII (extensors of the wrist, fingers and thumb)' is 'Yes' (all). Depends on: Yes, Group VIII (extensors of the wrist, fingers and thumb)
Side affected: Both (Group VIII)	Radiobutton	Check this box if the Muscle Group VIII injury affects both forearms/hands. Fill only if 'Yes', 'Group VIII (extensors of the wrist, fingers and thumb)' is 'Yes' (all). Depends on: Yes, Group VIII (extensors of the wrist, fingers and thumb)
Muscle Group XIII (Posterior Thigh/Hamstrings) Selection & Side Affected
Group XIII – Posterior thigh/hamstring muscles	Checkbox	Check this box if the veteran has (now or ever had) an injury involving Muscle Group XIII (posterior thigh/hamstrings). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected – Right	Radiobutton	Select this option if the Muscle Group XIII injury affects the right side. Fill only if 'Group XIII – Posterior thigh/hamstring muscles' is checked. Depends on: Group XIII – Posterior thigh/hamstring muscles
Side affected – Left	Radiobutton	Select this option if the Muscle Group XIII injury affects the left side. Fill only if 'Group XIII – Posterior thigh/hamstring muscles' is checked. Depends on: Group XIII – Posterior thigh/hamstring muscles
Side affected – Both	Radiobutton	Select this option if the Muscle Group XIII injury affects both the right and left sides. Fill only if 'Group XIII – Posterior thigh/hamstring muscles' is checked. Depends on: Group XIII – Posterior thigh/hamstring muscles
Muscle Group XIV (Anterior Thigh) Selection & Side Affected
Group XIV (Anterior thigh muscles)	Checkbox	Check this box if the veteran has (now or ever had) an injury to Muscle Group XIV (anterior thigh muscles such as sartorius, rectus femoris, quadriceps). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected: Right	Radiobutton	Check this box if the Muscle Group XIV injury affects the right side only. Fill only if 'Group XIV (Anterior thigh muscles)' is checked. Depends on: Group XIV (Anterior thigh muscles)
Side affected: Left	Radiobutton	Check this box if the Muscle Group XIV injury affects the left side only. Fill only if 'Group XIV (Anterior thigh muscles)' is checked. Depends on: Group XIV (Anterior thigh muscles)
Side affected: Both	Radiobutton	Check this box if the Muscle Group XIV injury affects both the right and left sides. Fill only if 'Group XIV (Anterior thigh muscles)' is checked. Depends on: Group XIV (Anterior thigh muscles)
Muscle Group XV (Mesial Thigh) Selection & Side Affected
Group XV (Mesial thigh muscles)	Checkbox	Check this box if the veteran has (or has ever had) an injury involving Muscle Group XV (mesial thigh/adductor muscles). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected: Right	Radiobutton	Check this box if the Muscle Group XV injury affects the right thigh/hip area. Fill only if 'Group XV (Mesial thigh muscles)' is checked. Depends on: Group XV (Mesial thigh muscles)
Side affected: Left	Radiobutton	Check this box if the Muscle Group XV injury affects the left thigh/hip area. Fill only if 'Group XV (Mesial thigh muscles)' is checked. Depends on: Group XV (Mesial thigh muscles)
Side affected: Both	Radiobutton	Check this box if the Muscle Group XV injury affects both the right and left thighs/hips. Fill only if 'Group XV (Mesial thigh muscles)' is checked. Depends on: Group XV (Mesial thigh muscles)
Muscle Group XVI (Pelvic Girdle - Psoas/Iliacus/Pectineus) Selection & Side Affected
Group XVI (Pelvic girdle muscles: psoas, iliacus, pectineus)	Checkbox	Check this box if the veteran has (now or ever had) an injury to Muscle Group XVI (psoas/iliacus/pectineus) affecting hip flexion. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected: Right	Radiobutton	Check this box if the Muscle Group XVI injury affects the right side. Fill only if 'Group XVI (Pelvic girdle muscles: psoas, iliacus, pectineus)' is checked. Depends on: Group XVI (Pelvic girdle muscles: psoas, iliacus, pectineus)
Side affected: Left	Radiobutton	Check this box if the Muscle Group XVI injury affects the left side. Fill only if 'Group XVI (Pelvic girdle muscles: psoas, iliacus, pectineus)' is checked. Depends on: Group XVI (Pelvic girdle muscles: psoas, iliacus, pectineus)
Side affected: Both	Radiobutton	Check this box if the Muscle Group XVI injury affects both the right and left sides. Fill only if 'Group XVI (Pelvic girdle muscles: psoas, iliacus, pectineus)' is checked. Depends on: Group XVI (Pelvic girdle muscles: psoas, iliacus, pectineus)
Muscle Group XVII (Gluteal Muscles) Selection & Side Affected
Group XVII (Gluteal muscles)	Checkbox	Check this box if the veteran has (now or ever had) an injury to Muscle Group XVII (gluteus maximus/medius/minimus). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected: Right	Radiobutton	Check this box if the Muscle Group XVII injury affects the right side. Fill only if 'Group XVII (Gluteal muscles)' is checked. Depends on: Group XVII (Gluteal muscles)
Side affected: Left	Radiobutton	Check this box if the Muscle Group XVII injury affects the left side. Fill only if 'Group XVII (Gluteal muscles)' is checked. Depends on: Group XVII (Gluteal muscles)
Side affected: Both	Radiobutton	Check this box if the Muscle Group XVII injury affects both sides. Fill only if 'Group XVII (Gluteal muscles)' is checked. Depends on: Group XVII (Gluteal muscles)
Muscle Group XVIII (Pelvic Girdle - Deep External Rotators) Selection & Side Affected
Group XVIII (pelvic girdle – deep external rotators)	Checkbox	Check this box if the veteran now has or has ever had an injury affecting Muscle Group XVIII (pelvic girdle deep external rotators such as piriformis, gemelli, obturator, quadratus femoris). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected: Right	Radiobutton	Check this box if the Muscle Group XVIII injury affects the right side. Fill only if 'Group XVIII (pelvic girdle – deep external rotators)' is checked. Depends on: Group XVIII (pelvic girdle – deep external rotators)
Side affected: Left	Radiobutton	Check this box if the Muscle Group XVIII injury affects the left side. Fill only if 'Group XVIII (pelvic girdle – deep external rotators)' is checked. Depends on: Group XVIII (pelvic girdle – deep external rotators)
Side affected: Both	Radiobutton	Check this box if the Muscle Group XVIII injury affects both the right and left sides. Fill only if 'Group XVIII (pelvic girdle – deep external rotators)' is checked. Depends on: Group XVIII (pelvic girdle – deep external rotators)
Muscle Injury History Summary
Muscle Injury History Summary	Text	Provide a brief summary of the veteran’s muscle injury history, including when it began and how it has progressed over time. Fill only if 'Yes', 'Yes' is 'Yes' (any). Depends on: Yes, Yes
Non-Penetrating Muscle Injury (Yes/No)
Yes	Radiobutton	Check this box if the Veteran has a non-penetrating muscle injury (e.g., muscle strain, torn Achilles tendon, or torn quadriceps muscle).
No	Radiobutton	Check this box if the Veteran does not have a non-penetrating muscle injury.
Other Assistive Device and Frequency
Other (assistive device)	Checkbox	Check this box if the veteran uses an assistive device not listed (wheelchair, braces, crutches, canes, walker) and you will specify what it is.
Other Assistive Device	Text	Enter the name or description of any other assistive device the veteran uses that is not listed (e.g., wheelchair, braces, crutches, cane, walker). Fill only if 'Other (assistive device)' is 'Yes'. Depends on: Other (assistive device)
Other device frequency of use: Occasional	Radiobutton	Select this option if the veteran uses the specified “Other” assistive device only occasionally. Fill only if 'Other (assistive device)' is 'Yes'. Depends on: Other (assistive device)
Other device frequency of use: Regular	Radiobutton	Select this option if the veteran uses the specified “Other” assistive device on a regular basis. Fill only if 'Other (assistive device)' is 'Yes'. Depends on: Other (assistive device)
Other device frequency of use: Constant	Radiobutton	Select this option if the veteran uses the specified “Other” assistive device constantly. Fill only if 'Other (assistive device)' is 'Yes'. Depends on: Other (assistive device)
Other Muscle Group Tested & Strength Ratings (Right & Left)
Other Muscle Group/Movement Tested	Text	Enter the name of any other movement or muscle group that was tested and should be documented here.
Right strength 5/5	Radiobutton	Check this box if the tested other movement/muscle group has normal (5/5) strength on the right side. Fill only if 'Other Muscle Group/Movement Tested' is not blank. Depends on: Other Muscle Group/Movement Tested
Right strength 4/5	Radiobutton	Check this box if the tested other movement/muscle group has 4/5 strength on the right side. Fill only if 'Other Muscle Group/Movement Tested' is not blank. Depends on: Other Muscle Group/Movement Tested
Right strength 3/5	Radiobutton	Check this box if the tested other movement/muscle group has 3/5 strength on the right side. Fill only if 'Other Muscle Group/Movement Tested' is not blank. Depends on: Other Muscle Group/Movement Tested
Right strength 2/5	Radiobutton	Check this box if the tested other movement/muscle group has 2/5 strength on the right side. Fill only if 'Other Muscle Group/Movement Tested' is not blank. Depends on: Other Muscle Group/Movement Tested
Right strength 1/5	Radiobutton	Check this box if the tested other movement/muscle group has 1/5 strength on the right side. Fill only if 'Other Muscle Group/Movement Tested' is not blank. Depends on: Other Muscle Group/Movement Tested
Right strength 0/5	Radiobutton	Check this box if the tested other movement/muscle group has 0/5 strength (no contraction) on the right side. Fill only if 'Other Muscle Group/Movement Tested' is not blank. Depends on: Other Muscle Group/Movement Tested
Left strength 5/5	Radiobutton	Check this box if the tested other movement/muscle group has normal (5/5) strength on the left side. Fill only if 'Other Muscle Group/Movement Tested' is not blank. Depends on: Other Muscle Group/Movement Tested
Left strength 4/5	Radiobutton	Check this box if the tested other movement/muscle group has 4/5 strength on the left side. Fill only if 'Other Muscle Group/Movement Tested' is not blank. Depends on: Other Muscle Group/Movement Tested
Left strength 3/5	Radiobutton	Check this box if the tested other movement/muscle group has 3/5 strength on the left side. Fill only if 'Other Muscle Group/Movement Tested' is not blank. Depends on: Other Muscle Group/Movement Tested
Left strength 2/5	Radiobutton	Check this box if the tested other movement/muscle group has 2/5 strength on the left side. Fill only if 'Other Muscle Group/Movement Tested' is not blank. Depends on: Other Muscle Group/Movement Tested
Left strength 1/5	Radiobutton	Check this box if the tested other movement/muscle group has 1/5 strength on the left side. Fill only if 'Other Muscle Group/Movement Tested' is not blank. Depends on: Other Muscle Group/Movement Tested
Left strength 0/5	Radiobutton	Check this box if the tested other movement/muscle group has 0/5 strength (no contraction) on the left side. Fill only if 'Other Muscle Group/Movement Tested' is not blank. Depends on: Other Muscle Group/Movement Tested
Patient/Veteran Identification
Patient/Veteran Name	Text	Enter the full name of the patient/veteran.
Patient/Veteran Social Security Number	Text	Enter the patient/veteran's Social Security Number.
Date of Examination	Date	Enter the date the examination was performed.
Pelvic Girdle/Thigh Injury History (Yes/No)
Yes	Radiobutton	Check this box if the veteran now has or has ever had an injury to a muscle group of the pelvic girdle or thigh.
No	Radiobutton	Check this box if the veteran does not now have and has never had an injury to a muscle group of the pelvic girdle or thigh.
Penetrating Muscle Injury (Yes/No)
Yes	Radiobutton	Check this box if the Veteran has a penetrating muscle injury (e.g., gunshot wound or shell fragment wound).
No	Radiobutton	Check this box if the Veteran does not have a penetrating muscle injury.
Requester Type and Details
Veteran/Claimant	Checkbox	Check this box if you are completing this questionnaire at the request of the Veteran/claimant.
Third party	Checkbox	Check this box if you are completing this questionnaire at the request of a third party (and then list the organization(s) or individual(s)).
Third-Party Requester Name(s)	Text	Enter the name(s) of the third-party organization(s) or individual(s) requesting completion of this questionnaire. Fill only if 'Third party' is 'Yes'. Depends on: Third party
Other (please describe)	Checkbox	Check this box if you are completing this questionnaire at the request of someone else not listed above and provide a description.
Other Requester Description	Text	Describe who or what entity is requesting completion of this questionnaire if the requester type is 'Other'. Fill only if 'Other (please describe)' is 'Yes'. Depends on: Other (please describe)
Second Muscle Injury Diagnosis
Diagnosis #2	Text	Enter the second diagnosed muscle injury condition. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Diagnosis #2 ICD Code	Text	Enter the ICD code corresponding to the second muscle injury diagnosis. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Diagnosis #2 Date of Diagnosis	Date	Enter the date when the second muscle injury diagnosis was made. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected (Diagnosis #2): Right	Radiobutton	Check this box if the veteran’s second listed muscle injury diagnosis affects the right side. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected (Diagnosis #2): Left	Radiobutton	Check this box if the veteran’s second listed muscle injury diagnosis affects the left side. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected (Diagnosis #2): Both	Radiobutton	Check this box if the veteran’s second listed muscle injury diagnosis affects both sides. Fill only if 'Yes' is 'Yes'. Depends on: Yes
SECTION VIII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
Yes	Radiobutton	Check this box if the Veteran has other pertinent physical findings, complications, conditions, signs, and/or symptoms related to the condition(s) listed in the diagnosis section.
No	Radiobutton	Check this box if the Veteran does not have any other pertinent physical findings, complications, conditions, signs, and/or symptoms related to the condition(s) listed in the diagnosis section.
Other Pertinent Physical Findings Summary	Text	Provide a brief summary of any other pertinent physical findings, complications, conditions, signs, and/or symptoms related to the diagnosed condition(s). Fill only if 'Yes' is 'Yes'. Depends on: Yes
8B. Comments, if any	Text
SECTION X - FUNCTIONAL IMPACT
Yes	Radiobutton	Check this box if the Veteran’s muscle injury(ies) impact his or her ability to work (e.g., inability to keep up with work requirements).
No	Radiobutton	Check this box if the Veteran’s muscle injury(ies) do not impact his or her ability to work.
Work Impact Description	Text	Describe how the Veteran's muscle injury(ies) affect the ability to work, including one or more specific examples of functional limitations or difficulties meeting work requirements. Fill only if 'Yes' is 'Yes'. Depends on: Yes
SECTION XI - REMARKS
Remarks	Text	Enter any additional remarks or comments relevant to this examination that were not captured elsewhere on the form.
Severe Damage to Muscle Group XVII (Yes/No)
Yes	Radiobutton	Check this box if there is severe damage to Muscle Group XVII such that the veteran is unable to rise from a seated and stooped position and cannot maintain postural stability without assistance. Fill only if 'Group XVII (Gluteal muscles)' is checked. Depends on: Group XVII (Gluteal muscles)
No	Radiobutton	Check this box if there is not severe damage to Muscle Group XVII as described (the veteran can rise from a seated and stooped position and/or maintain postural stability without assistance). Fill only if 'Group XVII (Gluteal muscles)' is checked. Depends on: Group XVII (Gluteal muscles)
Shoulder Abduction Strength Ratings (Right & Left)
Right 5/5	Radiobutton	Check this box if the patient’s RIGHT shoulder abduction strength is rated 5/5 (normal strength). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Right 4/5	Radiobutton	Check this box if the patient’s RIGHT shoulder abduction strength is rated 4/5 (less than normal strength). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Right 3/5	Radiobutton	Check this box if the patient’s RIGHT shoulder abduction strength is rated 3/5 (no movement against resistance). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Right 2/5	Radiobutton	Check this box if the patient’s RIGHT shoulder abduction strength is rated 2/5 (no movement against gravity). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Right 1/5	Radiobutton	Check this box if the patient’s RIGHT shoulder abduction strength is rated 1/5 (visible muscle movement, but no joint movement). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Right 0/5	Radiobutton	Check this box if the patient’s RIGHT shoulder abduction strength is rated 0/5 (no muscle movement). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Left 5/5	Radiobutton	Check this box if the patient’s LEFT shoulder abduction strength is rated 5/5 (normal strength). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Left 4/5	Radiobutton	Check this box if the patient’s LEFT shoulder abduction strength is rated 4/5 (less than normal strength). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Left 3/5	Radiobutton	Check this box if the patient’s LEFT shoulder abduction strength is rated 3/5 (no movement against resistance). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Left 2/5	Radiobutton	Check this box if the patient’s LEFT shoulder abduction strength is rated 2/5 (no movement against gravity). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Left 1/5	Radiobutton	Check this box if the patient’s LEFT shoulder abduction strength is rated 1/5 (visible muscle movement, but no joint movement). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Left 0/5	Radiobutton	Check this box if the patient’s LEFT shoulder abduction strength is rated 0/5 (no muscle movement). Fill only if '3A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?' is 'Yes'. Depends on: Yes
Shoulder Girdle/Arm Injury History (3A Yes/No)
Yes	Radiobutton	Check this box if the Veteran now has, or has ever had, an injury to a muscle group of the shoulder girdle or arm.
No	Radiobutton	Check this box if the Veteran does not now have and has never had an injury to a muscle group of the shoulder girdle or arm.
Third Muscle Injury Diagnosis
Diagnosis #3	Text	Enter the third diagnosed muscle injury condition. Fill only if 'Yes' is 'Yes'. Depends on: Yes
ICD Code (Diagnosis #3)	Text	Enter the ICD diagnostic code associated with the third muscle injury diagnosis. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Date of Diagnosis (Diagnosis #3)	Date	Enter the date when the third muscle injury diagnosis was made. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right	Radiobutton	Check this box if Diagnosis #3 affects the right side. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left	Radiobutton	Check this box if Diagnosis #3 affects the left side. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Both	Radiobutton	Check this box if Diagnosis #3 affects both the right and left sides. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Torso/Neck Muscle Group Injury (3E) - Yes/No
Yes	Radiobutton	Check this box if the veteran now has or has ever had an injury to a muscle group in the torso and/or neck.
No	Radiobutton	Check this box if the veteran does not now have and has never had an injury to a muscle group in the torso and/or neck.
Uncertainty of Movement (Side, Muscle Group, Frequency/Severity)
Uncertainty of movement	Checkbox	Check this box if the veteran has uncertainty of movement attributable to a muscle injury. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Uncertainty of movement - Right side	Radiobutton	Check this box if the uncertainty of movement affects the right side. Fill only if 'Uncertainty of movement' is 'Yes'. Depends on: Uncertainty of movement
Uncertainty of movement - Left side	Radiobutton	Check this box if the uncertainty of movement affects the left side. Fill only if 'Uncertainty of movement' is 'Yes'. Depends on: Uncertainty of movement
Uncertainty of movement - Both sides	Radiobutton	Check this box if the uncertainty of movement affects both sides. Fill only if 'Uncertainty of movement' is 'Yes'. Depends on: Uncertainty of movement
Uncertainty of Movement - Affected Muscle Group(s)	Text	Enter the muscle group number(s) or name(s) (I–XXIII, if possible) affected by uncertainty of movement. Fill only if 'Uncertainty of movement' is 'Yes'. Depends on: Uncertainty of movement
Uncertainty of movement frequency/severity - Occasional	Radiobutton	Check this box if the uncertainty of movement occurs occasionally. Fill only if 'Uncertainty of movement' is 'Yes'. Depends on: Uncertainty of movement
Uncertainty of movement frequency/severity - Consistent	Radiobutton	Check this box if the uncertainty of movement is consistent (ongoing/regular). Fill only if 'Uncertainty of movement' is 'Yes'. Depends on: Uncertainty of movement
Uncertainty of movement frequency/severity - Consistent at a more severe level	Radiobutton	Check this box if the uncertainty of movement is consistent and occurs at a more severe level. Fill only if 'Uncertainty of movement' is 'Yes'. Depends on: Uncertainty of movement
VA Healthcare Provider (Yes/No)
VA Healthcare provider — Yes	Radiobutton	Check this box if you are a VA healthcare provider.
VA Healthcare provider — No	Radiobutton	Check this box if you are not a VA healthcare provider.
Veteran Regular Patient in Clinic (Yes/No)
Yes	Radiobutton	Check this box if the Veteran is regularly seen as a patient in your clinic.
No	Radiobutton	Check this box if the Veteran is not regularly seen as a patient in your clinic.
Walker Use and Frequency
Walker	Checkbox	Check this box if the veteran uses a walker as an assistive device for locomotion.
Walker frequency: Occasional	Radiobutton	Check this box if the veteran uses a walker occasionally. Fill only if 'Walker' is 'Yes'. Depends on: Walker
Walker frequency: Regular	Radiobutton	Check this box if the veteran uses a walker regularly. Fill only if 'Walker' is 'Yes'. Depends on: Walker
Walker frequency: Constant	Radiobutton	Check this box if the veteran uses a walker constantly. Fill only if 'Walker' is 'Yes'. Depends on: Walker
Weakness (Side, Muscle Group, Frequency/Severity)
Weakness	Checkbox	Check this box if the veteran has weakness attributable to a muscle injury. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Weakness - Side affected: Right	Radiobutton	Check this box if the weakness affects the right side. Fill only if 'Weakness' is 'Yes'. Depends on: Weakness
Weakness - Side affected: Left	Radiobutton	Check this box if the weakness affects the left side. Fill only if 'Weakness' is 'Yes'. Depends on: Weakness
Weakness - Side affected: Both	Radiobutton	Check this box if the weakness affects both sides. Fill only if 'Weakness' is 'Yes'. Depends on: Weakness
Weakness Muscle Group(s) Affected	Text	Enter the muscle group or groups affected by weakness (e.g., Muscle Groups I–XXIII), if known. Fill only if 'Weakness' is 'Yes'. Depends on: Weakness
Weakness - Frequency/Severity: Occasional	Radiobutton	Check this box if the weakness occurs occasionally. Fill only if 'Weakness' is 'Yes'. Depends on: Weakness
Weakness - Frequency/Severity: Consistent	Radiobutton	Check this box if the weakness is consistent. Fill only if 'Weakness' is 'Yes'. Depends on: Weakness
Weakness - Frequency/Severity: Consistent at a more severe level	Radiobutton	Check this box if the weakness is consistent and occurs at a more severe level. Fill only if 'Weakness' is 'Yes'. Depends on: Weakness
Wheelchair Use and Frequency
Wheelchair	Checkbox	Check this box if the veteran uses a wheelchair as an assistive device for locomotion.
Wheelchair frequency of use: Occasional	Radiobutton	Check this box if the veteran uses a wheelchair occasionally. Fill only if 'Wheelchair' is 'Yes'. Depends on: Wheelchair
Wheelchair frequency of use: Regular	Radiobutton	Check this box if the veteran uses a wheelchair on a regular basis. Fill only if 'Wheelchair' is 'Yes'. Depends on: Wheelchair
Wheelchair frequency of use: Constant	Radiobutton	Check this box if the veteran uses a wheelchair constantly. Fill only if 'Wheelchair' is 'Yes'. Depends on: Wheelchair
Wrist Extension Strength Ratings (Right & Left)
Right wrist extension strength: 5/5	Radiobutton	Check this box if the patient’s RIGHT wrist extension strength is normal (5/5). Fill only if '3B. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?' is 'Yes'. Depends on: Yes
Right wrist extension strength: 4/5	Radiobutton	Check this box if the patient’s RIGHT wrist extension strength is less than normal (4/5). Fill only if '3B. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?' is 'Yes'. Depends on: Yes
Right wrist extension strength: 3/5	Radiobutton	Check this box if the patient’s RIGHT wrist extension strength has no movement against resistance (3/5). Fill only if '3B. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?' is 'Yes'. Depends on: Yes
Right wrist extension strength: 2/5	Radiobutton	Check this box if the patient’s RIGHT wrist extension strength has no movement against gravity (2/5). Fill only if '3B. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?' is 'Yes'. Depends on: Yes
Right wrist extension strength: 1/5	Radiobutton	Check this box if the patient’s RIGHT wrist extension strength shows visible muscle movement but no joint movement (1/5). Fill only if '3B. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?' is 'Yes'. Depends on: Yes
Right wrist extension strength: 0/5	Radiobutton	Check this box if the patient’s RIGHT wrist extension strength shows no muscle movement (0/5). Fill only if '3B. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?' is 'Yes'. Depends on: Yes
Left wrist extension strength: 5/5	Radiobutton	Check this box if the patient’s LEFT wrist extension strength is normal (5/5). Fill only if '3B. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?' is 'Yes'. Depends on: Yes
Left wrist extension strength: 4/5	Radiobutton	Check this box if the patient’s LEFT wrist extension strength is less than normal (4/5). Fill only if '3B. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?' is 'Yes'. Depends on: Yes
Left wrist extension strength: 3/5	Radiobutton	Check this box if the patient’s LEFT wrist extension strength has no movement against resistance (3/5). Fill only if '3B. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?' is 'Yes'. Depends on: Yes
Left wrist extension strength: 2/5	Radiobutton	Check this box if the patient’s LEFT wrist extension strength has no movement against gravity (2/5). Fill only if '3B. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?' is 'Yes'. Depends on: Yes
Left wrist extension strength: 1/5	Radiobutton	Check this box if the patient’s LEFT wrist extension strength shows visible muscle movement but no joint movement (1/5). Fill only if '3B. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?' is 'Yes'. Depends on: Yes
Left wrist extension strength: 0/5	Radiobutton	Check this box if the patient’s LEFT wrist extension strength shows no muscle movement (0/5). Fill only if '3B. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?' is 'Yes'. Depends on: Yes
Wrist Flexion Strength Ratings (Right & Left)
Right wrist flexion: 5/5	Radiobutton	Check this box if the patient’s RIGHT wrist flexion strength is rated 5/5 (normal strength). Fill only if '3B. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?' is 'Yes'. Depends on: Yes
Right wrist flexion: 4/5	Radiobutton	Check this box if the patient’s RIGHT wrist flexion strength is rated 4/5 (less than normal strength). Fill only if '3B. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?' is 'Yes'. Depends on: Yes
Right wrist flexion: 3/5	Radiobutton	Check this box if the patient’s RIGHT wrist flexion strength is rated 3/5 (no movement against resistance). Fill only if '3B. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?' is 'Yes'. Depends on: Yes
Right wrist flexion: 2/5	Radiobutton	Check this box if the patient’s RIGHT wrist flexion strength is rated 2/5 (no movement against gravity). Fill only if '3B. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?' is 'Yes'. Depends on: Yes
Right wrist flexion: 1/5	Radiobutton	Check this box if the patient’s RIGHT wrist flexion strength is rated 1/5 (visible muscle movement but no joint movement). Fill only if '3B. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?' is 'Yes'. Depends on: Yes
Right wrist flexion: 0/5	Radiobutton	Check this box if the patient’s RIGHT wrist flexion strength is rated 0/5 (no muscle movement). Fill only if '3B. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?' is 'Yes'. Depends on: Yes
Left wrist flexion: 5/5	Radiobutton	Check this box if the patient’s LEFT wrist flexion strength is rated 5/5 (normal strength). Fill only if '3B. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?' is 'Yes'. Depends on: Yes
Left wrist flexion: 4/5	Radiobutton	Check this box if the patient’s LEFT wrist flexion strength is rated 4/5 (less than normal strength). Fill only if '3B. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?' is 'Yes'. Depends on: Yes
Left wrist flexion: 3/5	Radiobutton	Check this box if the patient’s LEFT wrist flexion strength is rated 3/5 (no movement against resistance). Fill only if '3B. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?' is 'Yes'. Depends on: Yes
Left wrist flexion: 2/5	Radiobutton	Check this box if the patient’s LEFT wrist flexion strength is rated 2/5 (no movement against gravity). Fill only if '3B. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?' is 'Yes'. Depends on: Yes
Left wrist flexion: 1/5	Radiobutton	Check this box if the patient’s LEFT wrist flexion strength is rated 1/5 (visible muscle movement but no joint movement). Fill only if '3B. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?' is 'Yes'. Depends on: Yes
Left wrist flexion: 0/5	Radiobutton	Check this box if the patient’s LEFT wrist flexion strength is rated 0/5 (no muscle movement). Fill only if '3B. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE FOREARM OR HAND?' is 'Yes'. Depends on: Yes

Disability Benefits Questionnaire (DBQ) - Muscle Injuries Instructions