Disability Evaluation
Examination Worksheets


Department of Veterans Affairs
Memorandum

Date: September 24, 1997

From: Acting Under Secretary for Benefits (20)/Under Secretary for Health (10)

Subj: Examination Worksheets for Disability Claims

To: VBA Area Directors VHA VISN Directors Directors (00) VBA Regional Offices/VHA Medical Centers

1. The Disability Examination Worksheets generated through the VISTA Automated Medical Information Exchange (AMIE) system provide the criteria that must be used by examiners at VA Medical Centers in performing examinations for disability claims. The worksheets were recently revised by a VBA/VHA joint work group with assistance from the Board of Veterans Appeals. The revisions considered recent changes to the Schedule for Rating Disabilities, Court of Veterans Appeals decisions, General Counsel opinions, and comments received from within Central Office and the VBA and VHA field.

2. The revised examination worksheets are now ready for incorporation into the AMIE system. The AMIE patch was officially released by the VHA Information Resource Management (IRM) staff to the medical facilities on 9/12/97.

3. The revised examination worksheets should be installed in AMIE at the first opportunity since their use is a high priority for both VBA and VHA. We expect the revised examination worksheets to be in use by the regional offices and medical centers no later than 10/1/97. Examination adequacy will depend upon following the criteria specified in the worksheets. We believe the revised worksheets will improve the examination process and assist our veterans in receiving a quality examination in accordance with the Rating Schedule. We encourage our respective field personnel to continue to work together to coordinate the examination process.

4. Enclosed are the revised examination worksheets in MS Word format which completely replace previously provided draft versions. The content of the attachments is the same as the ones in AMIE although the appearance may be slightly different since the AMIE documents use a different format and contain AMIE worksheet numbers.

5. The AMIE patch will also remove the Physician's Guide for Disability Evaluation Examinations from AMIE. The Physician's Guide is being updated and will be published separately.

/s/

Stephen L. Lemons
Kenneth W. Kizer, M.D., M.P.H.


GENERAL MEDICAL EXAMINATION

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

Narrative: This is a complete, base-line examination covering all parts of the body, not just the areas claimed by the veteran. The examiner may request any additional studies or examinations as needed for proper diagnosis and evaluation. All important negatives should be reported. If a diagnosis is uncovered that was not originally claimed by the veteran, complete the appropriate worksheet, in addition to this one. A general medical examination may also be requested as evidence for nonservice-connected disability pension claims or for claimed entitlement to individual unemployability benefits in service-connected disability compensation claims.

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. If the injury or disease occurred in the military:

a. Completely describe the circumstances, injury, treatment, follow-up, and residuals in the military.

b. Completely describe the circumstances, injury, treatment, follow-up, and residuals after the military.

2. If the injury or disease occurred before the military:

a. Completely describe the circumstances, injury, treatment, follow-up and residuals before entering the military.

b. Completely describe any worsening of residuals due to being in the military.

c. Completely describe the circumstances, injury, treatment, follow-up, and residuals after the military.

3. If the injury or disease occurred after the military:

a. Completely describe the circumstances, injury, treatment, follow-up, and residuals after the military.

4. Occupational history:

a. Obtain the name and address of the employer (list most current first), type of occupation, employment dates, wages for last 12 months. If any time was lost from work, please describe the reason and extent of time lost.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings: The examiner should incorporate all ancillary study results into the final diagnoses.

1. VS: Heart rate, blood pressure (If the diagnosis of hypertension has not been established, take 2 or more blood pressure readings on at least 3 different days. If hypertension has been diagnosed, take 2 or more blood pressure readings.), respirations, height, weight, maximum weight past year, weight change in past year, body in build, and state of nutrition.

2. Dominant hand: Indicate the dominant hand and how determined (i.e., writes, eats, combs hair, etc.).

3. Posture and gait: (If abnormal, describe.)

4. Skin, including appendages: (If abnormal, describe appearance, location, extent of lesions, and limitations to daily activity.) If there are laceration or burn scars, describe the location, measurements (cm. x cm.), shape, depression, type of tissue loss, adherence, disfigurement, and tenderness. For each burn scar, state if due to a 2nd or 3rd degree burn. (NOTE: If the skin condition or scars are disfiguring, obtain color photographs of the affected area(s).

5. Hemic and Lymphatic: (Describe local or generalized adenopathy, tenderness, suppuration, etc.).

6. Head and face: Describe scars, deformities, etc.

7. Eyes: Describe external eye, pupil reaction, movements, field of vision, any uncorrectable refractive error, or any retinopathy.

8. Ears: Describe canals, drums, perforations, discharge.

9. Nose, sinuses, mouth and throat: Include gross dental findings.

10. Neck: Describe lymph nodes, thyroid, etc.

11. Chest: Inspection, palpation, percussion, auscultation. If abnormal, describe limitations of daily living (i.e., How far can the veteran walk, how many flights of stairs can he or she climb, etc.).

12. Breast: Comment on any masses palpated in breast parenchyma including axillary tail. Comment on any skin abnormalities. Comment on any discharge from nipples.

13. Cardiovascular: Record pulse, heart sounds, abnormalities (i.e., arrhythmias, murmurs, etc.), and status of peripheral vessels. Note edema. Describe varicose veins including location, size, extent, ulcers, scars, and competency of deep circulation. Examine for evidence of residuals of frostbite when indicated. See cold injuries examination worksheet. (NOTE: Cardiovascular signs and symptoms should be graded using NYHA scale.)

14. Abdomen: Inspection, auscultation, palpation, percussion. If abnormal, describe (i.e., abdominal enlargement, masses, tenderness, etc.).

15. Genital/rectal (male): Inspection and palpation of penis, testicles, epididymis, and spermatic cord. (If hernia, describe type, location, size, whether complete, reducible, recurrent, supported by truss or belt, and whether or not operable). Inspection of anus for fissures, hemorrhoids, ulcerations, etc. and digital exam of rectal walls, and prostate.

16. Genital/rectal (female): Pelvic exam should include inspection of introitus, vagina, and cervix, palpation of labia, vagina, cervix, uterus, adnexa, and ovaries. Pap smear (if none within past year). Inspection of anus for fissures, hemorrhoids, ulcerations, etc. and digital exam of rectal walls. Any severe abnormalities may be referred to a specialist.

17. Musculoskeletal: For joint or muscle defects, describe location, swelling, atrophy, tenderness, active and passive motion in degrees using a goniometer, angle of fixation, fracture, fibrous or bony residual, and mechanical aids used by veteran. Provide an assessment of the effect on range of motion and joint function of pain, weakness, fatigue, or incoordination following repetitive use or during flare-ups. (See the appropriate worksheet for more detail.) If foot problems exist, perform above exam and also include objective evidence of pain at rest and on manipulation, rigidity, spasm, circulatory disturbance, swelling, callus, loss of strength, mobility of ankles and feet, and whether acquired or congenital.

18. Endocrine: Describe disease of thyroid, pituitary, adrenals, gonads, other body systems affected, etc.

19. Neurological: Cerebrum - orientation and memory. Cerebellum - gait, stance, and coordination. Spinal Cord - deep tendon reflexes, pain, touch, temperature, vibration, and position. Cranial nerves - I-XII. If abnormalities are found, describe region of CNS affected.

20. Psychiatric: Describe behavior, comprehension, coherence of response, emotional reaction, signs of tension, and response to social and occupational environment. State whether the veteran is capable of managing his or her benefit payments in his or her own best interests without restriction. (A physical disability which prevents the veteran from attending to financial matters in person is not a proper basis for a finding of incompetency unless the veteran is, by reason of that disability, incapable of directing someone else in handling the individual's financial affairs.)

D. Diagnostic and Clinical Tests:

1. Include results of all diagnostic and clinical tests conducted in the examination report.

2. All test results must be reviewed prior to the final summary and diagnosis.

E. Diagnosis:

Signature:                                Date:


BONES (FRACTURES AND BONE DISEASE)

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Describe details of any injury, episodes of osteomyelitis, or surgery.

2. Symptoms of pain, weakness, stiffness, swelling, heat, redness, drainage, instability or giving way, "locking," abnormal motion, etc.

3. Treatment: medication type, dose, frequency, response, and side effects; other treatment.

4. If there are periods of flare-up of bone disease:

a. State their severity, frequency, and duration.

b. Name the precipitating and alleviating factors.

c. Estimate to what extent, if any, they affect functional impairment during the flare-up.

5. Is there current active infection? If not, when was the last active infection? How was it determined?

6. Describe whether crutches, brace, cane, corrective shoes, etc., are needed.

7. Are there constitutional symptoms of bone disease?

8. Describe the effects of the condition on the veteran's usual occupation and daily activities.

C. Physical Examination (Objective Findings):

Address each of the following as appropriate to the disability being examined and fully describe current findings:

1. Describe objective evidence of deformity, angulation, false motion, shortening, intra-articular involvement, etc.

2. Malunion, nonunion, any loose motion, false joint.

3. Tenderness, drainage, edema, painful motion, weakness, redness, heat.

4. For weight bearing joints (hip, knee, ankle), describe gait and functional limitations on standing and walking. Describe any callosities, breakdown, or unusual shoe wear pattern that would indicate abnormal weight bearing.

5. If ankylosis is present, describe the position of the bones of the joint in relationship to one another (in degrees of flexion, external rotation, etc.), and state whether the ankylosis is stable and pain free.

6. With joint involvement, a detailed assessment of each affected joint is required.

Note: See worksheet on Shoulder, Elbow, Wrist, Hip, Knee, and Ankle for normal range of motion of those joints.

a. Using a goniometer, measure the passive and active range of motion, including movement against gravity and against strong resistance.

b. If the joint is painful on motion, state at what point in the range of motion pain begins and ends.

c. State to what extent, if any, the range of motion or function is additionally limited by pain, fatigue, weakness, or lack of endurance. If more than one of these is present, state, if possible, which has the major functional impact.

7. If shortening of the leg may be present, measure the leg length from the anterior superior iliac spine to the medial malleolus.

8. Are there constitutional signs of bone disease - anemia, weight loss, fever, debility, amyloid liver, etc.?

D. Diagnostic and Clinical Tests:

1. As indicated: X-rays, including special views or weight bearing films, MRI, arthrogram, diagnostic arthroscopy. Note: The diagnosis of degenerative arthritis or post-traumatic arthritis of a joint requires X-ray confirmation. Once the diagnosis has been confirmed in a joint, further X-rays of that joint are not required.

2. For osteomyelitis, state whether there is an involucrum, sequestrum, or draining sinus.

3. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


FIBROMYALGIA

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

Narrative: For VA compensation purposes, the diagnosis of fibromyalgia (sometimes called fibrositis, primary fibromyalgia syndrome, or myofascial pain syndrome) requires the presence of widespread musculoskeletal pain and tender points. Additional findings may also be present: fatigue, sleep disturbance, stiffness, paresthesias, headache, irritable bowel symptoms, depression, anxiety, or Raynaud's-like symptoms. Widespread pain is defined as pain in both the left and right sides of the body, that is both above and below the waist, and that affects both the axial skeleton (i.e., cervical spine, anterior chest, thoracic spine, or low back) and the extremities. Rule out other diagnostic entities that may be responsible for the symptomatology presented.

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Date of onset of symptoms, date of diagnosis (if known).

2. What precipitates and alleviates symptoms?

3. Location, severity, frequency of any musculoskeletal pain, stiffness, or muscle weakness, whether episodic or constant, and what their effects are on daily activities.

4. Unexplained fatigue, sleep disturbances.

5. GI symptoms.

6. Treatment, (type, duration, response). Has treatment been continuous?

7. Is there depression or anxiety?

8. Lost time from work?

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings: (Please incorporate all ancillary study results into the final diagnosis.)

1. Is the condition currently active or in remission?

2. Musculoskeletal areas involved.

3. Trigger or tender points.

4. Muscle strength in involved areas.

D. Diagnostic and Clinical Tests:

1. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


RESIDUALS OF AMPUTATION

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. The location of the amputation site.

2. If symptoms exist, describe precipitating factors, aggravating factors, alleviating factors, alleviating medications, frequency, severity, and duration.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Swelling, deformity, tenderness of stump.

2. Skin, including scar.

3. Circulation.

4. Muscles.

5. Describe any limited motion or instability in the joint above the amputation site.

6. A detailed assessment of each affected joint is required.

a. Using a goniometer, measure the passive and active range of motion, including movement against gravity and against strong resistance.

b. If the joint is painful on motion, state at what point in the range of motion pain begins and ends.

c. State to what extent, if any, the range of motion or function is additionally limited by pain, fatigue, weakness, or lack of endurance. If more than one of these is present, state, if possible, which has the major functional impact.

7. Bones.

8. Length of stump.

9. Neuroma, if present.

10. Is amputation of lower extremity improvable by prosthesis controlled by natural knee action?

Measurement of the Stump:

The stump of an amputated thigh will be measured from the perineum, at the origin of the adductor tendons, to the bony end of the stump, with the claimant recumbent and the stump lying parallel with the other lower limb. It is to be kept in mind that if the limb is abducted, flexed, rotated or adducted, its length will be altered. The effective length of a thigh stump is governed by its inside dimension. Measure length of normal thigh if present and indicate whether amputation is in upper, middle, or lower third. When amputation is bilateral, estimate the same for a person of similar height.

The stump of an amputated leg below the knee must be measured from the insertion of the internal hamstring muscles to the bony end of the stump with the patient recumbent and the leg flexed at 90 degrees.

The stump of an amputated arm should be measured from the anterior axillary fold to the bony end of the stump, with the stump hanging parallel to the chest wall. Indicate whether the amputation site is above or below the insertion of the deltoid muscle. A statement of the remaining function is the best indicator of a disability's severity.

The stump of an amputated forearm should be measured from the insertion of the biceps tendon to the bony end, with the elbow flexed at 90 degrees. Indicate if the amputation site is above or below the attachment of the pronator teres.

Amputations of fingers should be described as through the distal, middle, or proximal phalanx or as disarticulations through the distal interphalangeal, proximal interphalangeal, or metacarpophalangeal joint. Resection of the head of the metacarpal will always be reported if shown. Complete or partial loss or resection of bones of the hand will described in terms of the fraction of each remaining. If surgery has altered the usefulness of remaining or transplanted digits, this will be described.

Complete or partial loss of toes or metatarsal or tarsal bones should be described as in the subparagraph above. Always report loss of metatarsal head or other defects. Indicate if amputation is through the tarsal-metatarsal joint and if any other portions of the bones of the foot remain.

D. Diagnostic and Clinical Tests:

1. X-ray if exact amputation level is not of record.

2. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Amputations must be described in accordance with the following levels:

1. ARM:

a. Disarticulation.

b. Amputation above insertion of deltoid muscle.

c. Amputation below insertion of deltoid muscle.

2. FOREARM:

a. Above radial insertion of pronator teres (function is best indicator of disability).

b. Below insertion of pronator teres.

3. THIGH:

a. Disarticulation, with loss of extrinsic pelvic girdle muscles.

b. Amputation of upper, middle or lower third, always measured from perineum to the bony end of the stump with the claimant recumbent and stump lying parallel with the other lower limb.

c. State whether this level permits satisfactory prosthesis.

4. LEG:

a. Give level of amputation and condition of stump.

b. State whether this level permits a satisfactory prosthesis.

c. Describe any stump defects (e.g., painful neuroma or circulatory disturbance).

Signature:                                Date:


JOINTS (SHOULDER, ELBOW, WRIST, HIP, KNEE AND ANKLE)

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Pain, weakness, stiffness, swelling, heat and redness, instability or giving way, "locking," fatigability, lack of endurance, etc.

2. Treatment - type, dose, frequency, response, side effects.

3. If there are periods of flare-up of joint disease:

a. State their severity, frequency, and duration.

b. Name the precipitating and alleviating factors.

c. Estimate to what extent, if any, they result in additional limitation of motion or functional impairment during the flare-up.

4. Describe whether crutches, brace, cane, corrective shoes, etc., are needed.

5. Describe details of any surgery or injury.

6. Describe any episodes of dislocation or recurrent subluxation.

7. For inflammatory arthritis, describe any constitutional symptoms.

8. Describe the effects of the condition on the veteran's usual occupation and daily activities.

9. For upper extremity, state which is dominant and means used to identify dominant extremity.

10. If there is a prosthesis, provide date of prosthetic implant and describe any complaint of pain, weakness, or limitation of motion. State whether crutches, brace, etc., are needed.

C. Physical Examination (Objective Findings):

Address each of the following as appropriate to the condition being examined and fully describe current findings: A detailed assessment of each affected joint is required, including joints with prostheses.

1. Using a goniometer, measure the passive and active range of motion, including movement against gravity and against strong resistance. Provide range of motion in degrees.

2. If the joint is painful on motion, state at what point in the range of motion pain begins and ends.

3. State to what extent (if any) and in which degrees (if possible) the range of motion or joint function is additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive use or during flare-ups. If more than one of these is present, state, if possible, which has the major functional impact.

4. Describe objective evidence of painful motion, edema, effusion, instability, weakness, tenderness, redness, heat, abnormal movement, guarding of movement, etc.

5. For weight bearing joints (hip, knee, ankle), describe gait and functional limitations on standing and walking. Describe any callosities, breakdown, or unusual shoe wear pattern that would indicate abnormal weight bearing.

6. If ankylosis is present, describe the position of the bones of the joint in relationship to one another (in degrees of flexion, external rotation, etc.), and state whether the ankylosis is stable and pain free.

7. If indicated, measure the leg length from the anterior superior iliac spine to the medial malleolus.

8. For inflammatory arthritis, describe any constitutional signs.

9. Describe range of motion with prosthesis in same detail as described above for nonprosthetic joints.

D. Normal Range of Motion:

All joint Range of Motion measurements must be made using a goniometer. Show each measured range of motion separately rather than as a continuum. For example, if the veteran lacks 10 degrees of full knee extension and has normal flexion, show the range of motion as extension to minus 10 degrees (or lacks 10 degrees of extension) and flexion 0 to 140 degrees.

1. Hip range of motion: (Movement of femur as it rotates in the acetabulum.)

a. Normal range of motion, using the anatomical position as zero degrees.

Flexion = 0 to 125 degrees (To gain a true picture of hip flexion, i.e., movement between the pelvis and femur in the hip joint, the opposite thigh should be extended to minimize motion between the pelvis and spine.)

Extension = 0 to 30 degrees.

Adduction = 0 to 25 degrees.

Abduction = 0 to 45 degrees.

External rotation = 0 to 60 degrees.

Internal rotation = 0 to 40 degrees.

2. Knee range of motion:

a. Normal range of motion, using the anatomical position as zero degrees.

Flexion = 0 to 140 degrees.

Extension - zero degrees = full extension. Show loss of extension by describing the degrees in which extension is not possible. (e.g., Show range of motion as extension to minus 10 degrees and flexion 0 to 140 degrees when full extension is limited by 10 degrees and full flexion is possible.)

b. Stability.

Medial and Lateral Collateral Ligaments: Varus/valgus in neutral and in 30 degrees of flexion - normal is no motion.

Anterior and Posterior Cruciate Ligaments: Anterior/posterior in 30 degrees of flexion with foot stabilized - normal is less than 5 mm. of motion (1/4 inch - Lachman's test) or in 90 degrees of flexion with foot stabilized - normal is less than 5mm. of motion (1/4 inch - anterior and posterior drawer test).

Medial and Lateral Meniscus: Perform McMurray's test.

3. Ankle range of motion:

a. Neutral position is with foot at 90 degrees to ankle. From that position, dorsiflexion is 0 to 20 degrees; plantar flexion is 0 to 45 degrees.

b. Describe any varus or valgus angulation of the os calcis in relationship to the long axis of the tibia and fibula.

4. Shoulder, elbow, forearm, and wrist range of motion:

a. Normal range of motion is measured with zero degrees the anatomical position except for 2 situations:

(1) Supination and pronation of the forearm is measured with the arm against the body, the elbow flexed to 90 degrees, and the forearm in mid position (zero degrees) between supination and pronation.

(2) Shoulder rotation is measured with the arm abducted to 90 degrees, the elbow flexed to 90 degrees, and the forearm reflecting the midpoint (zero degrees) between internal and external rotation of the shoulder.

b. Shoulder forward flexion = zero to 180 degrees.

c. Shoulder abduction = zero to 180 degrees.

d. Shoulder external rotation = zero to 90 degrees.

e. Shoulder internal rotation = zero to 90 degrees.

f. Elbow flexion = zero to 145 degrees.

g. Forearm supination = zero to 85 degrees.

h. Forearm pronation = zero to 80 degrees.

i. Wrist dorsiflexion (extension) = zero to 70 degrees.

j. Wrist palmar flexion = zero to 80 degrees.

k. Wrist radial deviation = zero to 20 degrees.

l. Wrist ulnar deviation = zero to 45 degrees.

E. Diagnostic and Clinical Tests:

1. As indicated: X-rays, including special views or weight bearing films, MRI, arthrogram, diagnostic arthroscopy.

2. Include results of all diagnostic and clinical tests in the examination report.

Note: The diagnosis of degenerative arthritis or post-traumatic arthritis of a joint requires X-ray confirmation. Once the diagnosis has been confirmed in a joint, further X-rays of that joint are not required.

F. Diagnosis:

Signature:                                Date:


HAND, THUMB AND FINGERS

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. If there are periods of flare-up of joint disease:

a. State their severity, frequency, and duration.

b. Name the precipitating and alleviating factors.

c. Estimate to what extent, if any, they result in additional limitation of motion or functional impairment during the flare-up.

C. Physical Examination (Objective Findings):

Address each of the following as appropriate to the condition being examined and fully describe current findings:

1. Anatomical defects.

2. Functional defects (motion of thumb and fingers should be described as to how near, in inches, the tip of thumb can approximate the fingers, or how near the tips of fingers can approximate the median transverse fold of the palm.

3. Grasping objects (strength and dexterity).

The hand should be evaluated as a unit intricately adapted for grasping, pushing, pulling, twisting, probing, writing, touching, and expression. Do not designate fingers numerically; use thumb, index, middle (or long), ring, and little. Specify which hand is involved and state whether the individual is right- or left-handed. Designate the joints as wrist, MP (metacarpophalangeal), PIP (proximal interphalangeal), or DIP (distal interphalangeal). Designate phalanges as proximal, middle or distal.

4. A detailed assessment of each affected joint is required.

a. Using a goniometer, measure the passive and active range of motion, including movement against gravity and against strong resistance.

b. State to what extent (if any) and in which degrees (if possible) the range of motion or joint function is additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive use or during flare-ups. If more than one of these is present, state, if possible, which has the major functional impact.

D. Diagnostic and Clinical Tests:

1. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


FEET

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Pain, weakness, stiffness, swelling, heat, redness, fatigability, lack of endurance, etc. Describe symptoms at rest and on standing and walking.

2. Treatment - type, dose, frequency, response, side effects.

3. If there are periods of flare-up of joint disease:

a. State their severity, frequency, and duration.

b. Name the precipitating and alleviating factors.

c. Estimate to what extent, if any, they result in additional limitation of motion or functional impairment during the flare-up.

4. Describe whether crutches, brace, cane, corrective shoes, etc., are needed.

5. Describe details of any surgery or injury.

6. Describe corrective shoes, shoe inserts, or braces used and their efficacy.

7. Describe effects of the condition(s) on the veteran's usual occupation and daily activities.

C. Physical Examination (Objective Findings)

Address each of the following as appropriate to the condition being examined and fully describe current findings: A detailed assessment of each affected joint is required.

1. Describe each foot separately. For nomenclature of toes use: great toe, second, third, fourth, and fifth. The functional loss should be related to the anatomical condition.

2. Using a goniometer, measure the passive and active range of motion, including movement against gravity and against strong resistance.

3. If the joint is painful on motion, state at what point in the range of motion pain begins and ends.

4. State to what extent (if any) and in which degrees (if possible) the range of motion or function is additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive use or during flare-ups. If more than one of these is present, state, if possible, which has the major functional impact.

5. Describe objective evidence of painful motion, edema, instability, weakness, tenderness, etc.

6. Describe gait and functional limitations on standing and walking.

7. Describe any callosities, breakdown, or unusual shoe wear pattern that would indicate abnormal weight bearing.

8. Describe any skin and vascular changes.

9. Posture on standing, squatting, supination, pronation, and rising on toes and heels.

10. Describe hammertoes, high arch, clawfoot, or other deformity - actively or passively correctable?

11. For flatfoot

a. Describe weight bearing and non-weight bearing alignment of the Achilles tendon.

b. Describe whether the Achilles tendon alignment can be corrected by manipulation and whether there is pain on manipulation.

c. Describe degrees of valgus and whether correctable by manipulation.

d. Describe extent of forefoot and midfoot malalignment and whether correctable by manipulation.

12. For hallux valgus, describe angulation and dorsiflexion at first metatarso-phalangeal joints.

D. Diagnostic and Clinical Tests:

Comment on:

1. X-rays for flatfoot and clawfoot - weight bearing AP and lateral views and non-weight bearing AP, lateral, and oblique views.

2. For other conditions, AP, lateral, and oblique of entire foot, as applicable.

3. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


SPINE (CERVICAL, THORACIC AND LUMBAR)

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Present Medical History (Subjective Complaints):

Comment on:

1. Complaints of pain, weakness, stiffness, fatigability, lack of endurance, etc.

2. Treatment - type, dose, frequency, response, side effects.

3. If there are periods of flare-up:

a. State their severity, frequency, and duration.

b. Name the precipitating and alleviating factors.

c. Estimate to what extent, if any, they result in additional limitation of motion or functional impairment during the flare-up.

4. Describe whether crutches, brace, cane, etc., are needed.

5. Describe details of any surgery or injury.

6. Functional Assessment - Describe effects of the condition(s) on the veteran's usual occupation and daily activities.

C. Physical Examination (Objective Findings):

Address each of the following as appropriate to the condition being examined and fully describe current findings:

1. Using a goniometer, measure the passive and active range of motion, including movement against gravity and against strong resistance. Provide range of motion in degrees.

2. If the spine is painful on motion, state at what point in the range of motion pain begins and ends.

3. State to what extent (if any) and in which degrees (if possible) the range of motion or spinal function is additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive use or during flare-ups. If more than one of these is present, state, if possible, which has the major functional impact.

4. Describe objective evidence of painful motion, spasm, weakness, tenderness, etc.

5. Postural abnormalities, fixed deformity.

6. Musculature of back.

7. Neurological abnormalities - if present, see appropriate worksheet.

D. Normal Range of Motion:

All joint Range of Motion measurements must be made using a goniometer. Show each measured range of motion separately rather than as a continuum.

E. Diagnostic and Clinical Tests:

Obtain the following and comment on them, as indicated:

1. X-rays, MRI, as indicated.

2. Include results of all diagnostic and clinical tests conducted in the examination report.

F. Diagnosis:

Signature:                                Date:


MUSCLES

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. If there are periods of flare-up of residuals of muscle injury:

a. State their severity, frequency, and duration.

b. Name the precipitating and alleviating factors.

c. Estimate to what extent, if any, they result in additional limitation of motion or functional impairment during the flare-up.

2. If injury is due to a missile: initial treatment in the field, length of initial hospitalization and any surgeries or other repairs undertaken, time until return to duty or limited duty or determination that duty could not be resumed.

3. Record exact muscles injured or destroyed and describe.

4. Record any associated injuries, particularly those affecting bony structures, nerves or vascular structures and specify the nature of treatment required.

5. Describe present symptoms of muscle pain, activity limited by fatigue or inability to move joint through a portion of its range; and the degree to which this interferes with activities of daily living.

6. For tumors of muscle, describe onset of symptoms, date(s) of biopsy and/or surgical excision and residual defects. If malignant neoplasm, need date of diagnosis, dates and type of treatment, and date of last treatment.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Entry and exit wound scars as well as dimensions.

2. Tissue loss comparison, and specify muscle group(s) penetrated.

3. Scar formation measurement (sensitivity, tenderness, etc.)

4. Adhesions.

5. Tendon damage.

6. Bone, joint or nerve damage.

7. Muscle strength.

8. Muscle herniation and, if any, if supported by a truss or belt.

9. Loss of muscle function. Can muscle group move joint through normal range with sufficient comfort, endurance and strength to accomplish activities of daily living? Can muscle group move joint independently through useful ranges of motion but with limitation by pain or easy fatigability or weakness? Can muscle group move joint only with assistance or with gravity eliminated? Is there no ability of muscle group to move joint even with gravity eliminated and joint passively moveable? Is any muscle contraction felt?

10. If joint function is affected:

a. Using a goniometer, measure the passive and active range of motion, including movement against gravity and against strong resistance

b. State to what extent (if any) and in which degrees (if possible) the range of motion or function is additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive use or during flare-ups. If more than one of these is present, state, if possible, which has the major functional impact.

D. Diagnostic and Clinical Tests:

1. If applicable, x-rays of joint(s) involved in two planes or anatomic area involved if not recorded in past (once taken, the x-rays do not need to be repeated).

2. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


EYE EXAMINATION

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Pain.

2. Duration and frequency of periods of incapacitation, and rest requirements.

3. Visual symptoms, including distorted or enlarged image, etc.

4. Current ophthalmologic treatment.

5. For malignant neoplasms, state type of treatment and last date. If treatment is current, describe.

C. Physical Examination (Objective Findings):

Address each of the following, as applicable, and fully describe current findings:

1. Visual Acuity:

a. Examine each eye independently and record the refractive information indicated below.

b. Use conventional lenses for correction unless the patient has keratoconus, is well adapted to contact lenses and wishes to wear them, and contact lenses result in best corrected visual acuity. In that case, use contact lenses to determine best corrected visual acuity.

c. Use Snellen's test type or its equivalent.

d. Carry out an examination with the pupils dilated unless contraindicated, and record the ophthalmic findings.

e. For visual acuity worse than 5/200 in either or both eyes, report the distance in feet/inches (or meters/centimeters) from the face at which the veteran can count fingers/detect hand motion/read the largest line on the chart. If the veteran cannot detect hand motion or count fingers at any distance, state whether he or she has light perception.

f. If keratoconus is present, state whether contact lenses are required or adequate correction is possible by other means.

NEAR FAR



RIGHT EYE UNCORRECTED __________ _________




RIGHT EYE CORRECTED __________ _________



NEAR FAR



LEFT EYE UNCORRECTED __________ _________




LEFT EYE CORRECTED __________ _________



2. Diplopia:

a. Perform the measurement of muscle function using a Goldmann Perimeter Chart and chart the areas in which diplopia exists. Include the chart as part of the examination report to be sent to the regional office.

b. If diplopia is present, state whether it is constant or intermittent, whether it is present at all distances or only for near or distant vision, and whether it is correctable by use of lenses or prisms.

c. If diplopia is constant and not correctable, indicate which sectors of the visual field are affected and provide the Goldmann perimeter chart showing the actual areas of diplopia, according to the format below. Diplopia outside these areas should also be reported even though it is not considered disabling because it may be used in the evaluation of the underlying disease or injury.

CENTRAL 20 DEGREES _________

21 TO 30 DEGREES

DOWN

RIGHT LATERAL ________

LEFT LATERAL ________

UP

RIGHT LATERAL ________

LEFT LATERAL ________

31 TO 40 DEGREES

DOWN

RIGHT LATERAL ________

LEFT LATERAL ________

UP

RIGHT LATERAL ________

LEFT LATERAL ________

3. Visual Field Deficit:

a. Chart any visual field defect using a Goldmann Perimeter Chart and include the chart as part of the examination report to be sent to the regional office.

b. For an aphakic eye which cannot be fitted with contact lenses or intra-ocular implant, use the IV/4e test object. For all other cases, use the III/4e test object.

c. If the examiner determines that charting with other test objects is indicated, those test results should be reported on a separate chart. All charts, along with an explanation of the need for using a different test object and an explanation of any discrepancies in results, should be included as part of the examination report.

d. All scotomas should be plotted carefully in order to allow measurements to be made for adjustments in the calculation of visual field defects.

4. Details of eye disease or injury (including eyebrows, eyelashes, eyelids) other than loss of visual acuity, diplopia, or visual field defect:

D. Diagnostic and Clinical Tests: (Other than for visual acuity, diplopia, and visual fields, as described above.)

1. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


AUDIO

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Chief complaint.

2. Situation of greatest difficulty.

3. Pertinent service history.

4. History of military, occupational, and recreational noise exposure.

5. Tinnitus - If present, state:

a. Date and circumstances of onset.

b. Whether it is unilateral or bilateral.

c. Whether it is constant or periodic (indicate frequency).

d. Severity and effect on daily life.

e. Veteran's account of loudness or pitch.

C. Physical Examination (Objective Findings):

1. Measure puretone thresholds in decibels at the indicated frequencies (air conduction):

= = = = = = =RIGHT EAR= = = = = = = = = = = = = = = = = LEFT EAR = = = = = = =

A* B C D E ** A* B C D E **

500 | 1000 | 2000 | 3000 | 4000 | average 500 | 1000 | 2000 | 3000 | 4000 | average

* The puretone threshold at 500 Hz is not used in determining the evaluation but is used in determining whether or not a ratable hearing loss exists.

** The average of B, C, D, and E.

2. Speech Recognition Score:

a. Maryland CNC word list _______% right ear ______% left ear.

b. W-22 word list (only if specifically requested by the regional office).

______% right ear ______% left ear.

3. When only puretone results should be used to evaluate hearing loss, the Chief of the Audiology Clinic should certify that language difficulties or other problems make the combined use of puretone average and speech discrimination inappropriate.

D. Diagnostic and Clinical Tests:

1. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

1. Summary of audiologic test results.

2. Note whether audiologic results indicate an ear or hearing problem that requires medical follow-up or a problem which, if treated, might cause a change in hearing threshold levels.

Signature:                                Date:


EAR DISEASE

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

C. Physical Examination (Objective Findings):

1. Address each of the following and describe current findings, including abnormalities of size, shape, or form:

a. Auricle.

b. External canal.

c. Tympanic membrane.

d. The tympanum.

e. The mastoid.

f. All conditions secondary to ear disease, such as disturbance of balance, upper respiratory disease, hearing loss, etc.

2. State whether an active ear disease is present.

3. Infections of the middle or inner ear.

D. Diagnostic and Clinical Tests:

1. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


SENSE OF SMELL AND TASTE

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

C. Physical Examination (Objective Findings):

D. Diagnostic and Clinical Tests:

1. For sense of smell, test each side of nose separately. State results with the following substances recommended for testing:

a. Coffee.

b. Soap.

c. Oil of lemon.

d. Other (state substance).

2. For sense of taste

a. Using electrogustometry if available, test for:

(1) Sweet.

(2) Sour.

(3) Bitter.

(4) Salt.

b. State results with the following substances recommended for testing:

(1) Sugar.

(2) Diluted acetic acid.

(3) Lemon or Orange.

(4) Salt.

3. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Provide:

1. State whether loss of sense of smell is partial or complete, and its basis.

2. State whether loss of sense of taste is partial or complete, and its basis.

3. If a psychiatric basis is suspected, a special psychiatric examination should be ordered.

Signature:                                Date:


INFECTIOUS, IMMUNE AND NUTRITIONAL DISABILITIES

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

Narrative: Many infectious diseases, immune disorders, and nutritional deficiencies have acute phases at onset and accompanying recurrences but leave little or no residual disability beyond the acute phase. Other such conditions may have slow progression and show significant residual disability. The examiner must diligently search for residual disabilities upon which adjudication of the case may be made.

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Date of symptom onset.

2. Date of diagnosis.

3. Clinical manifestations.

4. Treatment (type, frequency, duration, response, side effects).

5. Disease activity (exacerbations and/or remissions)? If there were exacerbations, what was the state of the veteran's health between exacerbations? Frequency and duration of exacerbations.

6. Current symptoms

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Is the condition still present?

2. Current weight, nutrition. Any residuals of malnutrition, vitamin deficiency?

3. General appearance.

4. Describe findings of all organ systems involved. See appropriate examination worksheets - respiratory, joints, cardiovascular, etc.

D. Diagnostic and Clinical Tests:

1. Include results of all diagnostic and clinical tests conducted in the examination report.

Note: If an infectious etiology is documented, specify the organism.

E. Diagnosis:

Signature:                                Date:


HIV RELATED ILLNESS

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment On:

1. Recurrent opportunistic infections.

2. Recurrent constitutional symptoms.

3. Diarrhea.

4. Debility.

5. Progressive weight loss.

6. Remissions in any symptomatology.

7. Depression or memory loss.

8. Treatment - Is this an approved medication?

9. Describe the effects of the condition on the veteran's usual occupation and daily activities.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe:

1. Definitive diagnosis of AIDS. (Use CDC Definition.)

2. Secondary diseases affecting multiple body systems - describe.

3. HIV-related illnesses - describe.

4. Neoplasm related to HIV-related illness. Describe.

5. T4 cell counts.

6. Hairy cell leukoplakia.

7. Oral candidiasis.

8. Use of HIV-related medications.

9. Lymphadenopathy.

D. Diagnostic and Clinical Tests:

Provide:

1. T4 Cell counts.

2. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


CHRONIC FATIGUE SYNDROME

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

Narrative: Chronic fatigue syndrome (CFS) is an illness characterized by debilitating fatigue and several flu-like symptoms. It may have both physical and psychiatric manifestations and closely resembles neurasthenia, neurocirculatory asthenia, fibrositis, or fibromyalgia.

For VA purposes, a diagnosis of CFS must meet both of the following criteria:

1. New onset of debilitating fatigue that is severe enough to reduce or impair average daily activity below 50 percent of the patient's pre-illness activity level for a period of 6 months, and

2. Other clinical conditions that may produce similar symptoms must be excluded by thorough evaluation, based on history, physical examination, and appropriate laboratory tests.

It must also meet six or more of the following ten criteria:

1. Describe in detail:

a. Acute onset of the condition.

b. Low grade fever.

c. Nonexudative pharyngitis.

d. Palpable or tender cervical or axillary lymph nodes.

e. Generalized muscle aches or weakness.

f. Fatigue following lasting 24 hours or longer after exercise.

g. Headaches (of a type, severity or pattern that is different from headaches in the premorbid state.

h. Migratory joint pains.

i. Neuropsychologic symptoms.

j. Sleep disturbance.

A. Review of Medical Records:

Comment on:

1. Date diagnosis established.

2. Does it meet the requirements outlined above?

B. Medical History (Subjective Complaints):

Comment on:

1. Estimate the amount of routine daily activities that are restricted due to CFS. Give specific examples.

2. If there are incapacitating episodes (requiring bed rest and treatment by a physician), what is their frequency and duration?

3. Does the patient require continuous medication for CFS?

C. Physical Examination (Objective Findings):

D. Diagnostic and Clinical Tests:

1. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


NOSE, SINUS, LARYNX AND PHARYNX

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Location and nature of the injury or disease.

2. Interference with breathing through nose.

3. Purulent discharge.

4. Dyspnea at rest or on exertion?

5. Treatments - type (surgery, medication, oxygen, respirator, etc.) frequency, duration, response, and side effects.

6. If speech impairment (ability to communicate by speech, ability to speak above a whisper, etc.).

7. For chronic sinusitis, indicate which sinuses are affected and whether pain and headaches are present. Describe severity and frequency.

8. If allergic attacks, frequency and baseline status between attacks.

9. Other symptoms noted.

10. Describe frequency and duration of periods of incapacitation (defined as requiring bedrest and treatment by a physician).

C. Physical Examination (Objective Findings):

Provide:

1. If there is nasal obstruction, indicate percent each nostril.

2. Sinusitis - Describe tenderness, purulent discharge, or crusting.

D. Diagnostic and Clinical Tests:

1. If there is stenosis of larynx, order FEV-1 with flow-volume loop.

2. If there is facial disfigurement, order color photographs.

3. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Comment on whether the disease primarily involves or originates from the nose, sinus, larynx, or pharynx.

Signature:                                Date:


RESPIRATORY (OBSTRUCTIVE, RESTRICTIVE AND INTERSTITIAL)

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Productive cough, sputum, hemoptysis, and/or anorexia.

2. Extent of dyspnea on exertion.

3. If veteran is asthmatic, report frequency of attacks and baseline functional status between attacks.

4. Treatment (type, frequency and duration including a need for oxygen), response, side effects.

5. Describe frequency and duration of any periods of incapacitation (defined as requiring bedrest and treatment by a physician).

C. Physical Examination (Objective Findings):

Address each of the following as appropriate to the condition being examined and fully describe current findings:

1. Presence of cor pulmonale, RVH, or pulmonary hypertension.

2. Weight loss or gain.

3. For restrictive disease, describe condition underlying restrictive disease, e.g., kyphoscoliosis, pectus excavatum, etc., unless already of record.

D. Diagnostic and Clinical Tests:

Provide:

1. Pulmonary Function Tests (unless carried out within past six months and the report is either in the claims folder or will be attached to this examination report). When the results of pre-bronchodilator pulmonary function tests are normal, post-bronchodilator studies are not required for VA evaluation purposes. In all other cases, post-bronchodilator studies should be conducted unless contraindicated (because of allergy to medication, etc.) or if the veteran was on bronchodilators before the test and had taken his or her medication within a few hours of the study. An examiner who determines that a post-bronchodilator study should not be performed should provide an explanation of why not. If there is a disparity between the results of different pulmonary function tests (FEV-1, FVC, etc.), the examiner should indicate which test result is the best indicator of the veteran's level of pulmonary functioning.

2. Chest X-ray (if no recent results available).

3. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


PULMONARY TUBERCULOSIS AND MYCOBACTERIAL DISEASES

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Activity of pulmonary tuberculosis or other mycobacterial disease.

2. Date of inactivity if it is not active.

3. Identity of organism (if possible).

C. Physical examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Extent of structural damage to lungs.

2. If patient was hospitalized for 6 months or more, what is the condition at the end of hospitalization?

3. If patient was hospitalized for 12 months or more, what is the condition at the end of hospitalization?

D. Diagnostic and Clinical Tests:

Provide:

1. Pulmonary Function Tests, if indicated. When the results of pre-bronchodilator pulmonary function tests are normal, post-bronchodilator studies are not required for VA evaluation purposes. In all other cases, post-bronchodilator studies should be conducted unless contraindicated (because of allergy to medication, etc.) or if the veteran was on bronchodilators before the test and had taken his or her medication within a few hours of the study. An examiner who determines that a post-bronchodilator study should not be performed should provide an explanation of why not. If there is a disparity between the results of different pulmonary function tests (FEV-1, FVC, etc.), the examiner should indicate which test result is the best indicator of the veteran's level of pulmonary functioning.

E. Diagnosis:

1. In reactivated cases, is this reactivation of the old disease or a separate and distinct new infection?

Additional Note to the Physician: In all claims, if the disease is inactive and if the inactivity was confirmed at a non-VA facility, obtain the name and mailing address of the facility from the veteran so that the Regional Office may request the report.

Signature:                                Date:


RESPIRATORY DISEASES, MISCELLANEOUS (PVD, NEOPLASMS, BACTERIAL INFECTIONS, MYCOTIC LUNG DISEASE, SARCOIDOSIS AND SLEEP APNEA)

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Fever and/or night sweats.

2. Weight loss or gain.

3. Daytime hypersomnolence.

4. Hemoptysis.

5. Describe current treatment such as anticoagulant, tracheostomy, CPAP, oxygen, or antimicrobial therapy.

6. If malignant disease, state initial treatment date, site of original tumor, type of tumor, types of treatment used, and date treatment is expected to end. If treatment has been completed, state date treatment was completed.

C. Physical Examination (Objective Findings):

Address each of the following as appropriate to the condition being examined and fully describe current findings:

1. Pulmonary Hypertension, RVH, cor pulmonale, or congestive heart failure.

2. Residuals of pulmonary embolism.

3. Respiratory Failure.

4. Evidence of chronic pulmonary thromboembolism.

5. If ankylosing spondylitis, is there restriction of the chest excursion and dyspnea on minimal exertion?

6. Describe all residuals of malignancy including those due to treatment.

D. Diagnostic and Clinical Tests:

Provide:

1. Pulmonary Function Tests, if indicated. When the results of pre-bronchodilator pulmonary function tests are normal, post-bronchodilator studies are not required for VA evaluation purposes. In all other cases, post-bronchodilator studies should be conducted unless contraindicated (because of allergy to medication, etc.) or if the veteran was on bronchodilators before the test and had taken his or her medication within a few hours of the study. An examiner who determines that a post-bronchodilator study should not be performed should provide an explanation of why not. If there is a disparity between the results of different pulmonary function tests (FEV-1, FVC, etc.), the examiner should indicate which test result is the best indicator of the veteran's level of pulmonary functioning.

2. If sleep apnea is suspected, order Sleep Studies.

3. Chest X-ray if necessary to document sarcoidosis or other parenchymal disease.

4. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


HEART AND HYPERTENSION

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Dyspnea on exertion. If present, what level of activity precipitates it?

2. Angina - Extent? Frequency? Level of activity that precipitates it?

3. Other cardiac symptoms? If present, what level of activity precipitates them?

4. Describe history, including dates and severity of episodes, of acute cardiac illness, including coronary occlusion or thrombosis, congestive heart failure, acute rheumatic heart disease, etc., and all cardiac surgery, including coronary artery bypass, valvular surgery, cardiac transplant, angioplasty, etc.

5. Current treatment, response, and side effects.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Heart size - How determined?

2. If the diagnosis of hypertension has not been established, take 2 or more blood pressure readings on at least 3 different days.

3. If hypertension has been diagnosed, take 2 or more blood pressure readings.

4. Cardiac arrhythmia - onset?

5. Murmurs, thrills.

6. Evidence of congestive heart failure - rales, edema, liver enlargement, etc.

D. Diagnostic and Clinical Tests:

1. Chest X-ray - heart size?, pericardial adhesions?

2. EKG.

3. Echocardiogram, exercise stress test, thallium study, angiography, etc., as appropriate, and as needed.

4. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

1. Etiology of any murmurs.

2. If both rheumatic heart disease and arteriosclerotic heart disease are present, state, if possible, which findings can be attributed to each condition. If it is not possible to separate the signs and symptoms of one from the other, so state, and explain.

3. Functional Assessment: - How does the heart disability or hypertension affect the daily activities of the veteran? Is more than sedentary employment feasible? Is more than light manual labor feasible? Explain.

Signature:                                Date:


ARRHYTHMIAS

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Syncope, Stokes-Adams attacks - frequency?, precipitating factors?

2. Other symptoms related to arrhythmia or its treatment

3. Current treatment, response, side effects.

4. Describe the effects of the condition on the veteran's usual occupation and daily activities.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Heart rate and rhythm.

2. If arrhythmia is paroxysmal, what is frequency? Severity? What are precipitating factors?

3. Pacemaker present? If so, when inserted, effectiveness, side effects.

D. Diagnostic and Clinical Tests:

1. EKG.

2. Holter monitor, other tests as indicated.

3. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


ARTERIES AND VEINS

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Symptoms due to aortic aneurysm, other large or small artery aneurysm, or arteriovenous aneurysm.

2. Current and past treatment, including surgery - e.g., aortic aneurysm grafting, varicose vein stripping, angioplasty of peripheral vessels, etc. Date and response, side effects.

3. Pain, cramping, claudication on exertion? standing? pain at rest? Give frequency, severity, level of exercise that precipitates pain, duration.

4. Paresthesias or other abnormal sensations.

5. Attacks of angioneurotic edema - severity, location, frequency, duration?

6. Cold sensitivity.

7. If treated for malignancy, state type of treatment and dates, including date of last treatment. Describe any residual or recurrent symptoms if treated has been completed.

8. Is exercise and exertion precluded by the condition?

9. Is veteran confined to house or bed because of the condition?

10. Describe the effects of the condition(s) on the veteran's usual occupation and daily activities.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Nutrition, general state of health.

2. Renal, cardiac, or cerebral arteriosclerotic foci.

3. Cardiac status - size, function.

4. Evidence and size of aneurysm.

5. Extremities:

a. Temperature.

b. Evidence of superficial phlebitis.

c. Ulceration or tissue loss.

d. Edema (constant or intermittent, relieved by elevation?).

e. Scar.

f. Color.

g. Eczema.

h. Tenderness.

6. If there are attacks of blanching or flushing, or blanching, rubor, and cyanosis, indicate their frequency and duration.

7. If evidence or history of erythromelalgia - severity, frequency, duration?

8. If varicosities are present, indicate their size (diameter?), location, appearance, and if deep circulation is involved.

D. Diagnostic and Clinical Tests:

1. X-rays, Doppler vascular studies, angiogram, etc., as appropriate, and if indicated.

2. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


MOUTH, LIPS AND TONGUE

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Disfigurement - if present, order color photographs.

2. Interference with mastication.

3. Interference with speech - state extent.

4. Absence of all or part of tongue - describe.

D. Diagnostic and Clinical Tests:

1. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


ESOPHAGUS AND HIATAL HERNIA

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Dysphagia - for solids, liquids (frequency and extent).

2. Pyrosis, epigastric or other pain, including associated substernal or arm pain (frequency and severity).

3. Hematemesis or melena (describe any episodes).

4. Reflux or regurgitation (frequency); for regurgitation, contents.

5. Nausea, vomiting (frequency, precipitants).

6. Current treatment - if dilatation, give frequency.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. General state of health, anemia.

2. Nutrition, weight gain or loss.

D. Diagnostic and Clinical Tests:

1. X-ray or endoscopic confirmation of obstruction, abnormal motility, esophagitis, reflux, etc.

2. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

1. With obstruction or spasm, amenable to dilatation?

Signature:                                Date:


INTESTINES (LARGE AND SMALL)

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Weight gain or loss.

2. Nausea and/or vomiting.

3. Constipation, diarrhea (frequency, severity, duration, and episodic or not?).

4. For fistula - frequency, duration, and amount of fecal discharge.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Malnutrition, anemia, other evidence of debility.

2. Abdominal pain - location, type, frequency, and duration.

3. Current treatment - type, duration, response, and side effects.

4. For fistula - location.

D. Diagnostic and Clinical Tests:

1. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


LIVER, GALL BLADDER AND PANCREAS

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Vomiting, hematemesis or melena.

2. Current treatment - type (medication, diet, enzymes, etc.), duration, response, side effects.

3. Episodes of colic or other abdominal pain, distention, nausea, vomiting - duration, frequency, severity, treatment, and response to treatment.

4. Fatigue, weakness, depression, or anxiety.

C. Physical Examination (Objective Findings):

Address each of the following as appropriate, and fully describe current findings:

1. Ascites.

2. Weight gain or loss, steatorrhea, malabsorption, malnutrition.

3. Hematemesis or melena (describe any episodes).

4. Pain or tenderness - location, type, precipitating factors.

5. Liver size, superficial abdominal veins.

6. Muscle strength and wasting.

D. Diagnostic and Clinical Tests:

1. For esophageal varices, X-ray, endoscopy, etc.

2. For adhesions, X-ray to show partial obstruction, delayed motility.

3. For gall bladder disease, X-ray or other objective confirmation.

4. Liver function tests.

5. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


DIGESTIVE CONDITIONS, MISCELLANEOUS (TUBERCULOUS PERITONITIS, INGUINAL HERNIA, VENTRAL HERNIA, FEMORAL HERNIA, VISCEROPTOSIS AND BENIGN AND MALIGNANT NEW GROWTH

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

1. Describe all hernia surgery and results.

2. For malignancy, state type of treatment, dates of treatment, including last date of treatment if it has ended.

3. For peritoneal tuberculosis, state date of diagnosis, treatment, and date on which inactivity was established.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. For inguinal or ventral hernia, state whether reducible, how well supported by truss or belt, and whether irremediable or inoperable.

2. For ventral hernia, state size of hernia, extent of diastasis of recti muscles, status of muscles and fascia of abdominal wall.

3. All residuals of malignancy, including residuals from treatment.

D. Diagnostic and Clinical Tests:

1. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


RECTUM AND ANUS

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Degree of sphincter control.

2. Extent and frequency of fecal leakage or involuntary bowel movements- is a pad needed?

3. Bleeding or thrombosis of hemorrhoids - frequency and extent.

4. Current treatment.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Colostomy.

2. Evidence of fecal leakage.

3. Size of lumen - rectum and anus.

4. Signs of anemia.

5. Fissures.

6. If hemorrhoids - location, size, and if thrombosed.

7. Evidence of bleeding.

D. Diagnostic and Clinical Tests:

1. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


STOMACH, DUODENUM AND PERITONEAL ADHESIONS

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Vomiting.

2. Hematemesis or melena (describe any episodes).

3. Treatment - type, duration, response, side effects.

4. Circulatory disturbance after meals, hypoglycemic reactions (state time of onset in relation to meals, frequency).

5. Diarrhea, constipation.

6. Episodes of colic, distention, nausea, and/or vomiting - frequency, duration, and severity.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Specific site of any ulcer disease.

2. Weight gain or loss.

3. Signs of anemia.

4. Pain or tenderness - location, type, precipitating factors.

D. Diagnostic and Clinical Tests:

1. For gastritis, endoscopic evidence - describe hemorrhage, ulcerated or eroded areas.

2. For adhesions, X-ray to show partial obstruction, delayed motility.

3. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


GENITOURINARY EXAMINATIONS

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Lethargy, weakness, anorexia, weight loss or gain.

2. Frequency (day or night, indicate voiding intervals), hesitancy, stream, dysuria.

3. Incontinence - if present, describe required frequency of absorbent material and whether an appliance is needed.

4. Provide details of any history of:

a. Surgery on any part of the urinary tract. Residuals? Impotence?

b. Recurrent urinary tract infections.

c. Renal colic or bladder stones.

d. Acute nephritis.

e. Hospitalization for urinary tract disease, if so, how many in the past year?

f. Treatment for malignancy, including type and date of last treatment.

5. Treatments.

a. Is catheterization needed? Intermittent or continuous?

b. Frequency of dilations?

c. Drainage procedures.

d. Diet therapy - specify.

e. Medications.

f. Frequency per year of invasive and noninvasive procedures.

6. Describe the effects of the condition(s) on the veteran's usual occupation and daily activities.

For Male Loss of Use of a Creative Organ

Comment on:

1. Trauma/surgery affecting penis/testicles (e.g. vasectomy?)

2. Local and/or systemic diseases affecting sexual function.

a. Endocrine.

b. Neurologic.

c. Infections.

d. Vascular.

e. Psychological.

3. Symptoms: Vaginal penetration with ejaculation possible?

4. Past treatment:

a. Medications, injections, implants, pump, counseling.

b. Effectiveness in allowing intercourse.

C. Physical Examination (Objective Findings):

Address each of the following, as appropriate, to the condition being examined and fully describe current findings:

1. Blood pressure, cardiovascular examination, if indicated, describe edema, to include persistence.

2. If on dialysis, type, where done, and how often?

3. Inspection and palpation of penis, testicles, epididymis, and spermatic cord. If there is penis deformity, state whether there is loss of erectile power. Inspection of anus and digital exam of rectal walls, prostate, and seminal vesicles.

4. Fistula.

5. Specific residuals of genitourinary disease, including post-treatment residuals of malignancy.

6. Testicular atrophy - size and consistency.

7. Sensation and reflexes.

8. Peripheral pulses.

D. Diagnostic and Clinical Tests:

1. CBC.

2. UA.

3. Creatinine, BUN, albumin, electrolytes.

4. Uroflowmetry, if indicated.

5. Measurement of post-void residual, if indicated.

6. Semen analysis, including sperm count and interpretation of results, if applicable.

7. Endocrine evaluation (glucose, TSH, testosterone, LH, FSH, prolactin), if applicable.

8. Psychiatric evaluation, if applicable.

9. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


GYNECOLOGICAL CONDITIONS AND DISORDERS OF THE BREAST

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Provide:

1. Date of onset of symptoms.

2. Describe symptoms, e.g., abnormal bleeding, vaginal discharge, fever, pain, bowel or bladder symptoms, etc.

3. Treatments:

a. Detail all breast and pelvic surgery.

b. If a malignant process has been identified, provide:

(1) Date of confirmed diagnosis.

(2) Date of the last surgical, X-ray, antineoplastic chemotherapy, radiation, or other therapeutic procedure.

(3) Expected date treatment regimen is to be completed.

(4) If already completed, provide date.

(5) Fully describe residuals.

c. Detail hormonal and other medications and whether continuous medication is required, response, and side effects.

4. Include complete menstrual history, pregnancy history, and urinary tract history.

C. Physical Examination (Objective Findings):

Provide a full gynecological and breast examination (unless only a particular condition or portion of the examination is requested).

Address each of the following and fully describe current findings:

1. Uterus.

a. If post operative, state extent of surgery.

b. If prolapse is present, is it through the introitus?

c. If displaced, are there adhesions and/or menstrual disturbances.

2. If rectovaginal fistula is present, describe extent and frequency of leakage and whether a pad is required.

3. If urethrovaginal fistula is present, describe whether absorbent material is required and how often it must be changed.

4. If rectocele, cystocele, or perineal relaxation is present, is it due to pregnancy?

5. Breasts.

If post-operative, Identify the type of surgery using the following definitions:

a. Radical mastectomy - removal of the entire breast, underlying pectoral muscles, and regional lymph nodes up to the coracoclavicular ligament.

b. Modified radical mastectomy - removal of the entire breast and axillary lymph nodes (in continuity with the breast). Pectoral muscles are left intact.

c. Simple (or total) mastectomy - removal of all the breast tissue, nipple, and a small portion of the overlying skin, but lymph nodes and muscles are left intact.

d. Wide local incision - includes partial mastectomy, lumpectomy, tylectomy, segmentectomy, and quadrantectomy. This means removal of a portion of the breast tissue.

e. Describe any alteration of size and form.

D. Diagnostic and Clinical Tests:

1. CBC.

2. Urinalysis.

3. Laparoscopy is required to establish diagnosis of endometriosis and to confirm bowel or bladder involvement.

4. Ultrasound, mammography, if indicated.

5. Pap smear (if none within past year).

6. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


HEMIC DISORDERS

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Frequency and duration of crisis if sickle cell disease.

2. Fatigability and/or weakness? (Is light manual labor precluded?)

3. Headaches?

4. History of infections? If yes, frequency and response to therapy?

5. Shortness of breath? If yes, with what degree of exertion?

6. Chest pain? Symptoms of claudication?

7. History and frequency of transfusions, phlebotomy, bone marrow transplant, myelo-suppressant therapy.

8. Symptoms of other end organ pathology?

9. Disease activity (exacerbations/remission)? If there were exacerbations, what was the state of the veteran's health between exacerbations?

10. Current and past treatment history including date and type of last treatment?

11. Syncope, lightheadedness.

C. Physical Examination (Objective Findings):

Address each of the following as appropriate to the condition being examined and fully describe current findings:

1. Swelling of hands and/or feet (edema)?

2. Presence of pallor (nail beds, mucosal surfaces, and skin)?

3. Any other significant physical exam findings?

4. Residuals of bone or other vascular infarction.

5. Congestive heart failure?

D. Diagnostic and Clinical Tests:

1. Hemoglobin level, platelet count, CBC.

2. X-rays of bones or joints as indicated.

3. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

1. Is the disease active?

Signature:                                Date:


LYMPHATIC DISORDERS

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Disease activity (exacerbations/remission)? If there were exacerbations, what was the state of the veteran's health between exacerbations?

2. Current and past treatment history including date and type of last treatment, response, side effects.

3. If malignant neoplasm need date of diagnosis, date of treatment, or if treatment stopped when did it end.

4. Location of disease.

5. Current symptoms.

C. Physical Examination (Objective Findings):

Describe the residuals of each body system affected.

D. Diagnostic and Clinical Tests:

1. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


SCARS

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

1. Type of injury or infection causing the wound or scar, its date, the treatment used and the response to such treatment.

2. Current symptoms.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings (for each scar):

1. Location, measurements (cm. x cm.), and shape of each scar.

2. Tenderness.

3. Adherence.

4. Texture.

5. Ulceration or breakdown of skin.

6. Elevation or depression of scar.

7. Extent of underlying tissue loss.

8. Inflammation, edema, or keloid formation.

9. Color of scar compared to normal areas of skin.

10. Disfigurement.

11. For each burn scar, state if due to a 2nd or 3rd degree burn.

12. Limitation of function by scar.

13. An attachment is provided in the Handout of Instructions for Compensation and Pension Examinations for plotting the location of scars.

D. Diagnostic and Clinical Tests:

1. With disfigurement or disfiguring scar of head, face, or neck, submit color photographs.

2. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


SKIN DISEASES (OTHER THAN SCARS)

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Onset of disease and course - intermittent, constant.

2. Current treatment - include side effects.

3. Symptoms - pruritus, pain, etc.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Extent of disease - specify what exposed areas are involved and how large they are.

2. Ulceration, exfoliation, or crusting.

3. Associated systemic or nervous manifestations.

D. Diagnostic and Clinical Tests:

1. Biopsy, scrapings if indicated.

2. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

1. Take color photographs if disfigurement or disfiguring scars are present.

Signature:                                Date:


ENDOCRINE DISEASES, MISCELLANEOUS (BENIGN AND MALIGNANT NEOPLASMS, HYPERPITUITARISM, HYPERALDOSTERONISM AND PHEOCHROMOCYTOMA)

Name:                                SSN:

Date of Exam: C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Date of diagnosis and how established.

2. Fatigability.

3. Headaches.

4. Changes in vision.

5. Neurologic, cardiovascular, or gastrointestinal symptoms.

6. Treatments (surgery, medications, hormones), including dose, frequency, response, side effects. For malignancy, provide date of completion of treatment for malignancy.

7. Weight gain or loss.

8. Excessive thirst, frequency of urination.

9. Describe the effects of the condition(s) on the veteran's usual occupation and daily activities.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. For hypoparathyroidism, thyroid surgery scar?

2. For diabetes insipidus, signs of dehydration?

3. For Addison's disease, muscle strength, blood pressure, skin pigmentary changes. Number of crises (with peripheral vascular collapse) or episodes (less acute and severe than crisis - no peripheral vascular collapse).

4. For pluriglandular syndromes, see examinations for glands affected.

5. Describe all residuals of benign or malignant neoplasm, including those related to treatment.

6. Is the disease active or in remission?

7. For hyperparathyroidism, history of kidney stones. History of demineralization of skeleton.

D. Diagnostic and Clinical Tests:

Provide, as appropriate:

1. Blood and urinary calcium.

2. X-ray of bones to confirm decalcification.

3. Glucose tolerance test, if necessary.

4. Antidiuretic hormone level.

5. Serum and urine electrolytes.

6. Urine specific gravity.

7. Serum cortisol.

8. Serum creatinine.

9. Serum glucose.

10. ACTH test.

11. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


THYROID AND PARATHYROID DISEASES

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Date diagnosis established.

2. Fatigability.

3. Mental assessment.

4. Neurologic, cardiovascular, or gastrointestinal symptoms.

5. Treatments (surgery, medications, hormones), including dose, frequency, response, side effects. For C-cell hyperplasia, provide date of completion of any treatment for malignancy.

6. Symptoms due to pressure (on larynx, esophagus, etc.).

7. Cold or heat intolerance.

8. Constipation.

9. Weight gain or loss.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Thyroid size.

2. Pulse and blood pressure.

3. Eye and vision abnormalities.

4. Muscle strength.

5. Tremor.

6. Myxedema.

7. All other residuals of thyroid disease or its treatment.

D. Diagnostic and Clinical Tests:

Provide:

1. T4, T3, TSH, and/or other thyroid function tests, if needed.

2. If thyroidectomy scar is disfiguring, order color photograph.

3. Thyroid scan, if indicated.

4. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Comment on:

1. Is the disease active or in remission?

Signature:                                Date:


CUSHING'S SYNDROME

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Date diagnosis established.

2. Weakness.

3. Etiology ? Iatrogenic?

4. Treatments (surgery, medication, etc.), dose, frequency, response, side effects.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Muscle strength.

2. Vascular fragility.

3. Gastrointestinal.

4. Blood Pressure.

5. Striae.

6. Weight gain or loss.

7. Moonface.

8. Glucose metabolism.

9. After control, describe adrenal insufficiency, cardiovascular, psychiatric, skin, or skeletal complications or residuals.

D. Diagnostic and Clinical Tests:

Provide:

1. CT of brain or X-ray of sella turcica.

2. Serum and urine cortisol levels.

3. High and low dose dexamethasone suppression test.

4. X-rays if osteoporosis suspected.

5. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Comment on:

1. Is the disease active or in remission?

Signature:                                Date:


ACROMEGALY

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Date diagnosis established.

2. Joint pains.

3. Changes in vision.

4. Headaches (severity and frequency).

5. Cardiac symptoms.

6. Change in shoe, glove, or hat size.

7. Symptoms of glucose intolerance.

8. Treatments.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Arthropathy.

2. Vascular fragility.

3. Evidence of increased intracranial pressure.

4. Size of acral parts, long bones.

5. Visual impairment, including visual fields.

D. Diagnostic and Clinical Tests:

Provide:

1. CT of brain or X-ray of sella turcica.

2. Glucose tolerance test.

3. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Comment on:

1. Is the disease active or in remission?

Signature:                                Date:


DIABETES MELLITUS

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Age of onset.

2. Frequency of ketoacidosis or hypoglycemic reactions (hospitalization required?).

3. Restricted diet, weight loss or gain since last exam.

4. Describe any restriction of activities.

5. Visual problems.

6. Vascular or cardiac symptoms.

7. Neurologic symptoms.

8. Treatment - oral hypoglycemic, insulin (frequency of injections).

9. Frequency of visits to diabetic care provider.

10. Other symptoms, such as anal pruritus, loss of strength.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Blood pressure, other cardiovascular findings, including status of peripheral vessels.

2. Neurologic examination.

3. Eye examination.

4. Skin examination.

5. Examination of extremities, including feet.

6. State if the veteran has bladder or bowel functional impairment. If present, state whether partial or total, intermittent or constant, and what measures are taken as a result of the impairment.

D. Diagnostic and Clinical Tests:

Provide:

1. Renal function tests, including 24 hour urine test for protein if renal involvement is uncertain.

2. Blood sugar.

3. Urinalysis.

4. Glucose tolerance test, if necessary to establish the diagnosis.

5. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Comment on:

1. All complications noted - visual, cardiac, vascular, nephrologic, neurologic (including both peripheral neuropathy and cerebral effects), amputations. See examination worksheets for the conditions found.

Signature:                                Date:


BRAIN AND SPINAL CORD

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. If flare-ups exist, describe precipitating factors, aggravating factors, alleviating factors, alleviating medications, frequency, severity, duration, and whether the flare-ups include pain, weakness, fatigue, or functional loss.

2. Current treatment, response, and side effects.

3. State whether condition has stabilized.

4. Seizures - type, frequency.

5. Headache, dizziness, etc.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. If a tumor is or was present, note location, type, and whether or not it is malignant. If a malignancy is present but is now cured or in remission, report the date of last surgery, radiation therapy, chemotherapy, or other treatment.

2. Describe in detail the motor and sensory impairment of all affected nerves.

3. Describe in detail any functional impairment of the peripheral and autonomic systems.

4. A detailed assessment of each affected joint is required.

a. Using a goniometer, measure the passive and active range of motion, including movement against gravity and against strong resistance.

b. If the joint is painful on motion, state at what point in the range of motion pain begins and ends.

c. State to what extent, if any, the range of motion or function is additionally limited by pain, fatigue, weakness, or lack of endurance. If more than one of these is present, state, if possible, which has the major functional impact.

5. Describe any psychiatric manifestations in detail - see worksheets for mental disorders.

6. Eye examination.

7. State if the veteran has bladder or bowel functional impairment. If present, state whether partial or total, intermittent or constant and what measures are taken as a result of the impairment.

8. State if the veteran is capable of managing his or her benefit payments in his or her own best interest without restriction. (A physical disability which prevents the veteran from attending to financial matters in person is not a proper basis for a finding of incompetency unless the veteran is, by reason of that disability, incapable of directing someone else in handling the individual's financial affairs.)

9. If smell or taste is affected, also complete the appropriate worksheet.

D. Diagnostic and Clinical Tests:

1. Skull X-rays to measure bony defect, if there was surgery; spine X-rays if there was spinal cord surgery.

2. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


CRANIAL NERVES

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. If flare-ups exist, describe precipitating factors, aggravating factors, alleviating factors, alleviating medications, frequency, severity, duration, and whether the flare-ups include pain, weakness, fatigue, or functional loss.

2. Current treatment, response, side effects.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Identify the nerve and the side.

2. Identify the disorder (i.e., paralysis, neuritis, neuralgia).

3. Describe in detail specific motor and sensory impairment, quantifying as much as possible.

4. If smell or taste is affected, please also complete the appropriate worksheet.

D. Diagnostic and Clinical Tests:

1. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

1. State etiology.

Signature:                                Date:


NEUROLOGICAL DISORDERS, MISCELLANEOUS (MIGRAINE, TIC, PARAMYOCLONUS, MULTIPLEX, SYDENHAM'S AND HUNTINGTON'S CHOREA, AND ATHETOSIS)

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Onset and course - If flare-ups exist, describe precipitating factors, aggravating factors, alleviating factors, alleviating medications, frequency, severity, duration, and whether the flare-ups include pain, weakness, fatigue, or functional loss.

2. Current treatment, response, side effects.

C. Physical Examination (Objective Findings):

1. If Migraine: - Obtain the history of frequency and duration of attacks and description of level of activity the veteran can maintain during the attacks. For example, state if the attacks are prostrating in nature or if ordinary activity is possible.

2. If Tics and Paramyoclonus Complex: - Ascertain the muscle group(s) involved and obtain the best possible history of frequency and severity of attacks. State the effects on daily activities.

3. If Chorea, Choreiform Disorders, etc.: - Describe manifestations by impairment of strength, coordination, tremor, etc., with particular attention to the effects of the performance of ordinary activities of daily living.

D. Diagnostic and Clinical Tests:

1. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


PERIPHERAL NERVES

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Onset and course - If flare-ups exist, describe precipitating factors, aggravating factors, alleviating factors, alleviating medications, frequency, severity, duration, and whether the flare-ups include pain, weakness, fatigue, or functional loss.

2. Current treatment, response, and side effects.

3. Paresthesias, dysesthesias, other sensory abnormalities.

4. Describe extent to which condition interferes with daily activity.

5. Specify nerves involved.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. If the disability is the result of brain disease or injury, spinal cord disease or injury, cervical disc disease, or trauma to the nerve roots themselves:

a. Report sensory and motor impairment by reference to the distribution of the affected groups as paralysis, neuritis, or neuralgia.

b. Report each affected extremity separately.

2. If disability is NOT from the above:

a. Identify the specific major nerve involved, localize the lesion and describe specific impairment of motor and sensory function, fine motor control, etc.

b. Characterize as paralysis, neuritis, or neuralgia, and indicate whether any muscle wasting or atrophy represents direct effect of nerve damage or merely disuse.

c. Report each affected extremity separately.

3. For each joint that is affected:

a. Using a goniometer, measure the passive and active range of motion, including movement against gravity and against strong resistance.

b. If the joint is painful on motion, state at what point in the range of motion pain begins and ends.

c. State to what extent, if any, the range of motion or function is additionally limited by pain, fatigue, weakness, or lack of endurance. If more than one of these is present, state, if possible, which has the major functional impact.

D. Diagnostic and Clinical Tests:

1. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

1. State etiology.

Signature:                                Date:


EPILEPSY AND NARCOLEPSY

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Discuss precipitating factors, aggravating factors, alleviating factors.

2. Current treatment, response, side effects.

3. State the frequency and type of seizures or episodes of narcolepsy during the past 12 months, including any change in frequency pattern. If possible, record the actual number of seizures in each calendar month. If the veteran keeps a seizure diary, record dates of seizures.

4. Discuss the effect of epilepsy or narcolepsy on daily activities, including the effects of medications.

C. Physical Examination (Objective Findings):

1. Order a psychiatric examination if there are indications of a mental disorder associated with epilepsy.

D. Diagnostic and Clinical Tests:

1. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

1. If the diagnosis is NOT established or is questioned, schedule any necessary special studies, including admission for a period of examination and observation, as appropriate to provide a definitive diagnosis.

Signature:                                Date:


MENTAL DISORDERS (EXCEPT PTSD AND EATING DISORDERS)

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

A: Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Past Medical History:

a. Previous hospitalizations and outpatient care.

b. Medical and occupational history from the time between last rating examination and the present, UNLESS the purpose of this examination is to ESTABLISH service connection, then the complete medical history since discharge from military service is required.

2. Present Medical, Occupational, and Social History - over the past one year.

a. Frequency, severity, and duration of psychiatric symptoms.

b. Length of remissions, to include capacity for adjustment during periods of remissions.

c. Extent of time lost from work over the past 12 month period and social impairment. If employed, identify current occupation and length of time at this job. If unemployed, note in complaints whether veteran contends it is due to the effects of a mental disorder. Further indicate following DIAGNOSIS what factors, and objective findings support or rebut that contention.

d. Treatments including statement on effectiveness and side effects experienced.

3. Subjective Complaints:

a. Describe fully.

C. Examination (Objective Findings):

Address each of the following and fully describe:

1. Mental status exam to confirm or establish diagnosis in accordance with DSM-IV.

2. Additionally, to allow evaluation by the rating specialist, describe and fully explain the existence, frequency, and extent of the following signs and symptoms, or any others present, and relate how they interfere with employment and social functioning:

a. Impairment of thought process or communication.

b. Delusions, hallucinations and their persistence.

c. Inappropriate behavior cited with examples.

d. Suicidal or homicidal thoughts, ideations or plans or intent.

e. Ability to maintain minimal personal hygiene and other basic activities of daily living.

f. Orientation to person, place, and time.

g. Memory loss or impairment (both short and/or long term).

h. Obsessive or ritualistic behavior which interferes with routine activities (describe with examples).

i. Rate and flow of speech and note irrelevant, illogical, or obscure speech patterns and whether constant or intermittent.

j. Panic attacks noting the severity, duration, frequency and effect on independent functioning and whether clinically observed or good evidence of prior clinical or equivalent observation.

k. Depression, depressed mood, or anxiety.

l. Impaired impulse control and its effect on motivation or mood.

m. Sleep impairment and describe extent it interferes with daytime activities.

n. Other symptoms and the extent to which they interfere with activities.

D. Diagnostic Tests:

1. Provide psychological testing if deemed necessary.

2. If testing is requested, the results must be reported and considered in arriving at the diagnosis.

3. Provide any specific evaluation information required by the rating board or on BVA Remand (in claims folder).

a. Competency: State whether the veteran is capable of managing his/her benefit payments in the individual's own best interests (a physical disability which prevents the veteran from attending to financial matters in person is not a proper basis for a finding of incompetency unless the veteran is, by reason of that disability, incapable of directing someone else in handling the individual's financial affairs).

b. Other Opinion: Furnish any other specific opinion requested by the rating board or BVA Remand furnishing the complete rationale and citation of medical texts or treatise supporting opinion, if medical literature review was undertaken. If the requested opinion is medically not ascertainable on exam or testing, please indicate why. If the requested opinion can not be expressed without resorting to speculation or making improbable assumptions say so, and explain why. If the opinion asks "...is it at least as likely as not...?", fully explain the clinical findings and rationale for the opinion.

4. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Provide:

1. The Diagnosis must conform to DSM-IV and be supported by the findings on the examination report.

2. If the diagnosis is changed, explain fully whether the new diagnosis represents a progression of the prior diagnosis or development of a new and separate condition.

3. If there are multiple mental disorders, delineate to the extent possible the symptoms associated with each and a discussion of relationship.

4. Evaluation is based on the effects of the signs and symptoms on occupational and social functioning.

NOTE: VA is prohibited by statute from paying compensation for a disability that is a result of the veteran's own ALCOHOL OR DRUG ABUSE, whether based on direct service connection, secondary service connection, or aggravation by a service-connected condition. Therefore, when alcohol or drug abuse accompanies or is associated with another mental disorder, separate, to the extent possible, the effects of the alcohol or drug abuse from the effects of the other mental disorder(s). If it is not possible to separate the effects, explain why.

F. Global Assessment of Functioning (GAF):

NOTE: The complete multi-axial format as specified by DSM-IV may be required by BVA REMAND or specifically requested by the rating specialist. If so, include the GAF score and note whether it refers to current functioning, functioning over the past year, etc.

If multiple Axis I or Axis II diagnoses exist, attempt to the extent possible, to provide a GAF score for the service connected conditions alone as well as a separate overall GAF score based on all mental disorders present, and explain and discuss your rationale. (See the above note pertaining to alcohol or drug abuse, the effects of which cannot be used to assess the effects of a service-connected condition.) If it is not possible to separate the symptomatology, explain why.

Signature:                                Date:


POST TRAUMATIC STRESS DISORDER (PTSD)

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

Narrative: Service connection for post-traumatic stress disorder (PTSD) requires medical evidence establishing a clear diagnosis of the condition, credible supporting evidence that the claimed in-service stressor actually occurred, and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. It is the responsibility of the examiner to indicate the extreme traumatic stressor leading to PTSD, if he or she makes the diagnosis of PTSD. It is the responsibility of the rating specialist to confirm that the cited stressor occurred during active duty.

A diagnosis of PTSD cannot be adequately documented or ruled out without obtaining a detailed military history and reviewing the claims folder. This means that initial review of the folder prior to examination, the history and examination itself, and the dictation for an examination initially establishing PTSD will often require more time than for examinations of other disorders. Ninety minutes to two hours on an initial exam is normal.

A: Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Past Medical History:

a. Previous hospitalizations and outpatient care.

b. Medical and occupational history (from the time between last rating examination and the present need be accounted for, UNLESS the purpose of this examination is to ESTABLISH service connection, then complete medical history including description of stressors and history since discharge from military service is required.

c. Review of Claims Folder is also required on initial exams to establish or rule out the diagnosis.

2. Present Medical, Occupational and Social History - over the past one year.

a. Frequency, severity, and duration of psychiatric symptoms.

b. Length of remissions, to include capacity for adjustment during periods of remissions.

c. Extent of social impairment and time lost from work over the past 12 month period. If employed, identify current occupation and length of time at this job. If unemployed, note in complaints whether veteran contends it is due to the effects of a mental disorder. Further discuss in DIAGNOSIS what factors, and objective findings support or rebut that contention.

3. Subjective Complaints:

a. Describe fully.

C. Examination (Objective Findings):

Address each of the following and fully describe:

1. Stressor information: Clearly describe the stressor. Particularly if the stressor is a type of personal assault, including sexual assault, provide information, with examples, if possible, on behavioral, cognitive, social, or affective changes that the veteran links to the stressor. Include information on related somatic symptoms. If there is a history of multiple stressors, assess the impact of each, to the extent possible.

2 Mental status exam to confirm or establish diagnosis in accordance with DSM-IV:

a. Are all diagnostic criteria to establish a diagnosis for 309.81 Post-traumatic Stress Disorder, as specified in DSM-IV, fully met?

b. For initial examination to establish service connection, fully discuss the criteria in steps A through F supporting or ruling out the diagnosis.

c. Describe any associated symptoms.

d. Specify onset and duration of symptoms as acute, chronic, or with delayed onset.

3. Describe in detail the linkage between the stressor and the current symptoms and clinical findings.

4. Describe and fully explain the existence, frequency, and extent of the following signs and symptoms, or any others present, and relate how they interfere with employment and social functioning:

a. Impairment of thought process or communication.

b. Delusions, hallucinations and their persistence.

c. Inappropriate behavior cited with examples.

d. Suicidal or homicidal thoughts, ideations or plans or intent.

e. Ability to maintain minimal personal hygiene and other basic activities of daily living.

f. Orientation to person, place, and time.

g. Memory loss, or impairment (both short and long-term).

h. Obsessive or ritualistic behavior which interferes with routine activities and describe any found.

i. Rate and flow of speech and note any irrelevant, illogical, or obscure speech patterns and whether constant or intermittent.

j. Panic attacks noting the severity, duration, frequency, and effect on independent functioning and whether clinically observed or good evidence of prior clinical or equivalent observation is shown.

k. Depression, depressed mood or anxiety.

l. Impaired impulse control and its effect on motivation or mood.

m. Sleep impairment and describe extent it interferes with daytime activities.

n. Other symptoms and the extent they interfere with activities.

D. Diagnostic Tests:

1. Provide psychological testing if deemed necessary.

2. If testing is requested, the results must be reported and considered in arriving at the diagnosis.

3. Provide specific evaluation information required by the rating board or on a BVA Remand.

a. Competency: State whether the veteran is capable of managing his or her benefit payments in the individual's own best interests (a physical disability which prevents the veteran from attending to financial matters in person is not a proper basis for a finding of incompetency unless the veteran is, by reason of that disability, incapable of directing someone else in handling the individual's financial affairs).

b. Other Opinion: Furnish any other specific opinion requested by the rating board or BVA remand furnishing the complete rationale and citation of medical texts or treatise supporting opinion, if medical literature review was undertaken. If the requested opinion is medically not ascertainable on exam or testing please state why. If the requested opinion can not be expressed without resorting to speculation or making improbable assumptions say so, and explain why. If the opinion asks " ... is it at least as likely as not ... ", fully explain the clinical findings and rationale for the opinion.

4. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Provide:

1. The Diagnosis must conform to DSM-IV and be supported by the findings on the examination report.

2. If the diagnosis is changed, explain fully whether the new diagnosis represents a progression of the prior diagnosis or development of a new and separate condition.

3. If there are multiple mental disorders, delineate to the extent possible the symptoms associated with each and a discussion of relationship.

4. Evaluation is based on the effects of the signs and symptoms on occupational and social functioning.

NOTE: VA is prohibited by statute from paying compensation for a disability that is a result of the veteran's own ALCOHOL OR DRUG ABUSE, whether based on direct service connection, secondary service connection, or aggravation by a service-connected condition. Therefore, when alcohol or drug abuse accompanies or is associated with another mental disorder, separate, to the extent possible, the effects of the alcohol or drug abuse from the effects of the other mental disorder(s). If it is not possible to separate the effects, explain why.

F. Global Assessment of Functioning (GAF):

NOTE: The complete multi-axial format as specified by DSM-IV may be required by BVA REMAND or specifically requested by the rating specialist. If so, include the GAF score and note whether it refers to current functioning, functioning over the past year, etc.

If multiple Axis I or Axis II diagnoses exist, attempt to the extent possible, to provide a GAF score for the service connected conditions alone as well as a separate overall GAF score based on all mental disorders present, and explain and discuss your rationale. (See the above note pertaining to alcohol or drug abuse, the effects of which cannot be used to assess the effects of a service-connected condition.) If it is not possible to separate the symptomatology, explain why.

DSM-IV is only for application from 11/7/96 on. Therefore, when applicable note whether the diagnosis of PTSD was supportable under DSM-III-R prior to that date. The prior criteria under DSM-III-R are provided as an attachment.

Signature:                                Date:

Attachment A -- Historical DSM-III-R Diagnostic Criteria for PTSD


ATTACHMENT A TO POST TRAUMATIC STRESS DISORDER (PTSD)

A. The veteran has experienced an event that is outside the range of usual human experience and that would be markedly distressing to almost anyone, e.g., serious threat to one's life or physical integrity; serious threat to one's children, spouse, or other close relatives and friends; sudden destruction of one's home or community; seeing another person who has recently been seriously injured or killed as the result of an accident or physical violence.

B. The traumatic event is persistently re-experienced in at least one of the following ways:

1. Recurrent and intrusive distressing recollections of the event.

2. Recurrent distressing dreams of the event.

3. Sudden acting or feeling as if the traumatic event were recurring (includes a sense of reliving the experience, illusions, hallucinations, and dissociative [flashback] episodes, even those that occur upon waking or when intoxicated).

4. Intense psychological distress at exposure to events that symbolize or resemble an aspect of the traumatic event, including anniversaries of the trauma.

C. Persistent avoidance of stimuli associated with the trauma or numbing of general responsiveness (not present before the trauma), as indicated by at least three of the following:

1. Efforts to avoid thoughts or feelings associated with the trauma.

2. Efforts to avoid activities or situations that arouse recollections of the trauma.

3. Inability to recall an important aspect of the trauma (psychogenic amnesia).

4. Markedly diminished interest in significant activities.

5. Feeling of detachment or estrangement from others.

6. Restricted range of affect, e.g., unable to have love feelings.

7. Sense of a foreshortened future, e.g., does not expect to have a career, marriage, children, or a long life.

D. Persistent symptoms of increased arousal (not present before the trauma), as indicated by at least two of the following:

1. Difficulty falling or staying asleep.

2. Irritability or outbursts of anger.

3. Difficulty concentrating.

4. Hyper vigilance.

5. Exaggerated startle response.

6. Physiologic reactivity upon exposure to events that symbolize or resemble an aspect of the traumatic event (e.g., a woman who was raped in an elevator breaks out in a sweat when entering any elevator).


EATING DISORDERS (MENTAL DISORDERS)

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Past Medical History:

a. Previous hospitalizations and outpatient care for parenteral nutrition or tube feeding.

b. Medical and occupational history from the time between the last such rating examination and the present needs to be accounted for, UNLESS the purpose of this examination is to ESTABLISH service connection, then a complete medical history since discharge from military service is required.

c. Periods of incapacitation (during which bedrest and treatment by a physician are required due to the eating disorder). Describe the frequency and duration.

d. Current treatment, response, side effects.

2. Present Medical, Occupational and Social History - over the past one year.

a. History of onset of eating disorder.

b. Its course, treatment, and current status to include symptoms.

c. Extent of time lost from work over the past 12 month period and social impairment. If employed, identify current occupation and length of time at this job.

3. Subjective Complaints:

a. Describe fully.

C. Examination (Objective Findings):

Address each of the following and fully describe:

1. Mental status exam to confirm or establish diagnosis in accordance with DSM-IV.

2. Additionally, please provide this specific information:

a. Current weight.

b. Expected minimum weight based on age, height, and body build.

c. Obtain weight history.

3. Additionally, to allow evaluation by the rating specialist, describe and fully explain the existence, frequency, and extent of the following signs and symptoms and relate how they interfere with employment:

a. Binge eating.

b. Self-induced vomiting or other measure to prevent weight gain when weight is already below expected minimum normal weight.

D. Diagnostic Tests (including psychological testing if deemed necessary):

1. Provide specific evaluation information required by the rating board or on a BVA Remand. Diagnostic Tests (See the examination request remarks for specifics.):

a. Competency: State whether the veteran is capable of managing his or her benefit payments in the individual's own best interests (a physical disability which prevents the veteran from attending to financial matters in person is not a proper basis for a finding of incompetency unless the veteran is, by reason of that disability, incapable of directing someone else in handling the individual's financial affairs).

b. Other Opinion: Furnish any other specific opinion requested by the rating board or BVA Remand furnishing the complete rationale and citation of medical texts or treatise supporting opinion, if medical literature review was undertaken. If the requested opinion is medically not ascertainable on exam or testing please state WHY. If the requested opinion can not be expressed without resorting to speculation or making improbable assumptions say so, and explain why. If the opinion asks "...is it at least as likely as not...", fully explain the clinical findings and rationale for the opinion.

2. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


DENTAL AND ORAL

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

Narrative: Regional Office action is required for all dental treatment based on combat wounds, service trauma, prisoner of war or extracted teeth under 38 CFR 17.123.

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

C. Physical Examination (Objective Findings):

Address each of the following and fully describe:

1. Describe extent of functional impairment due to loss of motion and masticatory function loss.

2. Describe the extent and number of missing teeth and whether the masticatory surface can be replaced by a prosthesis.

3. If limitation of inter-incisal range of motion, provide actual range in mm (i.e., 0-Xmm) and also provide lateral excursion (i.e., 0-Xmm).

4. Describe the extent of any bone loss of mandible, maxilla, or hard palate. For hard palate and maxilla bone loss, state whether replaceable by prosthesis.

D. Diagnostic and Clinical Tests:

Provide:

1. X-ray to determine extent of bone tissue loss.

2. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

1. Give etiology where there is loss of teeth due to loss of substance of body of maxilla or mandible.

Signature:                                Date:


AID AND ATTENDANCE OR HOUSEBOUND EXAMINATION

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

Narrative: Once the existence of at least a single disability rated at 100% has been established, additional benefits may be payable if the veteran requires:

1. The regular assistance of another person in attending to the ordinary activities of daily living,

2. Assistance of another in protecting himself or herself from the ordinary hazards of his or her daily environment, and/or

3. If the veteran is restricted to his or her home or the immediate vicinity thereof, including the ward or immediate clinical area, if hospitalized.

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

1. Indicate whether or not the veteran requires an attendant in reporting for this exam, and if so, identify the nurse or attendant and the mode of travel employed.

2. Indicate whether or not the veteran is hospitalized, and if so, state where and the date of admission.

3. Indicate whether or not the veteran is permanently bedridden.

4. Indicate whether or not the veteran's best corrected vision is 5/200 or worse in both eyes.

5. State whether the veteran is capable of managing benefit payments in his or her own best interests without restriction. (A physical disability which prevents the veteran from attending to financial matters in person is not a proper basis for a finding of incompetency unless he or she is, by reason of that disability, incapable of directing someone else in handling financial affairs.)

6. Capacity to protect oneself from the hazards/dangers of daily environment:

a. Describe briefly any pathological processes involving other body parts and systems, including the effects of advancing age, such as dizziness, loss of memory, poor balance affecting ability to ambulate, performing self- care, or travel beyond the premises of the home (or the ward or clinical area if hospitalized).

b. Describe where the veteran goes and what he or she does during a typical day.

C. Physical Examination (Objective Findings):

Comment on:

1. General appearance.

2. Height and weight (including maximum and minimum weight for past year).

3. Build and posture.

4. State of nutrition.

5. Gait.

6. Temperature, pulse, respiration.

7. Blood pressure.

8. Upper extremities (reporting each upper extremity separately):

a. Describe functional restrictions with reference to strength and coordination and ability for self-feeding, fastening clothing, bathing, shaving, and toileting.

b. If amputated, indicate level of amputation (or length of stump and state whether or not use of a prosthesis is feasible).

9. Lower extremities (reporting each lower extremity separately):

a. Describe functional restrictions with reference to extent of limitation of motion, muscle atrophy, contractures, weakness, lack of coordination, or other interference.

b. Indicate any deficits of weight bearing, balance, and propulsion.

c. If amputated, indicate level of amputation (or length of stump and state whether use of a prosthesis is feasible).

10. Spine, trunk and neck:

a. Describe any limitation of motion or deformity of lumbar, thoracic, and cervical spine.

11. Note if deformity of thoracic spine interferes with breathing.

12. Ambulation:

a. Indicate whether the veteran is able to walk without the assistance of another person and give the maximum distance.

b. Indicate any mechanical aid used or recommended by the examiner for ambulation.

c. Indicate the frequency, and under what circumstances, the veteran is able to leave the home or immediate premises.

13. Except as to amputations and other anatomical losses, indicate if any restrictions noted in the examination are permanent.

D. Diagnostic and Clinical Tests:

1. No specific diagnostic testing required unless required to evaluate the veteran as required above.

2. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:                                Date:


PRISONER OF WAR PROTOCOL EXAMINATION

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

Narrative: This is the protocol for conducting initial full examinations on former POWs. It should be faxed in its entirety to the regional office. Bear in mind that the POW experience likely resulted in a great deal of psychological and physical trauma. Approach these veterans with the greatest sensitivity. Details about diet, beatings, torture, forced marches, forced labor, disease, brainwashing, extremes of hot and cold, and anxiety may be significant parts of the veteran's history, and eliciting them requires that a trusting relationship with the veteran first be established.

Presumptive POW disabilities:

A. Review of Medical Records:

1. Include a review of VA Form 10-0048, Former POW Medical History, which the veteran should have completed, prior to conducting the examination.

2. Review the Social Survey.

B. Medical History (Subjective Complaints):

NOTE: If the veteran has had a previous protocol examination, only an interval history is required.

Comment on:

1. Past medical history, including childhood and adult illnesses and surgery.

2. Family history.

3. Social history - state civilian and military occupations, including dates and locations. Describe use of alcohol, tobacco, and drugs.

4. Complete system review, commenting on all positive symptoms.

a. Describe initial symptoms, time of onset, and current symptoms of all presumptive POW disabilities found.

b. Comment on amount of weight lost as a prisoner. Record initial and release weights.

5. Describe current treatment (specify type, frequency, duration, response, side effects).

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings: The examiner should incorporate all ancillary study results into the final diagnoses.

1. VS: Heart rate, blood pressure (If the diagnosis of hypertension has not been established, take 2 or more blood pressure readings on at least 3 different days. If hypertension has been diagnosed, take 2 or more blood pressure readings.), respirations, height, weight, maximum weight past year, weight change in past year, body in build, and state of nutrition.

2. Dominant hand: Indicate the dominant hand and how determined (i.e., writes, eats, combs hair, etc.).

3. Posture and gait: (If abnormal, describe.)

4. Skin, including appendages: (If abnormal, describe appearance, location, extent of lesions, and limitations to daily activity.) If there are laceration or burn scars, describe the location, measurements (cm. x cm.), shape, depression, type of tissue loss, adherence, disfigurement, and tenderness. For each burn scar, state if due to a 2nd or 3rd degree burn. (NOTE: If the skin condition or scars are disfiguring, obtain color photographs of the affected area(s).

5. Hemic and Lymphatic: (Describe local or generalized adenopathy, tenderness, suppuration, etc.).

6. Head and face: Describe scars, deformities, etc.

7. Eyes: Describe external eye, pupil reaction, movements, field of vision, any uncorrectable refractive error or any retinopathy.

8. Ears: Describe canals, drums, perforations, discharge.

9. Nose, sinuses, mouth and throat: Include gross dental findings.

10. Neck: Describe lymph nodes, thyroid, etc.

11. Chest: Inspection, palpation, percussion, auscultation. If abnormal, describe limitations of daily living (i.e., How far can the veteran walk, how many flights of stairs can he or she climb, etc.).

12. Breast: Comment on any masses palpated in breast parenchyma including axillary tail. Comment on any skin abnormalities. Comment on any discharge from nipples.

13. Cardiovascular: Record pulse, heart sounds, abnormalities (i.e., arrhythmias, murmurs, etc.), and status of peripheral vessels. Note edema. Describe varicose veins including location, size, extent, ulcers, scars, and competency of deep circulation. Examine for evidence of residuals of frostbite when indicated. See cold injuries examination worksheet. (NOTE: Cardiovascular signs and symptoms should be graded using NYHA scale.)

14. Abdomen: Inspection, auscultation, palpation, percussion. If abnormal, describe (i.e., abdominal enlargement, masses, tenderness, etc.).

15. Genital/rectal (male): Inspection and palpation of penis, testicles, epididymis, and spermatic cord. (If hernia, describe type, location, size, whether complete, reducible, recurrent, supported by truss or belt, and whether or not operable). Inspection of anus for fissures, hemorrhoids, ulcerations, etc. and digital exam of rectal walls, and prostate.

16. Genital/rectal (female): Pelvic exam should include inspection of introitus, vagina, and cervix, palpation of labia, vagina, cervix, uterus, adnexa, and ovaries. . Pap smear (if none within past year). ). Inspection of anus for fissures, hemorrhoids, ulcerations, etc. and digital exam of rectal walls. Any severe abnormalities may be referred to a specialist.

17. Musculoskeletal: For joint or muscle defects, describe location, swelling, atrophy, tenderness, active and passive motion in degrees using a goniometer, angle of fixation, fracture, fibrous or bony residual, and mechanical aids used by veteran. Provide an assessment of the effect on range of motion and joint function of pain, weakness, fatigue, or incoordination following repetitive use or during flare-ups. (See the appropriate worksheet for more detail.) If foot problems exist, perform above exam and also include objective evidence of pain at rest and on manipulation, rigidity, spasm, circulatory disturbance, swelling, callus, loss of strength, mobility of ankles and feet, and whether acquired or congenital.

18. Endocrine: Describe disease of thyroid, pituitary, adrenals, gonads, other body systems affected, etc.

19. Neurological: Cerebrum - orientation and memory. Cerebellum - gait, stance, and coordination. Spinal Cord - deep tendon reflexes, pain, touch, temperature, vibration, and position. Cranial nerves - I-XII. If abnormalities are found, describe region of CNS affected.

20. Psychiatric: Describe behavior, comprehension, coherence of response, emotional reaction, signs of tension and response to social and occupational capacity. State whether the veteran is capable of managing his or her benefit payments in his or her own best interests without restriction. (A physical disability which prevents the veteran from attending to financial matters in person is not a proper basis for a finding of incompetency unless the veteran is, by reason of that disability, incapable of directing someone else in handling the individual's financial affairs.)

D. Diagnostic and Clinical Tests:

1. As indicated - e.g., parasite studies, X-rays of joints, etc.

2. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

1. All laboratory and diagnostic tests should be completed and reviewed prior to completing the summary of findings.

2. The POW Physician Coordinator should complete summary of findings, diagnoses, and recommendations. The Coordinator should also express an opinion, with supporting reasons, concerning the relationship between the veteran's experiences as a POW and each current medical condition. If osteoarthritis is diagnosed, it should be clarified whether this is post-traumatic osteoarthritis, and, if so, whether it is related to the period of confinement.

Signature:                                Date:


COLD INJURY PROTOCOL EXAMINATION

Name:                                SSN:
Date of Exam:                        C-number:

Place of Exam:

Narrative: Veterans during World War II, the Korean War, and in smaller numbers during other campaigns, have suffered cold injuries, including frostbite (freezing cold injury or FCI) and immersion foot (nonfreezing cold injury or NCI). Documentation of such injuries may be lacking because of battlefield conditions. A number of long-term and delayed sequelae to cold injuries are recognized, including peripheral neuropathy, skin cancer in frostbite scars, and arthritis in involved limbs.

Review Examination: Any veteran examined for residuals of cold injury should undergo a cold injury protocol examination if it has not already been carried out. If the veteran has already had a cold injury protocol examination, only an interval history is required, and the extent of the examination, laboratory tests performed, etc., will be determined by the examiner based on the history, and as requested.

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

History of Cold Injury: If the cold injury protocol form has been filled out by the veteran, most details about the circumstances of the acute cold injury and its subsequent course will be recorded. Review for any needed expansion or clarification by the veteran. If the protocol history form has not been completed, obtain the following history and comment on each:

1. Description of the circumstances of the cold injury.

2. Parts of the body affected.

3. Signs and symptoms - at time of acute injury.

4. The type of treatment and where it was administered.

5. Any treatment since service - where and what type.

6. Current symptoms - specifically inquire about:

a. Amputations or other tissue loss.

b. Cold sensitization.

c. Raynaud's phenomenon.

d. Hyperhidrosis.

e. Paresthesias, numbness.

f. Chronic pain resembling causalgia or reflex sympathetic dystrophy.

g. Recurrent fungal infections.

h. Breakdown or ulceration of frostbite scars.

i. Disturbances of nail growth.

j. Skin cancer in chronic ulcers or scars.

k. Arthritis or joint stiffness, including limitation of motion of affected areas.

l. Edema.

m. Changes in skin color.

n. Skin thickening or thinning.

o. Any sleep disturbance due to associated symptoms.

p. Cold feeling (relationship to season or not).

q. Numbness, tingling, burning.

r. Excess sweating.

s. Pain - location, intensity, constancy, precipitating factors (cold, walking, standing, night pain); type (sharp burning, etc.).

7. Current treatment, including nonmedical measures taken - moving to warmer climate, wearing multiple pairs of socks, etc.

Other Medical History:

1. Major illnesses, surgery, current medical conditions and their treatment, including diabetes mellitus or hypertension.

2. Smoking history, other risk factors for vascular disease, history of skin cancer.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. General: Carriage, gait, posture.

2. Skin:

a. Color.

b. Edema.

c. Temperature.

d. Atrophy.

e. Dry or moist.

f. Texture.

g. Ulceration.

h. Hair growth.

i. Evidence of fungus or other infection.

3. Scars:

a. Location.

b. Length.

c. Width.

d. Color.

e. Tenderness.

f. Raised or depressed.

g. If of head or neck, any disfigurement.

4. Nails:

a. All or part missing.

b. Evidence of fungus infection.

c. Deformed or atrophic.

5. Neurological:

a. Reflexes.

b. Sensory - subjective complaints of pain, numbness, etc., Objective sensory changes - pinprick, touch.

c. Motor - weakness, atrophy.

6. Orthopedic:

a. Pain or stiffness of any joints affected by cold injury.

b. Deformity or swelling of any joints.

c. Measure range of motion of all affected joints.

d. Strength of ligaments in affected areas.

e. Pes planus.

f. Callus.

g. Pain on manipulation of joints.

h. Loss of tissue of digits or other affected parts.

7. Vascular:

a. Status of peripheral pulses.

b. Doppler study to confirm vascular compromise, if indicated.

c. Evidence of vascular insufficiency - edema, hair loss, shiny atrophic skin, etc.

d. Blood pressure in arms and legs (is ratio normal?).

e. Evidence of Raynaud's phenomenon.

D. Diagnostic and Clinical Tests:

Provide:

1. X-rays of affected areas of extremities if never done or if not done in past five years.

2. Doppler study of blood vessels, if indicated.

3. Nerve conduction studies, if indicated.

4. Biopsy of any area suspicious for malignancy.

5. Scrapings to confirm fungus infection.

6. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

1. List each diagnosis and state whether related to cold injury (if that can be determined).

2. Specialty exams that might be needed:

a. Neurology.

b. Podiatry.

c. Dermatology.

d. Rheumatology.

e. Others as needed.

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