DVBCWBS1 ;ALB/CMM BRAIN AND SPINAL CORD WKS TEXT - 1 ; 6 MARCH 1997 ;;2.7;AMIE;**12**;Apr 10, 1995 ; ; TXT ; ;;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. ;; ;;TOF ;; 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: ;;END