Disability Examination Worksheets
General Medical
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Narrative: This is a comprehensive base-line or
screening examination for all body systems, not just specific conditions
claimed by the veteran. It is often the initial post-discharge examination of a
veteran requested by the Compensation and Pension Service for disability
compensation purposes. As a screening examination, it is not meant to elicit
the detailed information about specific conditions that is necessary for rating
purposes. Therefore, all claimed conditions, and any found or suspected
conditions that were not claimed, should be addressed by referring to and
following all appropriate worksheets, in addition to this one, to assure that
the examination for each condition provides information adequate for rating
purposes. This does not require that a medical specialist conduct
examinations based on other worksheets, except in the case of vision and
hearing problems, mental disorders, or especially complex or unusual problems.
Vision, hearing, and mental disorder examinations must be conducted by a
specialist. The examiner may request any additional studies or
examinations needed for proper diagnosis and evaluation (see other worksheets
for guidance). All important negatives should be reported. The regional office
may also request a general medical examination as evidence for
nonservice-connected disability pension claims or for claimed entitlement to
individual unemployability benefits in service-connected disability
compensation claims. Barring unusual problems, examinations for pension should
generally be adequate if only this general worksheet is followed. A.
Review of Medical Records: Indicate whether the C-file was
reviewed. B. Medical History (Subjective Complaints):
- Discuss: Whether an injury or disease that is found occurred
during active service, before active service, or after active service. To the
extent possible, describe the circumstances, dates, specific injury or disease
that occurred, treatment, follow-up, and residuals. If the injury or disease
occurred before active service, describe any worsening of residuals due to
being in military service. Describe current symptoms and treatment.
- Occupational history (for pension and individual unemployability
claims): Obtain the name and address of employers (list most current first),
type of occupation, employment dates, and wages for last 12 months. If any time
was lost from work in the past 12-month period, please describe the reason and
extent of time lost.
- Describe details of current treatment, conditions being
treated, and side effects of treatment.
- Describe all surgery and hospitalizations in and after
service with approximate dates.
- If a malignant neoplasm is or was present, provide:
- Date of confirmed diagnosis.
- Date of the last surgical, X-ray, antineoplastic chemotherapy,
radiation, or other therapeutic procedure.
- State expected date treatment regimen is to be
completed.
- If treatment is already completed, provide date of
last treatment.
- If treatment is already completed, fully describe
residuals.
C. Physical Examination (Objective
Findings):
Address each of the following and fully describe current
findings: The examiner should incorporate results of all ancillary studies into
the final diagnoses.
- VS: Heart rate, blood pressure (see #13 below),
respirations, height, weight, maximum weight in past year, weight change in
past year, body build, and state of nutrition.
- Dominant hand: Indicate the dominant hand and
how this was determined, e.g., writes, eats, combs hair with that hand.
- Posture and gait: Describe abnormality and
reason for it. Describe any ambulatory aids.
- Skin, including appendages: If abnormal,
describe appearance, location, extent of lesions. If there are laceration or
burn scars, describe the location, exact measurements (cm. x cm.), shape,
depression, type of tissue loss, adherence, and tenderness. For each burn scar,
state if due to a 2nd or 3rd degree burn. Describe any limitation of activity
or limitation of motion due to scarring or other skin lesions. NOTE: If
there are disfiguring scars (of face, head, or neck), obtain color photographs
of the affected area(s) to submit with the examination report.
- Hemic and Lymphatic: Describe adenopathy,
tenderness, suppuration, edema, pallor, etc.
- Head and face: Describe scars, skin lesions,
deformities, etc., as discussed under item #4.
- Eyes: Describe external eye, pupil reaction, eye
movements.
- Ears: Describe canals, drums, perforations,
discharge.
- Nose, sinuses, mouth and throat: Include gross
dental findings. For sinusitis, describe headaches, pain, episodes of
incapacitation, frequency and duration of antibiotic treatment.
- Neck: Describe lymph nodes, thyroid, etc.
- Chest: Inspection, palpation, percussion,
auscultation. Describe respiratory symptoms and effect on daily activities,
e.g., how far the veteran can walk, how many flights of stairs veterans can
climb. If a respiratory condition is claimed or suspected, refer to appropriate
worksheet(s). Most respiratory conditions will require PFTs, including
post-bronchodilation studies. Describe in detail any treatment for pulmonary
disease.
- Breast: Describe masses, scars, nipple
discharge, skin abnormalities. Give date of last mammogram, if any. Describe
any breast surgery (with approximate date) and residuals.
- Cardiovascular: NOTE: If there is evidence of a
cardiovascular disease, or one is claimed, refer to appropriate worksheet(s).
- Record pulse, quality of heart sounds, abnormal heart sounds,
arrhythmias. Describe symptoms and treatment for any cardiovascular condition,
including peripheral arterial and venous disease. Give NYHA classification of
heart disease. A determination of METs by exercise testing may be required for
certain cardiovascular conditions, and an estimation of METS may be required if
exercise testing cannot be conducted for medical reasons. (See the
cardiovascular worksheets for further guidance.)
- Describe the status of peripheral vessels and pulses. Describe
edema, stasis pigmentation or eczema, ulcers, or other skin or nail
abnormalities. Describe varicose veins, including extent to which any resulting
edema is relieved by elevation of extremity. Examine for evidence of
residuals of cold injury when indicated. See and follow special cold injury
examination worksheet if there is a history of cold exposure in service and the
special cold injury examination has not been previously done.
- Blood Pressure: (Per the rating schedule, hypertension
means that the diastolic blood pressure is predominantly 90mm. or greater, and
isolated systolic hypertension means that the systolic blood pressure is
predominantly 160mm. or greater with a diastolic blood pressure of less than
90mm.)
- If the diagnosis of hypertension has not been previously
established, and it is a claimed issue, B.P. readings must be taken two or more
times on each of at least three different days.
- If hypertension has been previously diagnosed and is claimed,
but the claimant is not on treatment, B.P. readings must be taken two or more
times on at least three different days.
- If hypertension has been previously diagnosed, and the
claimant is on treatment, take three blood pressure readings on the day of the
examination.
- If hypertension has not been claimed, take three blood
pressure readings on the day of the examination. If they are suggestive of
hypertension or are borderline, readings must be taken two or more times on at
least two additional days to rule hypertension in or out.
- In the diagnostic summary, state whether hypertension is
ruled in or out after completing these B.P. measurements. Describe treatment
for hypertension and side effects. If hypertensive heart disease is suspected
or found, follow worksheet for Heart.
- Abdomen: Inspection, auscultation, palpation, percussion.
Describe any organ enlargement, ventral hernia, mass, tenderness, etc.
- Genital/rectal (male): Inspection and palpation
of penis, testicles, epididymis, and spermatic cord. If there is a hernia,
describe type, location, size, whether complete, reducible, recurrent,
supported by truss or belt, and whether or not operable. Describe anal
fissures, hemorrhoids, ulcerations, etc. Include digital exam of rectal walls
and prostate.
- Genital/rectal (female): Pelvic exam, including
inspection of introitus, vagina, and cervix, palpation of labia, vagina,
cervix, uterus, adnexa, and ovaries, rectal exam. Do Pap smear if none within
past year. If unable to conduct an examination and Pap smear, or if there is a
severe or complex problem, refer to a specialist.
- Musculoskeletal:
- For all joint or muscle disorders, state each muscle and joint
affected.
- Separately examine and describe in detail each affected joint.
Measure active and passive range of motion in degrees using a goniometer. In
addition, 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 musculoskeletal worksheet for more
detail.) NOTE: The diagnosis of degenerative or traumatic arthritis of any
joint requires X-ray confirmation, but once confirmed by X-ray, either in
service or after service, no further X-rays of that joint are required for
disability evaluation purposes.
- Describe swelling, effusion, tenderness, muscle spasm, joint
laxity, muscle atrophy, fibrous or bony residual of fracture. If joint is
ankylosed, describe the position and angle of fixation.
- Describe any mechanical aids used by veteran.
- If foot problems exist, also describe objective evidence of
pain at rest and on manipulation, rigidity, spasm, circulatory disturbance,
swelling, callus, loss of strength, and whether condition is acquired or
congenital.
- If there is amputation of a part, see the appropriate
worksheet.
- With disc disease, also describe any neurological
findings.
- Endocrine: Describe signs and symptoms of any endocrine
disease, effects on other body systems, and current and past treatment. See
endocrine worksheets for further guidance.
- Neurological: Assess orientation and memory,
gait, stance, and coordination, cranial nerve functions. Assess deep tendon
reflexes, pain, touch, temperature, vibration, and position, motor and sensory
status of peripheral nerves. If neurological abnormalities are found on
examination, or there is a history of seizures, refer to appropriate
worksheet.
- Psychiatric: Describe behavior, comprehension,
coherence of response, emotional reaction, signs of tension and effects on
social and occupational functioning. (This is meant to be a brief screening
examination. If a mental disorder is claimed, or suspected based on the
screening, an examination for diagnosis and assessment should be conducted by a
psychiatrist or psychologist.) 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:
- Include results of all diagnostic and clinical tests conducted in
the examination report.
- Review all test results before providing the summary
and diagnosis.
- Follow additional worksheets, as appropriate.
E. Diagnosis:
Provide a summary list of all disabilities diagnosed.
Include an interpretation of the results of all diagnostic and other tests
conducted in the final summary and diagnosis. For each condition diagnosed,
describe its effect on the veteran's usual occupation and daily
activities.
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Reviewed/Updated Date: December 15, 2008 |
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