Neck (Cervical Spine) Conditions Disability Benefits Questionnaire Instructions
This form contains 426 fields organized into 136 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| 13A Other Pertinent Physical Findings (Yes/No and Description) | ||
| Yes | Radiobutton |
Check this box if the Veteran has any other pertinent physical findings, complications, conditions, signs, or symptoms related to the diagnosed conditions.
|
| No | Radiobutton |
Check this box if the Veteran does not have any other pertinent physical findings, complications, conditions, signs, or symptoms related to the diagnosed conditions.
|
| Other Pertinent Physical Findings Description | Text |
Provide a brief summary describing any other pertinent physical findings, complications, conditions, signs, or symptoms related to the Veteran’s diagnosed conditions. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| 13B Scars or Skin Disfigurement Related to Condition (Yes/No) | ||
| Yes | Radiobutton |
Check this box if the Veteran has any scars or other skin disfigurement related to any diagnosed condition or its treatment.
|
| No | Radiobutton |
Check this box if the Veteran does not have any scars or other skin disfigurement related to any diagnosed condition or its treatment.
|
| 13C Additional Comments | ||
| Additional Comments | Text |
Enter any additional comments or relevant information related to Section 13 (other pertinent physical findings, complications, conditions, signs, symptoms, and scars).
|
| Active ROM Additional Comments | ||
| Active ROM Additional Comments | Text |
Enter any additional narrative comments about the active range of motion exam, including pain behavior, reasons testing could not be performed, and details of any limitation of motion attributable to pain, weakness, fatigability, incoordination, or other factors.
|
| Active ROM Limitation Degrees (If Different) | ||
| Forward Flexion Limitation Degree Endpoint | Number |
Enter the degree endpoint for forward flexion if the active range of motion is limited by factors such as pain, weakness, fatigability, incoordination, or other reasons and differs from the ROM value reported above.
|
| Left Lateral Flexion Limitation Degree Endpoint | Number |
Enter the degree endpoint for left lateral flexion if the active range of motion is limited by factors such as pain, weakness, fatigability, incoordination, or other reasons and differs from the ROM value reported above.
|
| Extension Limitation Degree Endpoint | Number |
Enter the degree endpoint for extension if the active range of motion is limited by factors such as pain, weakness, fatigability, incoordination, or other reasons and differs from the ROM value reported above.
|
| Right Lateral Rotation Limitation Degree Endpoint | Number |
Enter the degree endpoint for right lateral rotation if the active range of motion is limited by factors such as pain, weakness, fatigability, incoordination, or other reasons and differs from the ROM value reported above.
|
| Right Lateral Flexion Limitation Degree Endpoint | Number |
Enter the degree endpoint for right lateral flexion if the active range of motion is limited by factors such as pain, weakness, fatigability, incoordination, or other reasons and differs from the ROM value reported above.
|
| Left Lateral Rotation Limitation Degree Endpoint | Number |
Enter the degree endpoint for left lateral rotation if the active range of motion is limited by factors such as pain, weakness, fatigability, incoordination, or other reasons and differs from the ROM value reported above.
|
| Active ROM Measurements (Degrees) | ||
| Forward Flexion Endpoint (Active ROM) | Number |
Enter the measured active range of motion endpoint for forward flexion in degrees.
|
| Left Lateral Flexion Endpoint (Active ROM) | Number |
Enter the measured active range of motion endpoint for left lateral flexion in degrees.
|
| Extension Endpoint (Active ROM) | Number |
Enter the measured active range of motion endpoint for extension in degrees.
|
| Right Lateral Rotation Endpoint (Active ROM) | Number |
Enter the measured active range of motion endpoint for right lateral rotation in degrees.
|
| Right Lateral Flexion Endpoint (Active ROM) | Number |
Enter the measured active range of motion endpoint for right lateral flexion in degrees.
|
| Left Lateral Rotation Endpoint (Active ROM) | Number |
Enter the measured active range of motion endpoint for left lateral rotation in degrees.
|
| Active ROM Movements With Pain | ||
| Forward flexion | Checkbox |
Check this box if forward flexion active range of motion exhibited pain on examination.
|
| Right lateral flexion | Checkbox |
Check this box if right lateral flexion active range of motion exhibited pain on examination.
|
| Right lateral rotation | Checkbox |
Check this box if right lateral rotation active range of motion exhibited pain on examination.
|
| Extension | Checkbox |
Check this box if extension active range of motion exhibited pain on examination.
|
| Left lateral flexion | Checkbox |
Check this box if left lateral flexion active range of motion exhibited pain on examination.
|
| Left lateral rotation | Checkbox |
Check this box if left lateral rotation active range of motion exhibited pain on examination.
|
| Additional Contributing Factors - Detailed Description | ||
| Additional Contributing Factors Description | Text |
Provide a detailed narrative describing any additional factors contributing to the disability, including relevant symptoms, functional impacts, and any other details not captured above.
|
| Additional Contributing Factors - Options | ||
| None | Checkbox |
Check this box if there are no additional contributing factors of disability beyond those already addressed.
|
| Interference with sitting | Checkbox |
Check this box if the condition causes difficulty or limitation with sitting.
|
| Interference with standing | Checkbox |
Check this box if the condition causes difficulty or limitation with standing.
|
| Swelling | Checkbox |
Check this box if swelling is present as an additional contributing factor of disability.
|
| Deformity | Checkbox |
Check this box if there is a deformity present that contributes to disability.
|
| Disturbance of locomotion | Checkbox |
Check this box if the condition disrupts walking or other locomotion (e.g., gait disturbance).
|
| Less movement than normal | Checkbox |
Check this box if the joint/body part has reduced movement compared to normal.
|
| More movement than normal | Checkbox |
Check this box if the joint/body part has increased movement compared to normal (e.g., hypermobility).
|
| Weakened movement | Checkbox |
Check this box if weakness contributes to decreased ability to move or perform movements normally.
|
| Atrophy of disuse | Checkbox |
Check this box if muscle wasting/atrophy from disuse is present as a contributing factor.
|
| Instability of station | Checkbox |
Check this box if there is instability with standing balance or posture that contributes to disability.
|
| Additional Diagnoses List (1C) | ||
| Additional Diagnoses (Cervical Spine) | Text |
List any additional cervical spine diagnoses not already selected above, including the diagnosis name along with its ICD code and date of diagnosis for each entry.
|
| Additional Loss After Repetition | ||
| Yes | Radiobutton |
Check this box if there is additional loss of function or range of motion after three repetitions.
|
| No | Radiobutton |
Check this box if there is no additional loss of function or range of motion after three repetitions.
|
| Ankylosing Spondylitis Diagnosis | ||
| Ankylosing spondylitis | Checkbox |
Check this box if the veteran has a current diagnosis of ankylosing spondylitis associated with the claimed condition(s).
|
| Ankylosing Spondylitis ICD Code | Text |
Enter the ICD diagnostic code corresponding to the Ankylosing spondylitis diagnosis. Fill only if 'Ankylosing spondylitis' is 'Yes'.
Depends on:
Ankylosing spondylitis
|
| Ankylosing Spondylitis Date of Diagnosis | Date |
Enter the date when Ankylosing spondylitis was diagnosed. Fill only if 'Ankylosing spondylitis' is 'Yes'.
Depends on:
Ankylosing spondylitis
|
| Ankylosis Comments | ||
| Ankylosis Comments | Text |
Enter any additional comments or details regarding the presence, severity, and characteristics of the spine ankylosis.
|
| Ankylosis of the Spine (Presence and Severity Options) | ||
| Yes | Radiobutton |
Check this box if there is ankylosis (fixation) of the spine.
|
| No | Radiobutton |
Check this box if there is no ankylosis (fixation) of the spine.
|
| Unfavorable ankylosis of the entire spine | Radiobutton |
Check this box if ankylosis is present and it is unfavorable and involves the entire spine. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Unfavorable ankylosis of the entire cervical spine | Radiobutton |
Check this box if ankylosis is present and it is unfavorable and involves the entire cervical spine. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Favorable ankylosis of the entire cervical spine | Radiobutton |
Check this box if ankylosis is present and it is favorable and involves the entire cervical spine. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Arthritis Documented If Imaging Performed (14B) | ||
| Yes | Radiobutton |
Check this box if, based on the imaging performed (per 14A), degenerative or post-traumatic arthritis is documented. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if, based on the imaging performed (per 14A), degenerative or post-traumatic arthritis is not documented. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Assistive Device Use (Yes/No) | ||
| Yes | Radiobutton |
Check this box if the Veteran uses any assistive devices as a normal mode of locomotion.
|
| No | Radiobutton |
Check this box if the Veteran does not use any assistive devices as a normal mode of locomotion.
|
| Assistive Devices Conditions/Side/Device Details | ||
| Assistive Device Condition/Side/Device Details | Text |
For each condition that requires an assistive device, enter the condition name, the affected side (if applicable), and the specific assistive device used for that condition. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Atrophy Due To Claimed Condition and Rationale | ||
| Yes | Radiobutton |
Check this box if the Veteran’s muscle atrophy is due to the claimed condition listed in the diagnosis section. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if the Veteran’s muscle atrophy is not due to the claimed condition listed in the diagnosis section (and provide the rationale). Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Rationale for Atrophy Not Due to Claimed Condition | Text |
Provide the medical rationale explaining why the Veteran’s muscle atrophy is not due to the claimed condition listed in the diagnosis section. Fill only if 'Yes', 'No' is 'No' (all).
Depends on:
No, Yes
|
| Atrophy Location and Circumference Measurements | ||
| Atrophy Location and Measurement Details | Text |
Describe the specific location of the muscle atrophy and provide the circumference measurements for the normal side and the corresponding atrophied side taken at maximum muscle bulk. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Normal Side Circumference (cm) | Number |
Enter 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 |
Enter the circumference measurement of the atrophied (affected) side at maximum muscle bulk. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Brace Use and Frequency | ||
| Brace | Checkbox |
Check this box if the Veteran uses a brace as an assistive device for locomotion. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Brace frequency: Occasional | Checkbox |
Check this box if the Veteran uses the brace occasionally. Fill only if 'Yes', 'Brace' is 'Yes' (all).
Depends on:
Yes, Brace
|
| Brace frequency: Regular | Checkbox |
Check this box if the Veteran uses the brace regularly. Fill only if 'Yes', 'Brace' is 'Yes' (all).
Depends on:
Yes, Brace
|
| Brace frequency: Constant | Checkbox |
Check this box if the Veteran uses the brace constantly. Fill only if 'Yes', 'Brace' is 'Yes' (all).
Depends on:
Yes, Brace
|
| Cane Use and Frequency | ||
| Cane | Checkbox |
Check this box if the Veteran uses a cane as an assistive device for locomotion. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Cane frequency: Occasional | Checkbox |
Check this box if the Veteran uses a cane occasionally. Fill only if 'Yes', 'Cane' is 'Yes' (all).
Depends on:
Yes, Cane
|
| Cane frequency: Regular | Checkbox |
Check this box if the Veteran uses a cane on a regular basis. Fill only if 'Yes', 'Cane' is 'Yes' (all).
Depends on:
Yes, Cane
|
| Cane frequency: Constant | Checkbox |
Check this box if the Veteran uses a cane constantly. Fill only if 'Yes', 'Cane' is 'Yes' (all).
Depends on:
Yes, Cane
|
| Cervical Spine Condition History Summary | ||
| Cervical Spine Condition History Summary | Text |
Provide a brief summary describing the history of the Veteran’s cervical spine (neck) condition, including onset and course over time.
|
| Cervical Spine Flare-Ups | ||
| Yes | Radiobutton |
Check this box if the Veteran reports experiencing flare-ups of the cervical spine.
|
| No | Radiobutton |
Check this box if the Veteran does not report any flare-ups of the cervical spine.
|
| Cervical Spine Flare-Up Description | Text |
Enter the Veteran's description of cervical spine flare-ups, including frequency, duration, characteristics, precipitating and alleviating factors, severity, and any functional impairment experienced during flare-ups. Fill only if 'Yes', 'No' is 'Yes' (any).
Depends on:
Yes, No
|
| Cervical Spine Tenderness/Guarding/Muscle Spasm Present (Yes/No) | ||
| Yes | Radiobutton |
Check this box if the Veteran has localized tenderness, guarding, or muscle spasm of the cervical spine.
|
| No | Radiobutton |
Check this box if the Veteran does not have localized tenderness, guarding, or muscle spasm of the cervical spine.
|
| Cervical Strain Diagnosis | ||
| Cervical strain | Checkbox |
Check this box if the Veteran has a current diagnosis of cervical strain associated with the claimed condition(s).
|
| Cervical Strain ICD Code | Text |
Enter the ICD diagnosis code for the Veteran's cervical strain. Fill only if 'Cervical strain' is 'Yes'.
Depends on:
Cervical strain
|
| Cervical Strain Date of Diagnosis | Date |
Enter the date when cervical strain was diagnosed. Fill only if 'Cervical strain' is 'Yes'.
Depends on:
Cervical strain
|
| Cervical Vertebral Fracture and Height Loss (14D) | ||
| Cervical vertebral fracture imaging evidence — Yes | Radiobutton |
Check this box if imaging shows evidence of a cervical vertebral fracture.
|
| Cervical vertebral fracture imaging evidence — No | Radiobutton |
Check this box if imaging does not show evidence of a cervical vertebral fracture.
|
| Loss of 50% or more of height — Yes | Radiobutton |
Check this box if there is a loss of 50 percent or more of vertebral height (when a cervical vertebral fracture is present). Fill only if 'Cervical vertebral fracture imaging evidence — Yes' is 'Yes'.
Depends on:
Cervical vertebral fracture imaging evidence — Yes
|
| Loss of 50% or more of height — No | Radiobutton |
Check this box if there is not a loss of 50 percent or more of vertebral height (when a cervical vertebral fracture is present). Fill only if 'Cervical vertebral fracture imaging evidence — Yes' is 'Yes'.
Depends on:
Cervical vertebral fracture imaging evidence — Yes
|
| Claimed Conditions List (1A) | ||
| Claimed neck/cervical spine conditions | Text |
Enter the claimed condition(s) that pertain to this neck (cervical spine) disability benefits questionnaire.
|
| Constant Pain Severity - Left Upper Extremity | ||
| None | Checkbox |
Check this box if the Veteran has no constant pain in the left upper extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Mild | Checkbox |
Check this box if the Veteran’s constant pain in the left upper extremity is mild. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Moderate | Checkbox |
Check this box if the Veteran’s constant pain in the left upper extremity is moderate. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Severe | Checkbox |
Check this box if the Veteran’s constant pain in the left upper extremity is severe. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Constant Pain Severity - Right Upper Extremity | ||
| None | Checkbox |
Check this box if the Veteran has no constant pain in the right upper extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Mild | Checkbox |
Check this box if the Veteran has mild constant pain in the right upper extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Moderate | Checkbox |
Check this box if the Veteran has moderate constant pain in the right upper extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Severe | Checkbox |
Check this box if the Veteran has severe constant pain in the right upper extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Crepitus Present | ||
| Crepitus present (Yes) | Radiobutton |
Check this box if there is objective evidence of crepitus on examination.
|
| Crepitus present (No) | Radiobutton |
Check this box if there is no objective evidence of crepitus on examination.
|
| Crutches Use and Frequency | ||
| Crutches | Checkbox |
Check this box if the Veteran uses crutches as an assistive device for normal locomotion. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Crutches - Occasional | Checkbox |
Check this box if the Veteran uses crutches occasionally. Fill only if 'Yes', 'Crutches' is 'Yes' (all).
Depends on:
Yes, Crutches
|
| Crutches - Regular | Checkbox |
Check this box if the Veteran uses crutches on a regular basis. Fill only if 'Yes', 'Crutches' is 'Yes' (all).
Depends on:
Yes, Crutches
|
| Crutches - Constant | Checkbox |
Check this box if the Veteran uses crutches constantly. Fill only if 'Yes', 'Crutches' is 'Yes' (all).
Depends on:
Yes, Crutches
|
| Deep Tendon Reflexes (DTRs) - Left Side | ||
| Left Biceps DTR Rating | Text |
Enter the deep tendon reflex (DTR) grade for the left biceps using the form’s reflex scale.
|
| Left Triceps DTR Rating | Text |
Enter the deep tendon reflex (DTR) grade for the left triceps using the form’s reflex scale.
|
| Left Brachioradialis DTR Rating | Text |
Enter the deep tendon reflex (DTR) grade for the left brachioradialis using the form’s reflex scale.
|
| Deep Tendon Reflexes (DTRs) - Right Side | ||
| Right DTR - Bicep | Text |
Enter the right-side biceps deep tendon reflex (DTR) grade.
|
| Right DTR - Tricep | Text |
Enter the right-side triceps deep tendon reflex (DTR) grade.
|
| Right DTR - Brachioradialis | Text |
Enter the right-side brachioradialis deep tendon reflex (DTR) grade.
|
| Degenerative Arthritis Diagnosis | ||
| Degenerative arthritis | Checkbox |
Check this box if the Veteran has a current diagnosis of degenerative arthritis associated with the claimed condition(s).
|
| Degenerative Arthritis ICD Code | Text |
Enter the ICD diagnostic code for the Veteran's degenerative arthritis. Fill only if 'Degenerative arthritis' is 'Yes'.
Depends on:
Degenerative arthritis
|
| Degenerative Arthritis Date of Diagnosis | Date |
Enter the date when degenerative arthritis was diagnosed. Fill only if 'Degenerative arthritis' is 'Yes'.
Depends on:
Degenerative arthritis
|
| Degenerative Disc Disease (Other Than IVDS) Diagnosis | ||
| Degenerative disc disease (other than IVDS) | Checkbox |
Check this box if the Veteran is diagnosed with degenerative disc disease that is not intervertebral disc syndrome (IVDS).
|
| Degenerative Disc Disease (Other Than IVDS) ICD Code | Text |
Enter the ICD diagnosis code for degenerative disc disease other than intervertebral disc syndrome (IVDS). Fill only if 'Degenerative disc disease (other than IVDS)' is 'Yes'.
Depends on:
Degenerative disc disease (other than IVDS)
|
| Degenerative Disc Disease (Other Than IVDS) Date of Diagnosis | Date |
Provide the date when degenerative disc disease other than intervertebral disc syndrome (IVDS) was diagnosed. Fill only if 'Degenerative disc disease (other than IVDS)' is 'Yes'.
Depends on:
Degenerative disc disease (other than IVDS)
|
| DOMINANT HAND | ||
| Right | Radiobutton |
Check this box if the Veteran’s dominant hand is the right hand.
|
| Left | Radiobutton |
Check this box if the Veteran’s dominant hand is the left hand.
|
| Ambidextrous | Radiobutton |
Check this box if the Veteran is ambidextrous (uses both hands equally as dominant).
|
| Estimated Range of Motion During Flare-ups (Degrees) | ||
| Forward Flexion Endpoint (Flare-ups) | Number |
Enter the estimated forward flexion endpoint range of motion for this joint during flare-ups in degrees. Fill only if 'Does the Veteran report flare-ups of the cervical spine?' is 'Yes'.
Depends on:
Yes
|
| Left Lateral Flexion Endpoint (Flare-ups) | Number |
Enter the estimated left lateral flexion endpoint range of motion for this joint during flare-ups in degrees. Fill only if 'Does the Veteran report flare-ups of the cervical spine?' is 'Yes'.
Depends on:
Yes
|
| Extension Endpoint (Flare-ups) | Number |
Enter the estimated extension endpoint range of motion for this joint during flare-ups in degrees. Fill only if 'Does the Veteran report flare-ups of the cervical spine?' is 'Yes'.
Depends on:
Yes
|
| Right Lateral Rotation Endpoint (Flare-ups) | Number |
Enter the estimated right lateral rotation endpoint range of motion for this joint during flare-ups in degrees. Fill only if 'Does the Veteran report flare-ups of the cervical spine?' is 'Yes'.
Depends on:
Yes
|
| Right Lateral Flexion Endpoint (Flare-ups) | Number |
Enter the estimated right lateral flexion endpoint range of motion for this joint during flare-ups in degrees. Fill only if 'Does the Veteran report flare-ups of the cervical spine?' is 'Yes'.
Depends on:
Yes
|
| Left Lateral Rotation Endpoint (Flare-ups) | Number |
Enter the estimated left lateral rotation endpoint range of motion for this joint during flare-ups in degrees. Fill only if 'Does the Veteran report flare-ups of the cervical spine?' is 'Yes'.
Depends on:
Yes
|
| Evidence of Pain | ||
| Yes | Radiobutton |
Check this box if there is evidence of pain.
|
| No | Radiobutton |
Check this box if there is no evidence of pain.
|
| EVIDENCE REVIEW | ||
| No records were reviewed | Radiobutton |
Check this box if you did not review any records or evidence for this examination.
|
| Records reviewed | Radiobutton |
Check this box if you reviewed any records or evidence (e.g., service, VA, or private treatment records) for this examination.
|
| Evidence Reviewed and Date Range | Text |
List the evidence reviewed (e.g., service treatment records, VA treatment records, private treatment records) and the applicable date range covered by those records. Fill only if 'Records reviewed' is 'Yes'.
Depends on:
Records reviewed
|
| Examiner Contact Information | ||
| Examiner Phone/Fax Numbers | Text |
Enter the examiner’s phone number and/or fax number(s).
|
| Examiner Address | Text |
Enter the examiner’s mailing address.
|
| Examiner Practice and Credentials | ||
| Examiner Area of Practice/Specialty | Text |
Enter the examiner’s medical area of practice or specialty (for example, Cardiology, Orthopedics, or Psychology/Psychiatry).
|
| National Provider Identifier (NPI) | 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 state that issued the license.
|
| Examiner Signature Block | ||
| Examiner Signature | Text |
Enter the examiner’s signature as it should appear on the certification.
|
| Examiner Printed Name and Title | Text |
Enter the examiner’s printed full name and professional title/credentials (e.g., MD, DO, DDS, PhD).
|
| Date Signed | Date |
Enter the date the examiner signed the certification.
|
| Extremities this applies to | ||
| Right upper extremity | Checkbox |
Check this box if the functional impairment applies to the Veteran’s right upper extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Left upper extremity | Checkbox |
Check this box if the functional impairment applies to the Veteran’s left upper extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Right lower extremity | Checkbox |
Check this box if the functional impairment applies to the Veteran’s right lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Left lower extremity | Checkbox |
Check this box if the functional impairment applies to the Veteran’s left lower extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Factors Causing Functional Loss After Repetition | ||
| N/A | Checkbox |
Check this box if none of the listed factors apply as causes of functional loss after repetitive use (three repetitions).
|
| Pain | Checkbox |
Check this box if pain causes the functional loss after repetitive use (three repetitions).
|
| Fatigability | Checkbox |
Check this box if fatigability (getting fatigued with use) causes the functional loss after repetitive use (three repetitions).
|
| Weakness | Checkbox |
Check this box if weakness causes the functional loss after repetitive use (three repetitions).
|
| Lack of endurance | Checkbox |
Check this box if lack of endurance causes the functional loss after repetitive use (three repetitions).
|
| Incoordination | Checkbox |
Check this box if incoordination causes the functional loss after repetitive use (three repetitions).
|
| Other | Checkbox |
Check this box if another factor not listed causes the functional loss after repetitive use (three repetitions) and specify the factor in the space provided.
|
| Other Functional Loss Factor After Repetition | Text |
Enter any other factor causing additional functional loss after three repetitions that is not already listed (e.g., pain, fatigability, weakness, lack of endurance, or incoordination). Fill only if 'Yes', 'Other' is 'Yes' (all).
Depends on:
Yes, Other
|
| First Muscle Strength Testing Row | ||
| Right Elbow Flexion Strength Rating | Number |
Enter the muscle strength rating for right-side elbow flexion using the 0–5 scale shown on the form.
|
| Right Wrist Extension Strength Rating | Number |
Enter the muscle strength rating for right-side wrist extension using the 0–5 scale shown on the form.
|
| Left Elbow Flexion Strength Rating | Number |
Enter the muscle strength rating for left-side elbow flexion using the 0–5 scale shown on the form.
|
| Left Wrist Extension Strength Rating | Number |
Enter the muscle strength rating for left-side wrist extension using the 0–5 scale shown on the form.
|
| Flare-up Evidence Citation and Discussion | ||
| Flare-up Evidence Citation and Discussion | Text |
Cite and discuss the specific evidence (e.g., Veteran statements, medical records, and other relevant sources) supporting the flare-up findings and any estimated functional limitations or range-of-motion loss during flare-ups. Fill only if 'Does the Veteran report flare-ups of the cervical spine?' is 'Yes'.
Depends on:
Yes
|
| Flare-up Examination and Evidence (Yes/No) | ||
| Examined during a flare-up — Yes | Radiobutton |
Check this box if the Veteran is being examined during a flare-up at the time of this evaluation. Fill only if 'Does the Veteran report flare-ups of the cervical spine?' is 'Yes'.
Depends on:
Yes
|
| Examined during a flare-up — No | Radiobutton |
Check this box if the Veteran is not being examined during a flare-up at the time of this evaluation. Fill only if 'Does the Veteran report flare-ups of the cervical spine?' is 'Yes'.
Depends on:
Yes
|
| Evidence suggests functional limitation with flare-ups — Yes | Radiobutton |
Check this box if procured evidence (including the Veteran’s statements) indicates that flare-ups cause symptoms that significantly limit functional ability. Fill only if 'Does the Veteran report flare-ups of the cervical spine?' is 'Yes'.
Depends on:
Yes
|
| Evidence suggests functional limitation with flare-ups — No | Radiobutton |
Check this box if procured evidence (including the Veteran’s statements) does not indicate that flare-ups significantly limit functional ability. Fill only if 'Does the Veteran report flare-ups of the cervical spine?' is 'Yes'.
Depends on:
Yes
|
| Flare-up Functional Loss Factors (Check all that apply) | ||
| N/A | Checkbox |
Check this box if none of the listed factors cause functional loss during flare-ups. Fill only if 'Evidence suggests functional limitation with flare-ups — Yes' is 'Yes'.
Depends on:
Evidence suggests functional limitation with flare-ups — Yes
|
| Pain | Checkbox |
Check this box if pain causes or contributes to functional loss during flare-ups. Fill only if 'Evidence suggests functional limitation with flare-ups — Yes' is 'Yes'.
Depends on:
Evidence suggests functional limitation with flare-ups — Yes
|
| Fatigability | Checkbox |
Check this box if fatigability causes or contributes to functional loss during flare-ups. Fill only if 'Evidence suggests functional limitation with flare-ups — Yes' is 'Yes'.
Depends on:
Evidence suggests functional limitation with flare-ups — Yes
|
| Weakness | Checkbox |
Check this box if weakness causes or contributes to functional loss during flare-ups. Fill only if 'Evidence suggests functional limitation with flare-ups — Yes' is 'Yes'.
Depends on:
Evidence suggests functional limitation with flare-ups — Yes
|
| Lack of endurance | Checkbox |
Check this box if lack of endurance causes or contributes to functional loss during flare-ups. Fill only if 'Evidence suggests functional limitation with flare-ups — Yes' is 'Yes'.
Depends on:
Evidence suggests functional limitation with flare-ups — Yes
|
| Incoordination | Checkbox |
Check this box if incoordination causes or contributes to functional loss during flare-ups. Fill only if 'Evidence suggests functional limitation with flare-ups — Yes' is 'Yes'.
Depends on:
Evidence suggests functional limitation with flare-ups — Yes
|
| Other | Checkbox |
Check this box if another factor (not listed) causes functional loss during flare-ups, and specify the factor in the provided space. Fill only if 'Evidence suggests functional limitation with flare-ups — Yes' is 'Yes'.
Depends on:
Evidence suggests functional limitation with flare-ups — Yes
|
| Other functional loss factor (flare-ups) | Text |
Enter the other factor(s) not listed that cause functional loss during flare-ups. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Functional loss equivalent to amputation with prosthesis (Yes/No) | ||
| Yes | Radiobutton |
Check this box if the Veteran’s extremity function is so diminished that an amputation with prosthesis would equally serve the Veteran.
|
| No | Radiobutton |
Check this box if the Veteran retains effective function in the extremity and an amputation with prosthesis would not equally serve the Veteran.
|
| Functional Loss Explanation | ||
| Range of Motion Functional Loss Explanation | Text |
Provide an explanation of how the abnormal range of motion contributes to the Veteran’s functional loss, including the specific limitations experienced. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Functional Loss or Functional Impairment | ||
| Yes | Radiobutton |
Check this box if the Veteran reports any functional loss or functional impairment of the joint or extremity being evaluated (including after repeated use over time).
|
| No | Radiobutton |
Check this box if the Veteran does not report any functional loss or functional impairment of the joint or extremity being evaluated.
|
| Functional Loss/Impairment Description | Text |
Enter the Veteran’s own description of any functional loss or functional impairment of the joint or extremity being evaluated, including effects after repeated use over time. Fill only if 'Yes', 'No' is 'Yes' (any).
Depends on:
Yes, No
|
| Guarding Assessment | ||
| None | Checkbox |
Check this box if the Veteran has no cervical spine guarding.
|
| Resulting in abnormal gait or abnormal spine contour | Checkbox |
Check this box if cervical spine guarding is present and it results in an abnormal gait or abnormal spine contour.
|
| Not resulting in abnormal gait or abnormal spinal contour | Checkbox |
Check this box if cervical spine guarding is present but it does not result in an abnormal gait or abnormal spinal contour.
|
| Unable to evaluate, describe below | Checkbox |
Check this box if guarding cannot be evaluated and an explanation will be provided in the space below.
|
| Guarding Description/Etiology | Text |
Enter a narrative description of the cervical spine guarding observed and/or the suspected cause (etiology), including any relevant clinical details. Fill only if 'Resulting in abnormal gait or abnormal spine contour', 'Not resulting in abnormal gait or abnormal spinal contour', 'Unable to evaluate, describe below' is selected (any).
Depends on:
Resulting in abnormal gait or abnormal spine contour, Not resulting in abnormal gait or abnormal spinal contour, Unable to evaluate, describe below
|
| Imaging Studies Performed (14A) | ||
| Yes | Radiobutton |
Check this box if imaging studies of the cervical spine have been performed in conjunction with this examination.
|
| No | Radiobutton |
Check this box if imaging studies of the cervical spine have not been performed in conjunction with this examination.
|
| Imaging Test Details Summary (14C) | ||
| Imaging Test/Procedure Details and Results Summary | Text |
Provide the type of imaging test or procedure performed, the date it was performed, and a brief summary of the results. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| In-Person Examination and Method If Not In Person | ||
| Examined in person — Yes | Radiobutton |
Check this box if the Veteran was examined in person (face-to-face).
|
| Examined in person — No | Radiobutton |
Check this box if the Veteran was not examined in person and the exam was conducted by another method.
|
| Method of Examination (If Not In Person) | Text |
Describe how the examination was conducted if the Veteran was not examined in person. Fill only if 'Examined in person — No' is 'Yes'.
Depends on:
Examined in person — No
|
| Initial ROM Contributes to Functional Loss | ||
| Yes | Radiobutton |
Check this box if the Veteran’s abnormal initial range of motion (ROM) itself contributes to a functional loss.
|
| No | Radiobutton |
Check this box if the Veteran’s abnormal initial range of motion (ROM) does not itself contribute to a functional loss.
|
| Initial ROM Outside Normal Description | ||
| ROM Outside Normal Range Explanation | Text |
Describe why the initial range of motion is outside the normal range but is considered normal for the Veteran due to reasons other than a neck condition (e.g., age, body habitus, or neurologic disease). Fill only if 'Abnormal or outside of normal range' is 'Yes'.
Depends on:
Abnormal or outside of normal range
|
| Initial ROM Status | ||
| All normal | Radiobutton |
Check this box if the Veteran’s initial cervical spine range of motion (ROM) measurements are within normal limits.
|
| Abnormal or outside of normal range | Radiobutton |
Check this box if any initial cervical spine ROM measurement is abnormal or outside the normal range.
|
| Unable to test | Radiobutton |
Check this box if initial cervical spine ROM testing could not be performed.
|
| Not indicated | Radiobutton |
Check this box if initial cervical spine ROM measurements are not indicated for this evaluation.
|
| Initial ROM Status Explanation | ||
| Unable to Test / Not Indicated Explanation | Text |
Provide an explanation for why the initial range of motion (ROM) measurements were marked as "Unable to test" or "Not indicated." Fill only if 'Unable to test', 'Not indicated' is 'Yes' (any).
Depends on:
Unable to test, Not indicated
|
| Intermittent Pain Severity - Left Upper Extremity | ||
| None | Checkbox |
Check this box if the Veteran has no intermittent pain (usually dull) in the left upper extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Mild | Checkbox |
Check this box if the Veteran has mild intermittent pain (usually dull) in the left upper extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Moderate | Checkbox |
Check this box if the Veteran has moderate intermittent pain (usually dull) in the left upper extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Severe | Checkbox |
Check this box if the Veteran has severe intermittent pain (usually dull) in the left upper extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Intermittent Pain Severity - Right Upper Extremity | ||
| None | Checkbox |
Check this box if the Veteran has no intermittent (usually dull) pain in the right upper extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Mild | Checkbox |
Check this box if the Veteran’s intermittent (usually dull) pain in the right upper extremity is mild. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Moderate | Checkbox |
Check this box if the Veteran’s intermittent (usually dull) pain in the right upper extremity is moderate. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Severe | Checkbox |
Check this box if the Veteran’s intermittent (usually dull) pain in the right upper extremity is severe. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Intervertebral Disc Syndrome (IVDS) Diagnosis | ||
| Intervertebral disc syndrome (IVDS) | Checkbox |
Check this box if the Veteran has a current diagnosis of intervertebral disc syndrome (IVDS).
|
| IVDS ICD Code | Text |
Enter the ICD diagnosis code for the Veteran's intervertebral disc syndrome (IVDS). Fill only if 'Intervertebral disc syndrome (IVDS)' is 'Yes'.
Depends on:
Intervertebral disc syndrome (IVDS)
|
| IVDS Date of Diagnosis | Date |
Enter the date when intervertebral disc syndrome (IVDS) was diagnosed. Fill only if 'Intervertebral disc syndrome (IVDS)' is 'Yes'.
Depends on:
Intervertebral disc syndrome (IVDS)
|
| IVDS Bed Rest Episodes in Past 12 Months (Yes/No) | ||
| Yes | Radiobutton |
Check this box if, in the past 12 months, the Veteran has had any IVDS episodes that required bed rest prescribed by a physician and treatment by a physician. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| No | Radiobutton |
Check this box if, in the past 12 months, the Veteran has not had any IVDS episodes requiring physician-prescribed bed rest and treatment by a physician. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| IVDS of Cervical Spine (Yes/No) | ||
| Yes | Radiobutton |
Check this box if the Veteran has intervertebral disc syndrome (IVDS) of the cervical spine.
|
| No | Radiobutton |
Check this box if the Veteran does not have intervertebral disc syndrome (IVDS) of the cervical spine.
|
| Left Hand/Fingers (C6-8) Light Touch Sensation | ||
| Normal | Checkbox |
Check this box if light touch sensation in the left hand/fingers (C6–8) is normal.
|
| Decreased | Checkbox |
Check this box if light touch sensation in the left hand/fingers (C6–8) is decreased compared with normal.
|
| Absent | Checkbox |
Check this box if light touch sensation in the left hand/fingers (C6–8) is absent.
|
| Left Inner/Outer Forearm (C6-T1) Light Touch Sensation | ||
| Normal | Checkbox |
Check this box if light touch sensation on the left inner/outer forearm (C6–T1) is normal.
|
| Decreased | Checkbox |
Check this box if light touch sensation on the left inner/outer forearm (C6–T1) is decreased compared to normal.
|
| Absent | Checkbox |
Check this box if light touch sensation on the left inner/outer forearm (C6–T1) is absent.
|
| Left Shoulder Area (C5) Light Touch Sensation | ||
| Normal | Checkbox |
Check this box if light touch sensation in the left shoulder area (C5) is normal.
|
| Decreased | Checkbox |
Check this box if light touch sensation in the left shoulder area (C5) is decreased.
|
| Absent | Checkbox |
Check this box if light touch sensation in the left shoulder area (C5) is absent.
|
| Likely Cause of Abnormal/Positive Neurological Findings | ||
| Likely cause of neurological findings | Text |
Provide an explanation of the most likely cause of any abnormal or positive neurological findings (symptoms) identified in Sections 4–7. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Localized Tenderness Assessment | ||
| None | Checkbox |
Check this box if there is no localized tenderness of the cervical spine.
|
| Not resulting in abnormal gait or abnormal spinal contour | Checkbox |
Check this box if localized tenderness is present but it does not result in abnormal gait or abnormal spinal contour.
|
| Localized Tenderness Description/Etiology | Text |
Enter a narrative description and/or suspected cause (etiology) of the Veteran’s localized cervical spine tenderness. Fill only if 'Not resulting in abnormal gait or abnormal spinal contour' is selected (any).
Depends on:
Not resulting in abnormal gait or abnormal spinal contour
|
| Localized Tenderness Present | ||
| Yes | Radiobutton |
Check this box if there is objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue.
|
| No | Radiobutton |
Check this box if there is no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue.
|
| Loss of effective function and examples (brief summary) | ||
| Loss of effective function summary and examples | Text |
Describe the condition(s) causing loss of effective function for the affected extremity and provide a brief summary with specific examples of how function is diminished. Fill only if 'Yes', 'Right upper extremity', 'Left upper extremity', 'Right lower extremity', 'Left lower extremity' is 'Yes' and any fields selection.
Depends on:
Yes, Right upper extremity, Left upper extremity, Right lower extremity, Left lower extremity
|
| Muscle Atrophy Presence | ||
| Yes | Radiobutton |
Check this box if the Veteran has muscle atrophy.
|
| No | Radiobutton |
Check this box if the Veteran does not have muscle atrophy.
|
| Muscle Spasm Assessment | ||
| None | Checkbox |
Check this box if the Veteran has no muscle spasm of the cervical spine.
|
| Resulting in abnormal gait or abnormal spine contour | Checkbox |
Check this box if muscle spasm is present and it results in abnormal gait or abnormal spinal contour.
|
| Not resulting in abnormal gait or abnormal spine contour | Checkbox |
Check this box if muscle spasm is present but it does not result in abnormal gait or abnormal spinal contour.
|
| Unable to evaluate (describe below) | Checkbox |
Check this box if you are unable to evaluate muscle spasm and will provide an explanation in the description/etiology section below.
|
| Muscle Spasm Description/Etiology | Text |
Describe the cervical spine muscle spasm findings and/or the suspected cause (etiology), including any relevant details observed during the examination. Fill only if 'Resulting in abnormal gait or abnormal spine contour', 'Not resulting in abnormal gait or abnormal spine contour', 'Unable to evaluate (describe below)' is selected (any).
Depends on:
Resulting in abnormal gait or abnormal spine contour, Not resulting in abnormal gait or abnormal spine contour, Unable to evaluate (describe below)
|
| Nerve Root Involvement - C5/C6 and Side | ||
| Involvement of C5/C6 nerve roots (upper radicular group) | Checkbox |
Check this box if the Veteran has radiculopathy involving the C5/C6 nerve roots (upper radicular group). Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| C5/C6 involvement - Right | Radiobutton |
Check this box if the C5/C6 nerve root involvement affects the right side. Fill only if 'Yes', 'Involvement of C5/C6 nerve roots (upper radicular group)' are 'Yes' (all).
Depends on:
Yes, Involvement of C5/C6 nerve roots (upper radicular group)
|
| C5/C6 involvement - Left | Radiobutton |
Check this box if the C5/C6 nerve root involvement affects the left side. Fill only if 'Yes', 'Involvement of C5/C6 nerve roots (upper radicular group)' are 'Yes' (all).
Depends on:
Yes, Involvement of C5/C6 nerve roots (upper radicular group)
|
| C5/C6 involvement - Both | Radiobutton |
Check this box if the C5/C6 nerve root involvement affects both sides. Fill only if 'Yes', 'Involvement of C5/C6 nerve roots (upper radicular group)' are 'Yes' (all).
Depends on:
Yes, Involvement of C5/C6 nerve roots (upper radicular group)
|
| Nerve Root Involvement - C7 and Side | ||
| Involvement of C7 nerve root (middle radicular group) | Checkbox |
Check this box if the Veteran has radiculopathy findings indicating involvement of the C7 nerve root. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| C7 involvement side: Right | Radiobutton |
Check this option if the C7 nerve root involvement is on the right side. Fill only if 'Yes', 'Involvement of C7 nerve root (middle radicular group)' are 'Yes' (all).
Depends on:
Yes, Involvement of C7 nerve root (middle radicular group)
|
| C7 involvement side: Left | Radiobutton |
Check this option if the C7 nerve root involvement is on the left side. Fill only if 'Yes', 'Involvement of C7 nerve root (middle radicular group)' are 'Yes' (all).
Depends on:
Yes, Involvement of C7 nerve root (middle radicular group)
|
| C7 involvement side: Both | Radiobutton |
Check this option if the C7 nerve root involvement is present on both sides. Fill only if 'Yes', 'Involvement of C7 nerve root (middle radicular group)' are 'Yes' (all).
Depends on:
Yes, Involvement of C7 nerve root (middle radicular group)
|
| Nerve Root Involvement - C8/T1 and Side | ||
| Involvement of C8/T1 nerve roots (lower radicular group) | Checkbox |
Check this box if the Veteran has radiculopathy involving the C8/T1 nerve roots (lower radicular group). Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| C8/T1 involvement side: Right | Radiobutton |
Check this box to indicate the C8/T1 nerve root involvement is on the right side (right upper extremity). Fill only if 'Yes', 'Involvement of C8/T1 nerve roots (lower radicular group)' are 'Yes' (all).
Depends on:
Yes, Involvement of C8/T1 nerve roots (lower radicular group)
|
| C8/T1 involvement side: Left | Radiobutton |
Check this box to indicate the C8/T1 nerve root involvement is on the left side (left upper extremity). Fill only if 'Yes', 'Involvement of C8/T1 nerve roots (lower radicular group)' are 'Yes' (all).
Depends on:
Yes, Involvement of C8/T1 nerve roots (lower radicular group)
|
| C8/T1 involvement side: Both | Radiobutton |
Check this box to indicate the C8/T1 nerve root involvement is on both sides (bilateral upper extremities). Fill only if 'Yes', 'Involvement of C8/T1 nerve roots (lower radicular group)' are 'Yes' (all).
Depends on:
Yes, Involvement of C8/T1 nerve roots (lower radicular group)
|
| No Current Diagnosis Checkbox | ||
| No current diagnosis | Checkbox |
Check this box if the Veteran does not have a current diagnosis associated with any of the claimed condition(s) listed above.
|
| Numbness Severity - Left Upper Extremity | ||
| Numbness (Left upper extremity) - None | Checkbox |
Check this box if the Veteran has no numbness in the left upper extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Numbness (Left upper extremity) - Mild | Checkbox |
Check this box if the Veteran's numbness in the left upper extremity is mild. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Numbness (Left upper extremity) - Moderate | Checkbox |
Check this box if the Veteran's numbness in the left upper extremity is moderate. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Numbness (Left upper extremity) - Severe | Checkbox |
Check this box if the Veteran's numbness in the left upper extremity is severe. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Numbness Severity - Right Upper Extremity | ||
| Numbness severity (Right upper extremity): None | Checkbox |
Check this box if the Veteran has no numbness in the right upper extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Numbness severity (Right upper extremity): Mild | Checkbox |
Check this box if the Veteran’s numbness in the right upper extremity is mild. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Numbness severity (Right upper extremity): Moderate | Checkbox |
Check this box if the Veteran’s numbness in the right upper extremity is moderate. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Numbness severity (Right upper extremity): Severe | Checkbox |
Check this box if the Veteran’s numbness in the right upper extremity is severe. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other (Specify) Checkbox | ||
| Other (specify) | Checkbox |
Check this box if there is another diagnosis associated with the claimed condition(s) that is not listed above, and then specify the diagnosis details below.
|
| Other Assistive Device and Frequency | ||
| Other assistive device | Checkbox |
Check this box if the Veteran uses an assistive device not listed (e.g., not wheelchair, brace, crutches, cane, or walker). Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Assistive Device (Specify) | Text |
Enter the name or description of any other assistive device the Veteran uses as a normal mode of locomotion that is not listed above. Fill only if 'Yes', 'Other assistive device' is 'Yes' (all).
Depends on:
Yes, Other assistive device
|
| Other device frequency: Occasional | Checkbox |
Check this box if the Veteran uses the other assistive device only occasionally. Fill only if 'Yes', 'Other assistive device' is 'Yes' (all).
Depends on:
Yes, Other assistive device
|
| Other device frequency: Regular | Checkbox |
Check this box if the Veteran uses the other assistive device on a regular basis but not constantly. Fill only if 'Yes', 'Other assistive device' is 'Yes' (all).
Depends on:
Yes, Other assistive device
|
| Other device frequency: Constant | Checkbox |
Check this box if the Veteran uses the other assistive device constantly. Fill only if 'Yes', 'Other assistive device' is 'Yes' (all).
Depends on:
Yes, Other assistive device
|
| Other Contributing Factor (Option and Specify) | ||
| Other, describe | Checkbox |
Check this box if there is an additional contributing factor to the disability not listed above and you will describe it in the space provided.
|
| Other Contributing Factor (Specify) | Text |
Enter the other contributing factor to the disability that is not listed among the provided options. Fill only if 'Other, describe' is 'Yes'.
Depends on:
Other, describe
|
| Other Diagnosis #1 Details | ||
| Other Diagnosis #1 | Text |
Enter the name of the first other diagnosis not listed above. Fill only if 'Other (specify)' is 'Yes'.
Depends on:
Other (specify)
|
| Other Diagnosis #1 ICD Code | Text |
Enter the ICD code associated with Other Diagnosis #1. Fill only if 'Other (specify)' is 'Yes'.
Depends on:
Other (specify)
|
| Other Diagnosis #1 Date of Diagnosis | Date |
Enter the date when Other Diagnosis #1 was diagnosed. Fill only if 'Other (specify)' is 'Yes'.
Depends on:
Other (specify)
|
| Other Diagnosis #2 Details | ||
| Other Diagnosis #2 | Text |
Enter the name of the second additional diagnosis associated with the claimed condition(s). Fill only if 'Other (specify)' is 'Yes'.
Depends on:
Other (specify)
|
| Other Diagnosis #2 ICD Code | Text |
Enter the ICD diagnostic code for Other Diagnosis #2. Fill only if 'Other (specify)' is 'Yes'.
Depends on:
Other (specify)
|
| Other Diagnosis #2 Date of Diagnosis | Date |
Enter the date when Other Diagnosis #2 was diagnosed. Fill only if 'Other (specify)' is 'Yes'.
Depends on:
Other (specify)
|
| Other Diagnosis #3 Details | ||
| Other Diagnosis #3 | Text |
Enter the name of the third additional diagnosis not listed above. Fill only if 'Other (specify)' is 'Yes'.
Depends on:
Other (specify)
|
| Other Diagnosis #3 ICD Code | Text |
Enter the ICD code corresponding to Other Diagnosis #3. Fill only if 'Other (specify)' is 'Yes'.
Depends on:
Other (specify)
|
| Other Diagnosis #3 Date of Diagnosis | Date |
Enter the date on which Other Diagnosis #3 was diagnosed. Fill only if 'Other (specify)' is 'Yes'.
Depends on:
Other (specify)
|
| Other Radiculopathy Signs/Symptoms (Yes/No) and Description | ||
| Other radiculopathy signs/symptoms: Yes | Radiobutton |
Check this box if the Veteran has any other signs or symptoms of radiculopathy (beyond those already listed). Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other radiculopathy signs/symptoms: No | Radiobutton |
Check this box if the Veteran does not have any other signs or symptoms of radiculopathy. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Radiculopathy Signs/Symptoms Description | Text |
Describe any other signs or symptoms of radiculopathy the Veteran has (beyond those already listed), including relevant details such as location, frequency, and severity. Fill only if 'Yes', 'Other radiculopathy signs/symptoms: Yes' are 'Yes' (all).
Depends on:
Yes, Other radiculopathy signs/symptoms: Yes
|
| Other Sensory Findings (If Any) | ||
| Other Sensory Findings | Text |
Describe any other sensory findings not already captured elsewhere on the form, including location and details.
|
| Other Significant Diagnostic Findings and Summary (14E) | ||
| Yes | Radiobutton |
Check this box if there are other significant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es) that were reviewed with this examination.
|
| No | Radiobutton |
Check this box if there are no other significant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es) that were reviewed with this examination.
|
| Other Significant Diagnostic Findings Summary | Text |
Provide the type of diagnostic test or procedure, the date it was performed, and a brief summary of the findings/results related to the claimed condition(s) or diagnosis(es) reviewed for this examination. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Pain Comments | ||
| Pain Comments | Text |
Provide any additional comments describing the pain, including when it occurs, what movements or activities provoke it, and any related functional impact. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Pain on Palpation (Active ROM Exam) | ||
| Yes | Radiobutton |
Check this box if pain on palpation testing during the Active ROM exam can be performed.
|
| No | Radiobutton |
Check this box if pain on palpation testing during the Active ROM exam cannot be performed and an explanation will be provided.
|
| Pain on Palpation Explanation | ||
| Pain on Palpation Testing Explanation | Text |
Provide an explanation for why pain on palpation testing cannot be performed or is medically contraindicated, including any pain behaviors observed during attempted examination. Fill only if 'No' is 'Yes'.
Depends on:
No
|
| Pain Type/Effect Details | ||
| Weight-bearing | Checkbox |
Check this box if pain is present during weight-bearing activities.
|
| Nonweight-bearing | Checkbox |
Check this box if pain is present during nonweight-bearing positions or activities.
|
| Active motion | Checkbox |
Check this box if pain is present with active (patient-performed) motion.
|
| Passive motion | Checkbox |
Check this box if pain is present with passive (examiner-assisted) motion.
|
| On rest/non-movement | Checkbox |
Check this box if pain is present at rest or without movement.
|
| Causes functional loss | Checkbox |
Check this box if the pain results in or causes functional loss (and describe it in the comments section).
|
| Does not result in/cause functional loss | Checkbox |
Check this box if pain is present but does not result in or cause functional loss.
|
| Paresthesias/Dysesthesias Severity - Left Upper Extremity | ||
| None | Checkbox |
Check this box if the Veteran has no paresthesias and/or dysesthesias in the left upper extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Mild | Checkbox |
Check this box if the Veteran’s paresthesias and/or dysesthesias in the left upper extremity are mild. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Moderate | Checkbox |
Check this box if the Veteran’s paresthesias and/or dysesthesias in the left upper extremity are moderate. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Severe | Checkbox |
Check this box if the Veteran’s paresthesias and/or dysesthesias in the left upper extremity are severe. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Paresthesias/Dysesthesias Severity - Right Upper Extremity | ||
| None | Checkbox |
Check this box if the Veteran has no paresthesias and/or dysesthesias in the right upper extremity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Mild | Checkbox |
Check this box if paresthesias and/or dysesthesias in the right upper extremity are present and are mild in severity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Moderate | Checkbox |
Check this box if paresthesias and/or dysesthesias in the right upper extremity are present and are moderate in severity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Severe | Checkbox |
Check this box if paresthesias and/or dysesthesias in the right upper extremity are present and are severe in severity. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Passive ROM Limitation Degrees (If Different) | ||
| Forward Flexion Degree Endpoint | Number |
Enter the passive forward flexion degree endpoint if it differs from the value recorded above.
|
| Left Lateral Flexion Degree Endpoint | Number |
Enter the passive left lateral flexion degree endpoint if it differs from the value recorded above.
|
| Extension Degree Endpoint | Number |
Enter the passive extension degree endpoint if it differs from the value recorded above.
|
| Right Lateral Rotation Degree Endpoint | Number |
Enter the passive right lateral rotation degree endpoint if it differs from the value recorded above.
|
| Right Lateral Flexion Degree Endpoint | Number |
Enter the passive right lateral flexion degree endpoint if it differs from the value recorded above.
|
| Left Lateral Rotation Degree Endpoint | Number |
Enter the passive left lateral rotation degree endpoint if it differs from the value recorded above.
|
| Passive ROM Measurements (Degrees) | ||
| Passive ROM Forward Flexion Endpoint (Degrees) | Number |
Enter the measured passive range-of-motion endpoint for forward flexion in degrees. Fill only if 'Forward flexion - Same as active ROM' is 'No'.
Depends on:
Forward flexion - Same as active ROM
|
| Passive ROM Extension Endpoint (Degrees) | Number |
Enter the measured passive range-of-motion endpoint for extension in degrees. Fill only if 'Extension - Same as active ROM' is 'No'.
Depends on:
Extension - Same as active ROM
|
| Passive ROM Right Lateral Flexion Endpoint (Degrees) | Number |
Enter the measured passive range-of-motion endpoint for right lateral flexion in degrees. Fill only if 'Right lateral flexion - Same as active ROM' is 'No'.
Depends on:
Right lateral flexion - Same as active ROM
|
| Passive ROM Left Lateral Flexion Endpoint (Degrees) | Number |
Enter the measured passive range-of-motion endpoint for left lateral flexion in degrees. Fill only if 'Left lateral flexion - Same as active ROM' is 'No'.
Depends on:
Left lateral flexion - Same as active ROM
|
| Passive ROM Right Lateral Rotation Endpoint (Degrees) | Number |
Enter the measured passive range-of-motion endpoint for right lateral rotation in degrees. Fill only if 'Right lateral rotation - Same as active ROM' is 'No'.
Depends on:
Right lateral rotation - Same as active ROM
|
| Passive ROM Left Lateral Rotation Endpoint (Degrees) | Number |
Enter the measured passive range-of-motion endpoint for left lateral rotation in degrees. Fill only if 'Left lateral rotation - Same as active ROM' is 'No'.
Depends on:
Left lateral rotation - Same as active ROM
|
| Passive ROM Movements With Pain | ||
| Forward flexion | Checkbox |
Check this box if passive forward flexion produced pain during the examination.
|
| Right lateral flexion | Checkbox |
Check this box if passive right lateral flexion produced pain during the examination.
|
| Right lateral rotation | Checkbox |
Check this box if passive right lateral rotation produced pain during the examination.
|
| Extension | Checkbox |
Check this box if passive extension produced pain during the examination.
|
| Left lateral flexion | Checkbox |
Check this box if passive left lateral flexion produced pain during the examination.
|
| Left lateral rotation | Checkbox |
Check this box if passive left lateral rotation produced pain during the examination.
|
| Passive ROM Not Performed Explanation | ||
| Passive ROM Not Performed Explanation | Text |
Provide the explanation for why passive range of motion (ROM) testing was not performed. Fill only if 'No' is 'Yes'.
Depends on:
No
|
| Passive ROM Not Performed Reasons | ||
| Medically contraindicated | Checkbox |
Check this box if passive range of motion testing was not performed because it was medically contraindicated (e.g., could cause severe pain or risk further injury).
|
| Testing not necessary | Checkbox |
Check this box if passive range of motion testing was not performed because the examiner determined the testing was not necessary.
|
| Other | Checkbox |
Check this box if passive range of motion testing was not performed for any other reason not listed, and provide an explanation.
|
| Passive ROM Same As Active Indicators | ||
| Forward flexion - Same as active ROM | Checkbox |
Check this box if the passive forward flexion endpoint is the same as the active forward flexion ROM.
|
| Extension - Same as active ROM | Checkbox |
Check this box if the passive extension endpoint is the same as the active extension ROM.
|
| Right lateral flexion - Same as active ROM | Checkbox |
Check this box if the passive right lateral flexion endpoint is the same as the active right lateral flexion ROM.
|
| Left lateral flexion - Same as active ROM | Checkbox |
Check this box if the passive left lateral flexion endpoint is the same as the active left lateral flexion ROM.
|
| Right lateral rotation - Same as active ROM | Checkbox |
Check this box if the passive right lateral rotation endpoint is the same as the active right lateral rotation ROM.
|
| Left lateral rotation - Same as active ROM | Checkbox |
Check this box if the passive left lateral rotation endpoint is the same as the active left lateral rotation ROM.
|
| Passive ROM Testing Performed | ||
| Yes | Radiobutton |
Check this box if passive range of motion (ROM) testing was performed.
|
| No | Radiobutton |
Check this box if passive range of motion (ROM) testing was not performed.
|
| Patient/Veteran Identification | ||
| Patient/Veteran Name | Text |
Enter the full name of the 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.
|
| Post-Repetition ROM Measurements (Degrees) | ||
| Forward Flexion Endpoint After Repetition (Degrees) | Number |
Enter the forward flexion endpoint measurement after three repetitions, in degrees. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Left Lateral Flexion Endpoint After Repetition (Degrees) | Number |
Enter the left lateral flexion endpoint measurement after three repetitions, in degrees. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Extension Endpoint After Repetition (Degrees) | Number |
Enter the extension endpoint measurement after three repetitions, in degrees. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Right Lateral Rotation Endpoint After Repetition (Degrees) | Number |
Enter the right lateral rotation endpoint measurement after three repetitions, in degrees. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Right Lateral Flexion Endpoint After Repetition (Degrees) | Number |
Enter the right lateral flexion endpoint measurement after three repetitions, in degrees. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Left Lateral Rotation Endpoint After Repetition (Degrees) | Number |
Enter the left lateral rotation endpoint measurement after three repetitions, in degrees. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Questionnaire Requester (Veteran/Third Party/Other) | ||
| Veteran/Claimant | Checkbox |
Check this box if you are completing this Disability Benefits Questionnaire at the request of the Veteran/Claimant.
|
| Third party (list organization/individual) | Checkbox |
Check this box if you are completing this questionnaire at the request of a third party, such as an organization or individual, and list their name(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 (list organization/individual)' is 'Yes'.
Depends on:
Third party (list organization/individual)
|
| Other (describe) | Checkbox |
Check this box if you are completing this questionnaire at the request of someone else not covered above and describe who requested it.
|
| Other Requester Description | Text |
Describe the requester if the questionnaire is being completed at the request of someone other than the Veteran/Claimant or a third party listed above. Fill only if 'Other (describe)' is 'Yes'.
Depends on:
Other (describe)
|
| Radiculopathy Present (Yes/No) | ||
| Yes | Radiobutton |
Check this box if the Veteran has radicular pain or any other signs or symptoms due to radiculopathy.
|
| No | Radiobutton |
Check this box if the Veteran does not have radicular pain or any other signs or symptoms due to radiculopathy.
|
| Relationship of Abnormal Findings to Diagnosed Conditions (14F) | ||
| Relationship of Abnormal Findings to Diagnosed Conditions | Text |
Describe how any abnormal test results relate to the diagnosed conditions, including which condition(s) each abnormal finding supports or is associated with.
|
| Repeated Use Over Time - Cite and Discuss Evidence | ||
| Evidence Citation and Discussion (Repeated Use Over Time) | Text |
Provide a specific narrative citing and discussing all procurable evidence used to estimate functional loss and range-of-motion limitations after repeated use over time for this joint.
|
| Repeated Use Over Time - Estimated Range of Motion Endpoints (Degrees) | ||
| Forward Flexion Endpoint (Repeated Use) | Number |
Enter the estimated forward flexion range-of-motion endpoint immediately after repeated use over time, in degrees.
|
| Left Lateral Flexion Endpoint (Repeated Use) | Number |
Enter the estimated left lateral flexion range-of-motion endpoint immediately after repeated use over time, in degrees.
|
| Extension Endpoint (Repeated Use) | Number |
Enter the estimated extension range-of-motion endpoint immediately after repeated use over time, in degrees.
|
| Right Lateral Rotation Endpoint (Repeated Use) | Number |
Enter the estimated right lateral rotation range-of-motion endpoint immediately after repeated use over time, in degrees.
|
| Right Lateral Flexion Endpoint (Repeated Use) | Number |
Enter the estimated right lateral flexion range-of-motion endpoint immediately after repeated use over time, in degrees.
|
| Left Lateral Rotation Endpoint (Repeated Use) | Number |
Enter the estimated left lateral rotation range-of-motion endpoint immediately after repeated use over time, in degrees.
|
| Repeated Use Over Time - Evidence Suggests Functional Limitation (Yes/No) | ||
| Evidence suggests functional limitation with repeated use over time - Yes | Radiobutton |
Check this box if the procured evidence (e.g., the Veteran’s statements) suggests pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability with repeated use over time.
|
| Evidence suggests functional limitation with repeated use over time - No | Radiobutton |
Check this box if the procured evidence does not suggest any significant functional limitation with repeated use over time.
|
| Repeated Use Over Time - Examined Immediately After Repeated Use (Yes/No) | ||
| Yes | Radiobutton |
Check this box if the Veteran is being examined immediately after repeated use over time.
|
| No | Radiobutton |
Check this box if the Veteran is not being examined immediately after repeated use over time.
|
| Repeated Use Over Time - Factors Causing Functional Loss (Select All That Apply) | ||
| N/A | Checkbox |
Check this box if no factors (pain, fatigability, weakness, lack of endurance, incoordination, etc.) cause functional loss with repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time - No' is 'Yes'.
Depends on:
Evidence suggests functional limitation with repeated use over time - No
|
| Pain | Checkbox |
Check this box if pain causes functional loss with repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'.
Depends on:
Evidence suggests functional limitation with repeated use over time - Yes
|
| Fatigability | Checkbox |
Check this box if fatigability causes functional loss with repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'.
Depends on:
Evidence suggests functional limitation with repeated use over time - Yes
|
| Weakness | Checkbox |
Check this box if weakness causes functional loss with repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'.
Depends on:
Evidence suggests functional limitation with repeated use over time - Yes
|
| Lack of endurance | Checkbox |
Check this box if lack of endurance causes functional loss with repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'.
Depends on:
Evidence suggests functional limitation with repeated use over time - Yes
|
| Incoordination | Checkbox |
Check this box if incoordination causes functional loss with repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'.
Depends on:
Evidence suggests functional limitation with repeated use over time - Yes
|
| Other | Checkbox |
Check this box if another factor (not listed) causes functional loss with repeated use over time, and specify it in the space provided. Fill only if 'Evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'.
Depends on:
Evidence suggests functional limitation with repeated use over time - Yes
|
| Other Functional Loss Factor | Text |
Enter the other factor(s) causing functional loss with repeated use over time if not listed among the provided options. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Repetitive Use Testing Not Performed Explanation | ||
| Explanation for Not Performing Repetitive Use Testing | Text |
Provide the reason the Veteran was not able to perform repetitive use testing with at least three repetitions. Fill only if 'No' is 'Yes'.
Depends on:
No
|
| Repetitive Use Testing Performed | ||
| Yes | Radiobutton |
Check this box if the Veteran is able to perform repetitive use testing with at least three repetitions.
|
| No | Radiobutton |
Check this box if the Veteran is not able to perform repetitive use testing with at least three repetitions.
|
| Right Hand/Fingers (C6-8) Light Touch Sensation | ||
| Normal | Checkbox |
Check this box if light touch sensation in the right hand/fingers (C6–C8) is normal.
|
| Decreased | Checkbox |
Check this box if light touch sensation in the right hand/fingers (C6–C8) is decreased compared to normal.
|
| Absent | Checkbox |
Check this box if light touch sensation in the right hand/fingers (C6–C8) is absent.
|
| Right Inner/Outer Forearm (C6-T1) Light Touch Sensation | ||
| Normal | Checkbox |
Check this box if light-touch sensation is normal on the right inner/outer forearm (C6–T1).
|
| Decreased | Checkbox |
Check this box if light-touch sensation is decreased (reduced) on the right inner/outer forearm (C6–T1).
|
| Absent | Checkbox |
Check this box if light-touch sensation is absent on the right inner/outer forearm (C6–T1).
|
| Right Shoulder Area (C5) Light Touch Sensation | ||
| Normal | Checkbox |
Check this box if light touch sensation in the RIGHT shoulder area (C5 dermatome) is normal.
|
| Decreased | Checkbox |
Check this box if light touch sensation in the RIGHT shoulder area (C5 dermatome) is decreased compared with normal.
|
| Absent | Checkbox |
Check this box if light touch sensation in the RIGHT shoulder area (C5 dermatome) is absent.
|
| Second Muscle Strength Testing Row | ||
| Right Elbow Extension Strength | Text |
Enter the muscle strength rating for right elbow extension according to the 0–5 scale shown on the form.
|
| Right Finger Flexion Strength | Text |
Enter the muscle strength rating for right finger flexion according to the 0–5 scale shown on the form.
|
| Left Elbow Extension Strength | Text |
Enter the muscle strength rating for left elbow extension according to the 0–5 scale shown on the form.
|
| Left Finger Flexion Strength | Text |
Enter the muscle strength rating for left finger flexion according to the 0–5 scale shown on the form.
|
| SECTION IX - OTHER NEUROLOGIC ABNORMALITIES | ||
| Yes | Radiobutton |
Check this box if the Veteran has other neurologic abnormalities or findings (not already identified in Sections 4–7) related to a cervical spine condition.
|
| No | Radiobutton |
Check this box if the Veteran does not have any other neurologic abnormalities or findings (not already identified in Sections 4–7) related to a cervical spine condition.
|
| Other Neurologic Abnormalities Description | Text |
Describe any other neurologic abnormalities or findings related to the Veteran's cervical spine condition and explain how each condition is related. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| SECTION XV - FUNCTIONAL IMPACT | ||
| Yes | Radiobutton |
Check this box if the conditions listed in the diagnosis section impact the Veteran’s ability to perform occupational tasks (e.g., standing, walking, lifting, sitting).
|
| No | Radiobutton |
Check this box if the conditions listed in the diagnosis section do not impact the Veteran’s ability to perform occupational tasks.
|
| Functional Impact Description | Text |
Describe how the diagnosed condition(s) affect the Veteran’s ability to perform occupational tasks (e.g., standing, walking, lifting, sitting), including one or more examples. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| SECTION XVI - REMARKS | ||
| Remarks | Text |
Enter any additional remarks or explanations, identifying the section of the form to which each remark pertains when appropriate. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'Yes'.
Depends on:
No current diagnosis
|
| Segmental Instability Diagnosis | ||
| Segmental instability | Checkbox |
Check this box if the veteran’s current diagnosis associated with the claimed condition(s) is segmental instability.
|
| Segmental Instability ICD Code | Text |
Enter the ICD diagnosis code for the segmental instability diagnosis. Fill only if 'Segmental instability' is 'Yes'.
Depends on:
Segmental instability
|
| Segmental Instability Date of Diagnosis | Date |
Enter the date the segmental instability diagnosis was made. Fill only if 'Segmental instability' is 'Yes'.
Depends on:
Segmental instability
|
| Spinal Fusion Diagnosis | ||
| Spinal fusion | Checkbox |
Check this box if spinal fusion is a current diagnosis associated with the claimed condition(s).
|
| Spinal Fusion ICD Code | Text |
Enter the ICD diagnostic code associated with the spinal fusion diagnosis. Fill only if 'Spinal fusion' is 'Yes'.
Depends on:
Spinal fusion
|
| Spinal Fusion Date of Diagnosis | Date |
Enter the date when spinal fusion was diagnosed. Fill only if 'Spinal fusion' is 'Yes'.
Depends on:
Spinal fusion
|
| Spinal Stenosis Diagnosis | ||
| Spinal stenosis | Checkbox |
Check this box if the Veteran has a current diagnosis of spinal stenosis associated with the claimed condition(s).
|
| Spinal stenosis ICD code | Text |
Enter the ICD diagnosis code corresponding to the spinal stenosis diagnosis. Fill only if 'Spinal stenosis' is 'Yes'.
Depends on:
Spinal stenosis
|
| Spinal stenosis date of diagnosis | Date |
Enter the date on which spinal stenosis was diagnosed. Fill only if 'Spinal stenosis' is 'Yes'.
Depends on:
Spinal stenosis
|
| Spondylolisthesis Diagnosis | ||
| Spondylolisthesis | Checkbox |
Check this box if the Veteran has a current diagnosis of spondylolisthesis associated with the claimed condition(s).
|
| Spondylolisthesis ICD Code | Text |
Enter the ICD diagnosis code corresponding to the Veteran's spondylolisthesis. Fill only if 'Spondylolisthesis' is 'Yes'.
Depends on:
Spondylolisthesis
|
| Spondylolisthesis Date of Diagnosis | Date |
Enter the date when spondylolisthesis was first diagnosed. Fill only if 'Spondylolisthesis' is 'Yes'.
Depends on:
Spondylolisthesis
|
| Supporting Documentation - Documented in File (Details) | ||
| Medical history as shown and documented in the Veteran's file | Checkbox |
Check this box if the Veteran’s medical history is documented in the Veteran’s file and you relied on that file for the medical history information. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Treatment Record Dates Reviewed | Text |
Enter the individual date(s) of each treatment record that was reviewed from the Veteran's file. Fill only if 'Medical history as shown and documented in the Veteran's file' is 'Yes'.
Depends on:
Medical history as shown and documented in the Veteran's file
|
| Facility/Provider | Text |
Enter the name of the facility and/or provider associated with the treatment records. Fill only if 'Medical history as shown and documented in the Veteran's file' is 'Yes'.
Depends on:
Medical history as shown and documented in the Veteran's file
|
| Treatment Description | Text |
Describe the treatment documented in the reviewed records. Fill only if 'Medical history as shown and documented in the Veteran's file' is 'Yes'.
Depends on:
Medical history as shown and documented in the Veteran's file
|
| Supporting Documentation - Other (Describe) | ||
| Other, describe | Checkbox |
Check this box if you are providing other supporting documentation not listed elsewhere, and describe it in the space provided. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Other Supporting Documentation Description | Text |
Provide a detailed description of any other supporting documentation reviewed that is not covered by the listed categories. Fill only if 'Other, describe' is 'Yes'.
Depends on:
Other, describe
|
| Supporting Documentation - Veteran Report Only | ||
| Medical history as described by the Veteran only, without documentation | Checkbox |
Check this box if the support for the “Yes” response is based only on the Veteran’s reported medical history and no supporting medical documentation is available/provided. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Veteran-Reported Medical History (No Documentation) | Text |
Enter the medical history details as reported by the Veteran only to support the response, without attaching or referencing additional documentation. Fill only if 'Medical history as described by the Veteran only, without documentation' is 'Yes'.
Depends on:
Medical history as described by the Veteran only, without documentation
|
| Tenderness Description | ||
| Tenderness Details | Text |
Describe the location, severity, and relationship to the condition(s) of any localized tenderness or pain on palpation of the joint or associated soft tissue. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Third Muscle Strength Testing Row | ||
| Right Wrist Flexion Strength Rating | Text |
Enter the muscle strength rating for right wrist flexion using the scale provided in Section IV.
|
| Right Finger Abduction Strength Rating | Text |
Enter the muscle strength rating for right finger abduction using the scale provided in Section IV.
|
| Left Wrist Flexion Strength Rating | Text |
Enter the muscle strength rating for left wrist flexion using the scale provided in Section IV.
|
| Left Finger Abduction Strength Rating | Text |
Enter the muscle strength rating for left finger abduction using the scale provided in Section IV.
|
| Total Duration of Bed Rest Episodes (Past 12 Months) | ||
| No episodes of bed rest (past 12 months) | Checkbox |
Check this box if the Veteran has had no physician-prescribed bed rest episodes due to IVDS during the past 12 months. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Bed rest total at least 1 week but less than 2 weeks | Checkbox |
Check this box if the total duration of physician-prescribed bed rest episodes due to IVDS in the past 12 months is at least 1 week but less than 2 weeks. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Bed rest total at least 2 weeks but less than 4 weeks | Checkbox |
Check this box if the total duration of physician-prescribed bed rest episodes due to IVDS in the past 12 months is at least 2 weeks but less than 4 weeks. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Bed rest total at least 4 weeks but less than 6 weeks | Checkbox |
Check this box if the total duration of physician-prescribed bed rest episodes due to IVDS in the past 12 months is at least 4 weeks but less than 6 weeks. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Bed rest total at least 6 weeks | Checkbox |
Check this box if the total duration of physician-prescribed bed rest episodes due to IVDS in the past 12 months is at least 6 weeks. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Traumatic Paralysis (Complete) Diagnosis | ||
| Traumatic paralysis, complete | Checkbox |
Check this box if the Veteran has a current diagnosis of complete traumatic paralysis associated with the claimed condition(s).
|
| Traumatic paralysis (complete) ICD code | Text |
Enter the ICD diagnosis code corresponding to the diagnosis of traumatic paralysis, complete. Fill only if 'Traumatic paralysis, complete' is 'Yes'.
Depends on:
Traumatic paralysis, complete
|
| Traumatic paralysis (complete) date of diagnosis | Date |
Enter the date when traumatic paralysis, complete was diagnosed. Fill only if 'Traumatic paralysis, complete' is 'Yes'.
Depends on:
Traumatic paralysis, complete
|
| VA Provider and Clinic Relationship | ||
| 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 regularly seen in your clinic - Yes | Radiobutton |
Check this box if the Veteran is regularly seen as a patient in your clinic.
|
| Veteran regularly seen in your clinic - No | Radiobutton |
Check this box if the Veteran is not regularly seen as a patient in your clinic.
|
| Vertebral Dislocation Diagnosis | ||
| Vertebral dislocation | Checkbox |
Check this box if the veteran has a current diagnosis of vertebral dislocation associated with the claimed condition(s).
|
| Vertebral dislocation ICD code | Text |
Enter the ICD diagnostic code corresponding to the vertebral dislocation diagnosis. Fill only if 'Vertebral dislocation' is 'Yes'.
Depends on:
Vertebral dislocation
|
| Vertebral dislocation date of diagnosis | Date |
Enter the date when vertebral dislocation was first diagnosed. Fill only if 'Vertebral dislocation' is 'Yes'.
Depends on:
Vertebral dislocation
|
| Vertebral Fracture Diagnosis | ||
| Vertebral fracture | Checkbox |
Check this box if the Veteran has a current diagnosis of a vertebral fracture associated with the claimed condition(s).
|
| Vertebral Fracture ICD Code | Text |
Enter the ICD diagnosis code corresponding to the Veteran's vertebral fracture. Fill only if 'Vertebral fracture' is 'Yes'.
Depends on:
Vertebral fracture
|
| Vertebral Fracture Date of Diagnosis | Date |
Enter the date when the vertebral fracture was diagnosed. Fill only if 'Vertebral fracture' is 'Yes'.
Depends on:
Vertebral fracture
|
| Walker Use and Frequency | ||
| Walker | Checkbox |
Check this box if the Veteran uses a walker as an assistive device for locomotion. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Walker frequency: Occasional | Checkbox |
Check this box if the Veteran uses a walker occasionally. Fill only if 'Yes', 'Walker' is 'Yes' (all).
Depends on:
Yes, Walker
|
| Walker frequency: Regular | Checkbox |
Check this box if the Veteran uses a walker regularly. Fill only if 'Yes', 'Walker' is 'Yes' (all).
Depends on:
Yes, Walker
|
| Walker frequency: Constant | Checkbox |
Check this box if the Veteran uses a walker constantly. Fill only if 'Yes', 'Walker' is 'Yes' (all).
Depends on:
Yes, Walker
|
| Wheelchair Use and Frequency | ||
| Wheelchair | Checkbox |
Check this box if the Veteran uses a wheelchair as an assistive device for normal locomotion. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Wheelchair frequency of use: Occasional | Checkbox |
Check this box if the Veteran uses a wheelchair occasionally. Fill only if 'Yes', 'Wheelchair' is 'Yes' (all).
Depends on:
Yes, Wheelchair
|
| Wheelchair frequency of use: Regular | Checkbox |
Check this box if the Veteran uses a wheelchair regularly. Fill only if 'Yes', 'Wheelchair' is 'Yes' (all).
Depends on:
Yes, Wheelchair
|
| Wheelchair frequency of use: Constant | Checkbox |
Check this box if the Veteran uses a wheelchair constantly. Fill only if 'Yes', 'Wheelchair' is 'Yes' (all).
Depends on:
Yes, Wheelchair
|