Brain and Spinal Cord

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

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.
4. A detailed assessment of each affected joint is required.

1. Using a goniometer, measure the passive and active range of motion, including movement against gravity and against strong resistance.
2. If the joint is painful on motion, state at what point in the range of motion pain begins and ends.
3. 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: