Elbow and Forearm Conditions Disability Benefits Questionnaire Completed Form Examples and Samples

Patient: Smith, John A.
DOB: 1980-05-12
SSN: 789-00-1234
Date of Visit: 2025-11-20

**Subjective:** Mr. Smith, a right-hand dominant veteran, presents today for a follow-up regarding his chronic right elbow and forearm pain. He reports the pain originated in late 2020 while on active duty, following repetitive tasks. He describes constant dull ache, exacerbated by lifting, gripping, and any repetitive arm movements. He experiences flare-ups approximately once a week, lasting 1-2 days, with pain intensity reaching 7/10. These flare-ups are typically triggered by heavy lifting or prolonged computer use and are somewhat relieved by rest and ice. He notes significant functional impairment during these episodes, making it hard to perform daily tasks. He struggles with tasks like turning doorknobs, lifting grocery bags, and using power tools. He reports using an elbow brace constantly, specifically for his right elbow, which provides some support during his work as a mechanic.

**Objective:**
Physical Exam: Right elbow ROM is abnormal. Left elbow ROM is normal. 
Right Elbow: Active ROM: Flexion 130°, Extension 10°, Supination 70°, Pronation 65°. Pain is noted on all active movements. Passive ROM is congruent with active ROM, also eliciting pain. Pain is evident during weight-bearing, non-weight-bearing, active, and passive motions, and causes functional loss. No crepitus noted. Localized tenderness present over the lateral epicondyle, triceps insertion, and olecranon bursa, moderate severity, correlating with his diagnosed conditions.
Repetitive use testing of the right elbow performed, patient able to complete 3 repetitions. After 3 repetitions, ROM further diminished: Flexion 120°, Extension 15°, Supination 60°, Pronation 50°. These limitations are due to pain, weakness, and lack of endurance.

Veteran was not examined immediately after repeated use or during a flare-up. However, based on his statements and prior PT records (2021-2024), during repeated use over time, his estimated ROM would be: Flexion 110°, Extension 20°, Supination 55°, Pronation 45°. During flare-ups, estimated ROM would be: Flexion 100°, Extension 25°, Supination 50°, Pronation 40°. Other contributing factors to disability include swelling, weakened movement, and less movement than normal in the right elbow. Muscle atrophy of the right upper extremity noted 5cm above the elbow: normal side circumference 28 cm, atrophied side 26 cm. This is attributed to the claimed conditions. No ankylosis or other major impairments.

**Assessment:** Chronic right lateral epicondylitis (M77.11, diagnosed 2021-03-15), right tricep tendinitis (M76.01, diagnosed 2021-06-20), and right olecranon bursitis (M70.31, diagnosed 2022-01-10). These conditions significantly impact his ability to perform occupational tasks requiring grip strength, lifting, and repetitive arm motion. 

**Evidence Reviewed:** VA treatment records (2020-present), private physical therapy notes (2021-2024), X-ray of right elbow dated 2021-03-01 showing mild degenerative changes. MRI of right elbow dated 2022-02-05 confirmed lateral epicondylitis, tricep tendinopathy, and olecranon bursitis with fluid. Degenerative arthritis of the right elbow is documented. No other significant diagnostic findings.

**Plan:** Continue physical therapy, consider steroid injection. Refer for DBQ completion. Dr. Emily R. White, Orthopedics, NPI 1234567890, License 54321 CA, 789 Medical Plaza, Anytown, CA 90210. Phone: (555) 123-4567, Fax: (555) 123-4568.