ELBOW DISABILITY Mini -DBQ
(Disability Benefits Questionnaire)
Please mark your diagnosed condition from the list below:
Olecranon Bursitis
Lateral Epicondylitis
Instability (medial/post lateral rotatory)
Osteoarthritis
Other, specify:
Triceps Tendinitis
Medial Epicondylitis
Dislocation
Total elbow arthroplasty
Ankylosis of elbow joint
Olecranon Bursitis | Triceps Tendinitis | ||
Lateral Epicondylitis | Medial Epicondylitis | ||
Instability (medial/post lateral rotatory) | Dislocation | ||
Osteoarthritis | Total elbow arthroplasty | ||
Other, specify: | Ankylosis of elbow joint |
Please answer the following questions related to your disease.
a) When and how did you first experience the symptoms of this disease?
b) In your own words, how does this condition affect your daily life and ability to work (walking, sitting, pain)?
c) Did the symptoms get worse over time? If so, what makes the symptoms worse? (e.g., lifting weights, working etc.)
d) Do you experience flare-ups (worsening of symptoms)? If so, how do these flare-ups affect you (e.g., weakness, fatigue, loss of movement)?
Are you right- handed or left-handed (dominant arm)?
Right-handed | Left-handed |
Which elbow is service-connected?
Right elbow | Left elbow | Both elbows |
ELBOW DISABILITY Mini -DBQ (Disability Benefits Questionnaire)
RANGE OF MOTION FOR THE ELBOW: FLEXION AND EXTENSION
RANGE OF MOTION: FLEXION;
Flex (bring your elbow closer to your arm) your elbow upwards (as shown below)
To which degree can you flex your elbows? (145 degrees is full range of motion)
Right
Left
FLARE-UPS:
Think about your elbow disability over the past year at its worst during a flare-up (Even if you only have severe episodes once a year or once every 6 months): REMEMBER this figure should be less than the one above
To which degree can you flex your elbows?
Right
Left
RANGE OF MOTION: EXTENSION;
Flex your elbow downwards (straighten out)
Which degree can you extend your elbows? (0 degrees is full range of motion)
Right
Left
FLARE-UPS:
Think about your elbow disability over the past year at its worst during a flare-up (Even if you only have severe episodes once a year or once every 6 months): REMEMBER this figure should be more than the one above
To which degree can you flex your elbows?
Right
Left
RANGE OF MOTION FOR THE ELBOW: PRONATION AND SUPINATION
RANGE OF MOTION: PRONATION
Perform the pronation as shown in picture with your palm facing downward
To which degree can you pronate your forearms (80degree is maximum):
Right
Left
FLARE-UPS:
Think about your elbow disability over the past year at its worst during a flare-up or when it starts HURTING. (Even if you only have severe episodes once a year or once every 6months): REMEMBER this figure should be less than the one above
To which degree can you To which degree can you pronate your right elbow?
Right
Left
RANGE OF MOTION: SUPINATION;
Perform the pronation as shown in picture with your palm facing upward
To which degree can you supinate your forearms (85degree is maximum):
Right
Left
FLARE-UPS:
Think about your elbow disability over the past year at its worst during a flare-up or when it starts HURTING. (Even if you only have severe episodes once a year or once every 6 months): REMEMBER this figure should be more than the one above
To which degree can you supinate your right elbow?
Right
Left
Check the contributing factors affecting the functionality of your elbow:
Less movement than normal
More movement than normal
Weakend movement
Pain on movement
Excess fatigability
Incoordination (Impaired ability to execute skilled movements smoothly)
Swelling
Deformity
Atrophy of disuse
Interferes with standing
Disturbance of locomotion
Interferes with sitting
Pain on weight bearing
Pain on non-weight bearing/rest/non-movement
Less movement than normal | More movement than normal | ||
Weakend movement | Pain on movement | ||
Excess fatigability | Incoordination (Impaired ability to execute skilled movements smoothly) | ||
Swelling | Deformity | ||
Atrophy of disuse | Interferes with standing | ||
Disturbance of locomotion | Interferes with sitting | ||
Pain on weight bearing | Pain on non-weight bearing/rest/non-movement |
Do you have ankylosis of the elbow joint? If so, indicate side affected and severity of ankylosis.
Indicate any surgical procedures that you may have performed along with date of surgery
Do you have any scars related to your elbow condition? If so, are the scars painful?
Do you use any assistive device to help in movement? (If yes, please specify)
Brace:
Frequency of use;
Occasional | Regular | Constant |
Other:
Frequency of use;
Occasional | Regular | Constant |
CERTIFICATION
To the best of my knowledge, the information contained herein is accurate, complete and current. I understand that over stating the severity of my conditions on official Disability Benefits Questionnaires (DBQs) could result in loss of benefits and/or be consider fraudulent. I am conveying the severity of my symptoms to the best of my ability on this personal assessment form. No one has advised me to misrepresent my conditions or overstate the severity of my symptoms.
Dated:
SIGNED:
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