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DIABETIC SENSORY-MOTOR PERIPHERAL NEUROPATHY DISABILITY BENEFITS QUESTIONNAIRE (U.S. Department of Veterans Affairs)

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Diabetic Peripheral Neuropathy Disability Benefits Questionnaire
Released January 2022
Updated on: December 2, 2020 ~v20_2
Page 1 of 6
DIABETIC SENSORY-MOTOR PERIPHERAL NEUROPATHY
DISABILITY BENEFITS QUESTIONNAIRE
NAME OF PATIENT/VETERAN PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
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.
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.
Are you completing this Disability Benefits Questionnaire at the request of:
Veteran/Claimant
Other, please describe:
Was the Veteran examined in person?
Is the Veteran regularly seen as a patient in your clinic?
Are you a VA Healthcare provider?
If no, how was the examination conducted?
No records were reviewed
Records reviewed
Evidence reviewed:
EVIDENCE REVIEW
Please identify the evidence reviewed (e.g. service treatment records, VA treatment records, private treatment records) and the date range.
Yes No
Yes No
Yes No
Diabetic Peripheral Neuropathy Disability Benefits Questionnaire
Released January 2022
Updated on: December 2, 2020 ~v20_2
Page 2 of 6
DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH DIABETIC PERIPHERAL NEUROPATHY?
3A. DOES THE VETERAN HAVE ANY SYMPTOMS ATTRIBUTABLE TO DIABETIC PERIPHERAL NEUROPATHY?
AMBIDEXTROUSRIGHT
IF YES, PROVIDE ONLY DIAGNOSES THAT PERTAIN TO DIABETIC PERIPHERAL NEUROPATHY:
LEFT UPPER EXTREMITY
:
RIGHT LOWER EXTREMITY:
SECTION III - SYMPTOMS
LEFT LOWER EXTREMITY:
NOYES
CONSTANT PAIN (may be excruciating at times)
2A. DOES THE VETERAN HAVE DIABETES MELLITUS TYPE I OR TYPE II?
2B. DESCRIBE THE HISTORY (including cause, onset and course) OF THE VETERAN'S DIABETIC PERIPHERAL NEUROPATHY
LEFT
SECTION II - MEDICAL HISTORY
2C. DOMINANT HAND
SevereNone Mild Moderate
IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO DIABETIC PERIPHERAL NEUROPATHY, LIST USING ABOVE FORMAT:
SECTION I - DIAGNOSIS
NOYES
DATE OF DIAGNOSIS -
DATE OF DIAGNOSIS -
DATE OF DIAGNOSIS -
ICD CODE -
ICD CODE -
ICD CODE -
DIAGNOSIS # 3 -
DIAGNOSIS # 2 -
DIAGNOSIS # 1 -
NOYES
(If "Yes," indicate symptoms' location and severity) (Check all that apply):
RIGHT UPPER EXTREMITY
:
SevereModerateMildNone
SevereModerateMildNone
SevereModerateMildNone
LEFT UPPER EXTREMITY:
RIGHT LOWER EXTREMITY:
LEFT LOWER EXTREMITY:
INTERMITTENT PAIN (usually dull)
SevereNone Mild Moderate
RIGHT UPPER EXTREMITY:
SevereModerateMildNone
SevereModerateMildNone
SevereModerateMildNone
PARESTHESIAS AND/OR DYSESTHESIAS
LEFT UPPER EXTREMITY
:
RIGHT LOWER EXTREMITY:
LEFT LOWER EXTREMITY:
SevereNone Mild Moderate
RIGHT UPPER EXTREMITY:
SevereModerateMildNone
SevereModerateMildNone
SevereModerateMildNone
NUMBNESS
LEFT UPPER EXTREMITY
:
RIGHT LOWER EXTREMITY:
LEFT LOWER EXTREMITY:
SevereNone Mild Moderate
RIGHT UPPER EXTREMITY:
SevereModerateMildNone
SevereModerateMildNone
SevereModerateMildNone
OTHER SYMPTOMS (Describe symptoms, location and severity):
Diabetic Peripheral Neuropathy Disability Benefits Questionnaire
Released January 2022
Updated on: December 2, 2020 ~v20_2
Page 3 of 6
SECTION IV - NEUROLOGIC EXAM
4A. STRENGTH - RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE:
5/5 Normal strength
0/5 No muscle movement
1/5 Visible muscle movement, but no joint movement
2/5 No movement against gravity
3/5 No movement against resistance
4/5 Less than normal strength
Pinch
(thumb to index finger)
LEFT: 1/5 0/52/5
Knee Extension
LEFT: 1/5 0/52/54/5 3/55/5
RIGHT: 1/5 0/52/5
4/5 3/55/5
4/5 3/55/5
RIGHT: 1/5 0/52/54/5 3/55/5
Ankle Dorsiflexion
LEFT: 1/5 0/52/54/5 3/55/5
RIGHT: 1/5 0/52/54/5 3/55/5
Wrist Flexion
LEFT: 1/5 0/52/54/5 3/55/5
RIGHT: 1/5 0/52/54/5 3/55/5
Wrist Extension
LEFT: 1/5 0/52/54/5 3/55/5
RIGHT: 1/5 0/52/54/5 3/55/5
Grip
LEFT: 1/5 0/52/54/5 3/55/5
RIGHT: 1/5 0/52/54/5 3/55/5
Ankle Plantar Flexion
LEFT: 1/5 0/52/54/5 3/55/5
RIGHT: 1/5 0/52/54/5 3/55/5
Elbow Flexion
LEFT: 1/5 0/52/54/5 3/55/5
RIGHT: 1/5 0/52/54/5 3/55/5
Elbow Extension
LEFT: 1/5 0/52/5
4/5 3/55/5
RIGHT: 1/5 0/52/54/5 3/55/5
Knee Flexion
LEFT: 1/5 0/52/54/5 3/55/5
RIGHT: 1/5 0/52/54/5 3/55/5
0 - Absent
1+ Decreased
2+ Normal
3+ Increased without clonus
4+ Increased with clonus
4B. DEEP TENDON REFLEXES (DTRs) - RATE REFLEXES ACCORDING TO THE FOLLOWING SCALE:
Brachioradialis
LEFT:
RIGHT:
Ankle
LEFT:
RIGHT:
Knee
LEFT:
RIGHT:
3+ 4+1+ 2+0
1+ 2+0 3+ 4+
Biceps
LEFT:
3+ 4+
3+ 4+
2+0 1+
RIGHT:
Triceps
LEFT:
3+ 4+
3+
1+ 2+0
RIGHT:
4+
1+ 2+0
2+0 1+ 3+ 4+
3+
1+ 2+0
4+
1+ 2+0 3+ 4+
2+0 1+
3+ 4+
2+0 1+
All normal
All normal
4C. LIGHT TOUCH/MONOFILAMENT TESTING RESULTS
Normal Decreased
Normal Decreased Absent
Normal
Ankle/lower leg
LEFT:
RIGHT:
LEFT:
Decreased
Normal Decreased Absent
Absent
Foot/toes
LEFT:
RIGHT:
Knee/thigh
LEFT:
RIGHT:
Normal Decreased
Normal Decreased Absent
Normal Decreased Absent
Absent
Absent
Normal Decreased
Hand/fingers
Normal Decreased Absent
RIGHT:
Normal Decreased
Normal Decreased Absent
Absent
Absent
Normal Decreased Absent
Shoulder area
LEFT:
RIGHT:
Inner/outer forearm
LEFT:
RIGHT:
All Normal
4D. POSITION SENSE (grasp index finger/great toe on sides and ask patient to identify up and down movement)
Not tested
Normal Decreased Absent
Normal
LEFT LOWER EXTREMITY
Decreased AbsentLEFT UPPER EXTREMITY
Normal Decreased AbsentRIGHT UPPER EXTREMITY
Normal Decreased AbsentRIGHT LOWER EXTREMITY
Diabetic Peripheral Neuropathy Disability Benefits Questionnaire
Released January 2022
Updated on: December 2, 2020 ~v20_2
Page 4 of 6
SECTION IV - NEUROLOGIC EXAM (Continued)
Not tested
Normal Decreased Absent
Normal
LEFT LOWER EXTREMITY
Decreased Absent
LEFT UPPER EXTREMITY
Normal Decreased AbsentRIGHT UPPER EXTREMITY
Normal Decreased AbsentRIGHT LOWER EXTREMITY
4E. VIBRATION SENSATION (place low-pitched tuning fork over DIP joint of index finger/IP joint of great toe)
Not tested
Normal Decreased AbsentLEFT LOWER EXTREMITY
Normal Decreased AbsentRIGHT LOWER EXTREMITY
4F. COLD SENSATION (test distal extremities for cold sensation with side of tuning fork)
Normal Decreased Absent
LEFT UPPER EXTREMITY
Normal Decreased AbsentRIGHT UPPER EXTREMITY
(For each instance of muscle atrophy, provide measurements in cm between normal and atrophied side, measured at maximum muscle bulk:
(If muscle atrophy is present, indicate location):
cm.)
4G. DOES THE VETERAN HAVE MUSCLE ATROPHY?
NOYES
5A. DOES THE VETERAN HAVE AN UPPER EXTREMITY DIABETIC PERIPHERAL NEUROPATHY?
(If "Yes," describe):
SECTION V - SEVERITY
NOYES
4H. DOES THE VETERAN HAVE TROPHIC CHANGES
(characterized by loss of extremity hair, smooth, shiny skin, etc.) ATTRIBUTABLE TO DIABETIC PERIPHERAL
NEUROPATHY?
RIGHT:
NOYES
(If incomplete paralysis is checked, indicate
severity):
(If "Yes," indicate nerve affected, severity and side affected)
Normal Complete paralysisIncomplete paralysis
NOTE: Based on symptoms and findings from Sections III and IV, complete Items a and b below to provide an evaluation of the severity of the Veteran's diabetic peripheral
neuropathy.
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.
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.)
SevereModerateMild
LEFT:
Severe
Moderate
Mild
(If incomplete paralysis is checked, indicate
severity):
Complete paralysis
Incomplete paralysisNormal
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:
(If incomplete paralysis is checked, indicate
severity):
Normal Complete paralysisIncomplete paralysis
SevereModerateMild
LEFT:
(If incomplete paralysis is checked, indicate
severity):
Normal Complete paralysisIncomplete paralysis
SevereModerateMild
(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.)
ULNAR NERVE
RIGHT:
(If incomplete paralysis is checked, indicate
severity):
Normal Complete paralysisIncomplete paralysis
SevereModerateMild
LEFT:
(If incomplete paralysis is checked, indicate
severity):
Normal Complete paralysisIncomplete paralysis
SevereModerateMild
Diabetic Peripheral Neuropathy Disability Benefits Questionnaire
Released January 2022
Updated on: December 2, 2020 ~v20_2
Page 5 of 6
SECTION VI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
SECTION V - SEVERITY (Continued)
5B. DOES THE VETERAN HAVE A LOWER EXTREMITY DIABETIC PERIPHERAL NEUROPATHY?
Moderately
Severe
SCIATIC NERVE
FEMORAL NERVE (anterior crural)
Mild
Severe, with marked
muscular atrophy
RIGHT:
NOYES
(If "Yes," indicate nerve affected, severity and side affected)
Moderate
(NOTE: Complete paralysis (foot dangles and drops, no active movement of muscles below the knee, flexion of knee weakened or lost.)
Complete paralysisIncomplete paralysisNormal
Moderately
Severe
Mild
Severe, with marked
muscular atrophy
LEFT:
Moderate
Complete paralysisIncomplete paralysisNormal
(If incomplete paralysis is checked, indicate
severity):
(If incomplete paralysis is checked, indicate
severity):
Moderately SevereMild
RIGHT:
Moderate
(NOTE: Complete paralysis (paralysis of quadriceps extensor muscles.)
Complete paralysis
Incomplete paralysisNormal
Moderately SevereMild
LEFT:
Moderate
Complete paralysisIncomplete paralysisNormal
(If incomplete paralysis is checked, indicate
severity):
(If incomplete paralysis is checked, indicate
severity):
6C. COMMENTS, IF ANY:
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.
6B. 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
YES
IF YES, ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT.
LOCATION: MEASUREMENTS: length cm X width cm.
IF NO, PROVIDE LOCATION AND MEASUREMENTS OF SCAR IN CENTIMETERS.
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?
IF YES, DESCRIBE (brief summary):
NO
YES
6A. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN THE DIAGNOSIS SECTION ABOVE?
NOTE: For purposes of this examination, electromyography (EMG) studies are rarely required to diagnose diabetic peripheral neuropathy. The diagnosis of diabetic peripheral
neuropathy can be made in the appropriate clinical setting by a history of characteristic pain and/or sensory changes in a stocking/glove distribution and objective clinical
findings, which may include symmetrical lost/decreased reflexes, decreased strength, lost/decreased sensation for cold, vibration and/or position sense, and/or lost/decreased
sensation to monofilament testing.
SECTION VII - DIAGNOSTIC TESTING
LEFT LOWER EXTREMITY Results:
Normal
Abnormal
RIGHT LOWER EXTREMITY
(If abnormal, describe):
NOYES
(Extremities tested):
Abnormal
Date:
Normal
Date:
Abnormal
Date:
7A. HAVE EMG STUDIES BEEN PERFORMED?
7B. IF THERE ARE OTHER SIGNIFICANT FINDINGS OR DIAGNOSTIC TEST RESULTS, PROVIDE DATES AND DESCRIBE
NormalResults:
Results:
Results:
Date:
LEFT UPPER EXTREMITY
RIGHT UPPER EXTREMITY
Normal Abnormal
Diabetic Peripheral Neuropathy Disability Benefits Questionnaire
Released January 2022
Updated on: December 2, 2020 ~v20_2
Page 6 of 6
SECTION IX - REMARKS
9. REMARKS, if any:
DOES THE VETERAN'S DIABETIC PERIPHERAL NEUROPATHY IMPACT HIS OR HER ABILITY TO WORK?
SECTION VIII - FUNCTIONAL IMPACT
If "Yes," describe impact of the veteran's diabetic peripheral neuropathy, providing one or more examples:NOYES
SECTION X - EXAMINER'S CERTIFICATION AND SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
10A. Examiner's signature: 10B. Examiner's printed name and title (e.g. MD, DO, DDS, DMD, Ph.D, Psy.D, NP, PA-C):
10E. Examiner's phone/fax numbers: 10F. National Provider Identifier (NPI) number:
10G. Medical license number and state:
10H. Examiner's address:
10C. Examiner's Area of Practice/Specialty (e.g. Cardiology, Orthopedics, Psychology/Psychiatry, General Practice): 10D. Date Signed:
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DIABETIC SENSORY-MOTOR PERIPHERAL NEUROPATHY DISABILITY BENEFITS QUESTIONNAIRE (U.S. Department of Veterans Affairs)

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Completed 17 June 2022

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