PERIPHERAL NERVES CONDITIONS (Not Including Diabetic Sensory - Motor Peripheral

Neuropathy) DISABILITY BENEFITS QUESTIONNAIRE

NAME OF PATIENT/VETERAN PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

Antonio Vincent Hardy 336-64-2198

IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE PROCESS OF
COMPLETING AND/OR SUBMITTING THIS FORM.

Note - The Veteran is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you provide on this questionnaire as part
of their evaluation in processing the Veteran's claim. VA may obtain additional medical information, including an examination, if necessary, to complete VA's review of the
veteran's application. VA reserves the right to confirm the authenticity of ALL questionnaires completed by providers. It is intended that this questionnaire will be completed
by the Veteran's provider.

Are you completing this Disability Benefits Questionnaire at the request of:

Veteran/Claimant

Other: please describe

Are you a VA Healthcare provider? Yes No

Is the Veteran regularly seen as a patient in your clinic? Yes No

Was the Veteran examined in person? Yes No

If no, how was the examination conducted?

EVIDENCE REVIEW
Evidence reviewed:

No records were reviewed

Records reviewed

Please identify the evidence reviewed (e.g. service treatment records, VA treatment records, private treatment records) and the date range.

Military service treatment records, VA treatment records, VA Compensation award

notification letter

Peripheral Nerves Conditions Benefits Questionnaire Updated on: April 1, 2020 ~v20_1
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 SECTION I - DIAGNOSIS

1A. DOES THE VETERAN HAVE A PERIPHERAL NERVE CONDITION OR PERIPHERAL NEUROPATHY?

Yes No (If "Yes," complete Item 1B)

1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO A PERIPHERAL NERVE CONDITION AND/OR PERIPHERAL NEUROPATHY:

Diagnosis # 1: RLE neuropathy ICD Code: M54.16 Date of diagnosis: 09/17/2024

Diagnosis # 2: ICD Code: Date of diagnosis:

Diagnosis # 3: ICD Code: Date of diagnosis:

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO A PERIPHERAL NERVE CONDITION AND/OR PERIPHERAL NEUROPATHY, LIST USING ABOVE
FORMAT:

DEFINITIONS: For VA purposes, neuralgia indicates a condition characterized by a dull and intermittent pain of typical distribution so as to identify the nerve, while neuritis is
characterized by loss of reflexes, muscle atrophy, sensory disturbances and constant pain, at times excruciating.

SECTION II - MEDICAL HISTORY

2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S PERIPHERAL NERVE CONDITION (brief summary):
Veteran has a s/c history of right lower extremity neuropathy affecting the sciatic nerve
and external popliteal secondary to injuring his right ankle during active duty. Veteran
complains of worsening pain, numbness, and loss of feeling.

2B. DOMINANT HAND

Right Left Ambidextrous

SECTION III - SYMPTOMS

3A. Does the Veteran have any symptoms attributable to any peripheral nerve conditions?

Yes No

If yes, indicate symptoms' location and severity (check all that apply):

Constant pain (may be excruciating at times)

Right upper extremity: None Mild Moderate Severe
Left upper extremity: None Mild Moderate Severe
Right lower extremity: None Mild Moderate Severe
Left lower extremity: None Mild Moderate Severe

Intermittent pain (usually dull)

Right upper extremity: None Mild Moderate Severe
Left upper extremity: None Mild Moderate Severe
Right lower extremity: None Mild Moderate Severe
Left lower extremity: None Mild Moderate Severe

Paresthesias and/or dysesthesias

Right upper extremity: None Mild Moderate Severe
Left upper extremity: None Mild Moderate Severe
Right lower extremity: None Mild Moderate Severe
Left lower extremity: None Mild Moderate Severe

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 SECTION III - SYMPTOMS (Continued)
3A. Does the veteran have any symptoms attributable to any peripheral nerve conditions? (Continued)
Numbness
Right upper extremity: None Mild Moderate Severe
Left upper extremity: None Mild Moderate Severe
Right lower extremity: None Mild Moderate Severe
Left lower extremity: None Mild Moderate Severe
3B. Other symptoms (describe symptoms, location and severity):

SECTION IV - MUSCLE STRENGTH TESTING

4A. Rate strength according to the following scale:
0/5 No muscle movement
1/5 Palpable or visible muscle contraction, but no joint movement
2/5 Active movement with gravity eliminated
3/5 Active movement against gravity
4/5 Active movement against some resistance
5/5 Normal strength
All normal
Elbow flexion: Right: 5/5 4/5 3/5 2/5 1/5 0/5
Left: 5/5 4/5 3/5 2/5 1/5 0/5
Elbow extension: Right: 5/5 4/5 3/5 2/5 1/5 0/5
Left: 5/5 4/5 3/5 2/5 1/5 0/5
Wrist flexion: Right: 5/5 4/5 3/5 2/5 1/5 0/5
Left: 5/5 4/5 3/5 2/5 1/5 0/5
Wrist extension: Right: 5/5 4/5 3/5 2/5 1/5 0/5
Left: 5/5 4/5 3/5 2/5 1/5 0/5
Grip: Right: 5/5 4/5 3/5 2/5 1/5 0/5
Left: 5/5 4/5 3/5 2/5 1/5 0/5
Pinch Right: 5/5 4/5 3/5 2/5 1/5 0/5
(thumb to index finger): Left: 5/5 4/5 3/5 2/5 1/5 0/5
Knee extension: Right: 5/5 4/5 3/5 2/5 1/5 0/5
Left: 5/5 4/5 3/5 2/5 1/5 0/5

Ankle plantar flexion: Right: 5/5 4/5 3/5 2/5 1/5 0/5
Left: 5/5 4/5 3/5 2/5 1/5 0/5
Ankle dorsiflexion: Right: 5/5 4/5 3/5 2/5 1/5 0/5
Left: 5/5 4/5 3/5 2/5 1/5 0/5
4B. Does the veteran have muscle atrophy?
Yes No
If muscle atrophy is present, indicate location:
For each instance of muscle atrophy, provide measurements in centimeters of normal side and atrophied side, measured at maximum muscle bulk:

Normal side: cm Atrophied side: cm

SECTION V - REFLEX EXAM
5. Rate deep tendon reflexes (DTRs) according to the following scale:
0 - Absent
1+ Hypoactive
2+ Normal
3+ Hyperactive without clonus
4+ Hyperactive with clonus
All normal
Biceps Right: 0 1+ 2+ 3+ 4+
Left: 0 1+ 2+ 3+ 4+
Triceps Right: 0 1+ 2+ 3+ 4+
Left: 0 1+ 2+ 3+ 4+
Brachioradialis Right: 0 1+ 2+ 3+ 4+
Left: 0 1+ 2+ 3+ 4+
Knee Right: 0 1+ 2+ 3+ 4+
Left: 0 1+ 2+ 3+ 4+
Ankle Right: 0 1+ 2+ 3+ 4+
Left: 0 1+ 2+ 3+ 4+

Peripheral Nerves Conditions Benefits Questionnaire Updated on: April 1, 2020 ~v20_1
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 SECTION VI - SENSORY EXAM
6. Indicate results for sensation testing for light touch:

All normal

Shoulder area (C5): Right: Normal Decreased Absent

Left: Normal Decreased Absent

Inner/outer forearm (C6/T1): Right: Normal Decreased Absent

Left: Normal Decreased Absent
Hand/fingers (C6-8): Right: Normal Decreased Absent
Left: Normal Decreased Absent
Upper anterior thigh (L2): Right: Normal Decreased Absent
Left: Normal Decreased Absent
Thigh/knee (L3/4): Right: Normal Decreased Absent
Left: Normal Decreased Absent
Lower leg/ankle (L4/L5/S1): Right: Normal Decreased Absent
Left: Normal Decreased Absent
Foot/toes (L5): Right: Normal Decreased Absent
Left: Normal Decreased Absent

Other sensory findings, if any:

SECTION VII - TROPHIC CHANGES

7. DOES THE VETERAN HAVE TROPHIC CHANGES (characterized by loss of extremity hair, smooth, shiny skin, etc.) ATTRIBUTABLE TO PERIPHERAL NEUROPATHY?

Yes No

If yes, describe:

SECTION VIII - GAIT

8. IS THE VETERAN'S GAIT NORMAL?

Yes No

If no, describe abnormal gait:

Gait is guarded and slow. Becomes uncoordinated during flare-ups with some limping.

Provide etiology of abnormal gait:

RLE neuropathy secondary to ankle injury

SECTION IX - SPECIAL TESTS FOR MEDIAN NERVE

9. WERE SPECIAL TESTS INDICATED AND PERFORMED FOR MEDIAN NERVE EVALUATION?

Yes No

If yes, indicate results:

Phalen's sign: Right: Positive Negative

Left: Positive Negative

Tinel's sign: Right: Positive Negative

Left: Positive Negative

SECTION X - NERVES AFFECTED: Severity Evaluation for Upper Extremity Nerves and Radicular Groups
Based on symptoms and findings from this exam, complete the following section to provide an estimation of the severity of the veteran's peripheral neuropathy. This summary
provides useful information for VA purposes.

NOTE: For VA purposes, the term “incomplete paralysis" indicates a degree of lost or impaired function substantially less than the description of complete paralysis that is
given with each nerve.

If the nerve is completely paralyzed, check the box for “complete paralysis.” If the nerve is not completely paralyzed, check the box for “incomplete paralysis” and indicate
severity. For VA purposes, when nerve impairment is wholly sensory, the evaluation should be mild, or at most, moderate.
Peripheral Nerves Conditions Benefits Questionnaire Updated on: April 1, 2020 ~v20_1
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 SECTION X - NERVES AFFECTED: Severity Evaluation for Upper Extremity Nerves and Radicular Groups (Continued)
NOTE: INDICATE THE AFFECTED NERVES, SIDE AFFECTED AND SEVERITY OF CONDITION.
10A. Radial nerve (musculospiral nerve)
Note: Complete paralysis (hand and fingers drop, wrist and fingers flexed; cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb or make
lateral movement of wrist; supination of hand, elbow extension and flexion weak, hand grip impaired)

Right: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

Left: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

10B. Median nerve

Note: Complete paralysis (hand inclined to the ulnar side, index and middle fingers extended, atrophy of thenar eminence, cannot make fist, defective opposition of
thumb, cannot flex distal phalanx of thumb; wrist flexion weak)

Right: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

Left: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

10C. Ulnar nerve

Note: Complete paralysis ("griffin claw" deformity, atrophy in dorsal interspaces, thenar and hypothenar eminences; cannot extend ring and little finger, cannot
spread fingers, cannot adduct the thumb; wrist flexion weakened)

Right: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

Left: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

10D. Musculocutaneous nerve

Note: Complete paralysis (weakened flexion of elbow and supination of forearm)

Right: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

Left: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

10E. Circumflex nerve

Note: Complete paralysis (innervates deltoid and teres minor; cannot abduct arm, outward rotation is weakened)

Right: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

Left: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

10F. Long thoracic nerve

Note: Complete paralysis (inability to raise arm above shoulder level, winged scapula deformity)

Right: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

Left: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

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 SECTION X - NERVES AFFECTED: Severity Evaluation for Upper Extremity Nerves and Radicular Groups (Continued)
10G. Upper radicular group (5th & 6th cervicals)
Note: Complete paralysis (all shoulder and elbow movements lost; hand and wrist movements not affected)
Right: Normal Incomplete paralysis Complete paralysis
If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

Left: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

10H. Middle radicular group

Note: Complete paralysis (adduction, abduction, rotation of arm, flexion of elbow and extension of wrist lost)
Right: Normal Incomplete paralysis Complete paralysis
If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

Left: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

10I. Lower radicular group

Note: Complete paralysis (intrinsic hand muscles, wrist and finger flexors paralyzed; substantial loss of use of hand)
Right: Normal Incomplete paralysis Complete paralysis
If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

Left: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

SECTION XI - NERVES AFFECTED: Severity Evaluation for Lower Extremity Nerves

Based on symptoms and findings from this exam, complete the following section to provide an estimation of the severity of the veteran's peripheral neuropathy. This summary
provides useful information for VA purposes.

NOTE: For VA purposes, the term “incomplete paralysis" indicates a degree of lost or impaired function substantially less than the description of complete paralysis that is
given with each nerve.

If the nerve is completely paralyzed, check the box for “complete paralysis.” If the nerve is not completely paralyzed, check the box for “incomplete paralysis” and indicate
severity. For VA purposes, when nerve impairment is wholly sensory, the evaluation should be mild, or at most, moderate.
NOTE: INDICATE AFFECTED NERVES, SIDE AFFECTED AND SEVERITY OF CONDITION.
11A. Sciatic nerve
Note: Complete paralysis (foot dangles and drops, no active movement of muscles below the knee, flexion of knee weakened or lost)

Right: Normal Incomplete paralysis Complete paralysis

If incomplete paralysis is checked, indicate severity:
Mild Moderate Moderately Severe Severe, with marked muscular atrophy

Left: Normal Incomplete paralysis Complete paralysis

If incomplete paralysis is checked, indicate severity:
Mild Moderate Moderately Severe Severe, with marked muscular atrophy

11B. External popliteal (common peroneal) nerve

Note: Complete paralysis (foot drop, cannot dorsiflex foot or extend toes; dorsum of foot and toes are numb)
Right: Normal Incomplete paralysis Complete paralysis
If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

Left: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

11C. Musculocutaneous (superficial peroneal) nerve

Note: Complete paralysis (eversion of foot weakened)

Right: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

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 SECTION XI - NERVES AFFECTED: Severity Evaluation for Lower Extremity Nerves (Continued)
11C. Musculocutaneous (superficial peroneal) nerve (continued)
Left: Normal Incomplete paralysis Complete paralysis
If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

11D. Anterior tibial (deep peroneal) nerve

Note: Complete paralysis (dorsiflexion of foot lost)

Right: Normal Incomplete paralysis Complete paralysis
If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

Left: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

11E. Internal popliteal (tibial) nerve

Note: Complete paralysis (plantar flexion lost, frank adduction of foot impossible, flexion and separation of toes abolished; no muscle in sole can move; in lesions of the
nerve high in popliteal fossa, plantar flexion of foot is lost)
Right: Normal Incomplete paralysis Complete paralysis
If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

Left: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

11F. Posterior tibial nerve

Note: Complete paralysis (paralysis of all muscles of sole of foot, frequently with painful paralysis of a causalgic nature; loss of toe flexion; adduction weakened; plantar
flexion impaired)
Right: Normal Incomplete paralysis Complete paralysis
If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

Left: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

11G. Anterior crural (femoral) nerve

Note: Complete paralysis (paralysis of quadriceps extensor muscles)
Right: Normal Incomplete paralysis Complete paralysis
If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

Left: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

11H. Internal saphenous nerve

Right: Normal Incomplete paralysis Complete paralysis
If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

Left: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

11I. Obturator nerve

Right: Normal Incomplete paralysis Complete paralysis
If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

Left: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

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 SECTION XI - NERVES AFFECTED: Severity Evaluation for Lower Extremity Nerves (Continued)
11J. External cutaneous nerve of the thigh

Right: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

Left: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

11K. Illio-inguinal nerve

Right: Normal Incomplete paralysis Complete paralysis
If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

Left: Normal Incomplete paralysis Complete paralysis

If Incomplete paralysis is checked, indicate severity:
Mild Moderate Severe

SECTION XII - ASSISTIVE DEVICES

12A. DOES THE VETERAN USE ANY ASSISTIVE DEVICES AS A NORMAL MODE OF LOCOMOTION ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS
MAY BE POSSIBLE?
YES NO
If yes, identify assistive device(s) used (check all that apply and indicate frequency):
Wheelchair Frequency of use: Occasional Regular Constant
Brace(s) Frequency of use: Occasional Regular Constant
Crutch(es) Frequency of use: Occasional Regular Constant
Cane(s) Frequency of use: Occasional Regular Constant
Walker Frequency of use: Occasional Regular Constant
Other:
Frequency of use: Occasional Regular Constant

12B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:
Veteran regularly utilizes a brace and cane to assist with pain and locomotion.

SECTION XIII - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES

13. Due to peripheral nerve conditions, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by
an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.)

Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran
No

If yes, indicate extremity(ies) (check all extremities for which this applies):
Right upper Left upper Right lower Left lower

For each checked extremity, describe loss of effective function, identify the condition causing loss of function, and provide specific examples (brief summary):

SECTION XIV - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
14A. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN THE DIAGNOSIS SECTION ABOVE?
YES NO

IF YES, DESCRIBE (brief summary):

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 SECTION XIV - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS (Continued)
14B. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN THE
DIAGNOSIS SECTION ABOVE?
YES NO

IF YES, ARE ANY OF THESE SCARS PAINFUL OR UNSTABLE; HAVE A TOTAL AREA EQUAL TO OR GREATER THAN 39 SQUARE CM (6 square inches); OR
ARE LOCATED ON THE HEAD, FACE OR NECK?

YES NO

IF YES, ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT.

IF NO, PROVIDE LOCATION AND MEASUREMENTS OF SCAR IN CENTIMETERS.
LOCATION: MEASUREMENTS: length cm X width cm.

NOTE: An "unstable scar" is one where, for any reason, there is frequent loss of covering of the skin over the scar. If there are multiple scars,enter additional locations and
measurements in Comment section below. It is not necessary to also complete a Scars DBQ.
14C. COMMENTS, IF ANY:

SECTION XV - DIAGNOSTIC TESTING

NOTE: For the purpose of this examination, electromyography (EMG) studies are usually rarely required to diagnose specific peripheral nerve conditions in the appropriate clinical
setting. If EMG studies are in the medical record and reflect the veteran's current condition, repeat studies are not indicated.
15A. HAVE EMG STUDIES BEEN PERFORMED?
Yes No

Extremities tested:
Right upper extremity Results: Normal Abnormal Date:
Left upper extremity Results: Normal Abnormal Date:
Right lower extremity Results: Normal Abnormal Date:
Left lower extremity Results: Normal Abnormal Date:

If abnormal, describe:

15B. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
Yes No

If yes, provide type of test or procedure, date and results (brief summary):

Peripheral Nerves Conditions Benefits Questionnaire Updated on: April 1, 2020 ~v20_1
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