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1DVBCWAH1 ;ALB/CMM A&A OR HOUSEBOUND WKS TEXT - 1 ; 7 MARCH 1997
2 ;;2.7;AMIE;**12**;Apr 10, 1995
3 ;
4 ;
5TXT ;
6 ;;NARRATAIVE: Once the existence of at least a single disability rated
7 ;;at 100% has been established, additional benefits may be payable if
8 ;;the veteran requires:
9 ;;
10 ;; 1. The regular assistance of another person in attending to the
11 ;; ordinary hazards of daily living.
12 ;; 2. Assistance of another in protecting himself or herself from
13 ;; the ordinary hazards of his or her daily environment, and/or
14 ;; 3. If the veteran is restricted to his or her home or the immediate
15 ;; vicinity thereof, including the ward or immediate clinical
16 ;; area, if hospitalized.
17 ;;
18 ;;
19 ;;A. Review Of Medical Records:
20 ;;
21 ;;
22 ;;B. Medical History (Subjective Complaints):
23 ;;
24 ;; 1. Indicate whether or not the veteran requires an attendant in
25 ;; reporting for this exam, and if so, identify the nurse or attendant
26 ;; and the mode of travel employed.
27 ;;
28 ;;
29 ;; 2. Indicate whether or not the veteran is hospitalized, and if so,
30 ;; state where and the date of admission.
31 ;;
32 ;;
33 ;; 3. Indicate whether or not the veteran is permanently bedridden.
34 ;;
35 ;;
36 ;; 4. Indicate whether of not the veteran's best corrected vision is
37 ;; 5/200 or worse in both eyes.
38 ;;
39 ;;
40 ;; 5. State whether the veteran is capable of managing benefit patments
41 ;; in his or her own best interests without restriction. (A physical
42 ;; disability which prevents the veteran from attending to financial
43 ;; matters in person is not a proper basis for a finding of incompetency
44 ;; unless he or she is, by reason of that disability, incapable or
45 ;; directing someone else in handling financial affairs.)
46 ;;
47 ;;
48 ;; 6. Capacity to protect oneself from the hazards/dangers of daily
49 ;; environment:
50 ;;
51 ;; a. Describe briefly any pathological processes involving other
52 ;; body parts and systems, including the effects of advancing
53 ;; age, such as dizziness, bowel/bladder incontinence, loss of
54 ;; memory, poor balance affecting ability to ambulate, performing
55 ;; self-care, or travel beyond the premises of the home (or the
56 ;; ward or clinical area if hospitalized).
57 ;;
58 ;;
59 ;; b. Describe where the veteran goes and what he or she does
60 ;; during a typical day.
61 ;;
62 ;;
63 ;;C. Physical Examination (Objective Findings):
64 ;;
65 ;; Comment on:
66 ;; 1. General Appearance.
67 ;;
68 ;;
69 ;; 2. Height and weight (including maximum and minimum weight for past year.
70 ;;
71 ;;
72 ;; 3. Build and posture.
73 ;;
74 ;;
75 ;; 4. State of nutrition.
76 ;;
77 ;;
78 ;; 5. Gait.
79 ;;
80 ;;
81 ;; 6. Temperature, pulse, respiration.
82 ;;
83 ;;
84 ;; 7. Blood Pressure.
85 ;;
86 ;;
87 ;; 8. Upper extremities (reporting each upper extremity separately):
88 ;;
89 ;; a. Describe functional restrictions with reference to
90 ;; strength and coordination and ability for self-feeding,
91 ;; fastening clothing, bathing, shaving, and toileting.
92 ;;
93 ;;
94 ;; b. If amputated, indicate level of amputation (or length of
95 ;; stump and whether or not use of a prosthesis is feasible).
96 ;;
97 ;; 9. Lower extremities (reporting each lower extremity separately):
98 ;;
99 ;; a. Describe functional restrictions with reference to extent
100 ;; of limitation of motion, muscle atrophy, contractures,
101 ;; weakness, lack of coordination, or other interference.
102 ;;
103 ;;
104 ;; b. Indicate any deficits of weight bearing, balance, and propulsion.
105 ;;
106 ;;
107 ;; c. If amputated, indicate level of amputation (or length of
108 ;; stump and whether use of a prosthesis is feasible).
109 ;;
110 ;;
111 ;; 10. Spine, trunk and neck:
112 ;; Describe any limitation of motion or deformity of lumbar,
113 ;; thoracic, and cervical spine.
114 ;;
115 ;;
116 ;; 11. Note if deformity of thoracic spine interferes with breathing.
117 ;;
118 ;;
119 ;; 12. Ambulation:
120 ;;
121 ;; a. Indicate whether the veteran is able to walk without the
122 ;; assistance of another person and give the maximum distance.
123 ;;
124 ;;
125 ;; b. Indicate any mechanical aid used or recommended by the examiner.
126 ;;
127 ;;
128 ;; c. Indicate the frequency, and under what circumstances, the
129 ;; veteran is able to leave the home or immediate premises.
130 ;;
131 ;; 13. Except as to amputations and other anatomical losses, indicate
132 ;; if any restrictions noted in the examination are permanent.
133 ;;
134 ;;
135 ;;D. Diagnostic and Clinical Tests:
136 ;;
137 ;; 1. No specific diagnostic testing required unless required to evaluate
138 ;; the veteran as required above.
139 ;; 2. Include results of all diagnostic and clinical tests conducted
140 ;; in the examination report.
141 ;;
142 ;;
143 ;;E. Diagnosis:
144 ;;
145 ;;
146 ;;Signature: Date:
147 ;;END
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