Muscles

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

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. If there are periods of flare-up of residuals of muscle injury:

1. State their severity, frequency, and duration.
2. Name the precipitating and alleviating factors.
3. Estimate to what extent, if any, they result in additional limitation of motion or functional impairment during the flare-up.

2. If injury is due to a missile: initial treatment in the field, length of initial hospitalization and any surgeries or other repairs undertaken, time for return to duty or limited duty or determination that duty could not be resumed.
3. Record exact muscles injured or destroyed and describe.
4. Record any associated injuries, particularly those affecting bony structures, nerves or vascular structures and specify the nature of treatment required.
5. Describe present symptoms of muscle pain, activity limited by fatigue or inability to move joint through a portion of its range; and the degree to which this interferes with activities of daily living.
6. For tumors of muscle, describe onset of symptoms, date(s) of biopsy and/or surgical excision and residual defects. If malignant neoplasm, need date of diagnosis, dates and type of treatment, and date of last treatment.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. Entry and exit wound scars as well as dimensions.
2. Tissue loss comparison, and specify muscle group(s) penetrated.
3. Scar formation measurement (sensitivity, tenderness, etc.)
4. Adhesions.
5. Tendon damage.
6. Bone, joint or nerve damage.
7. Muscle strength.
8. Muscle herniation and, if any, if supported by a truss or belt.
9. Loss of muscle function. Can muscle group move joint through normal range with sufficient comfort, endurance and strength to accomplish activities of daily living? Can muscle group move joint independently through useful ranges of motion but with limitation by pain or easy fatigability or weakness? Can muscle group move joint only with assistance or with gravity eliminated? Is there no ability of muscle group to move joint even with gravity eliminated and joint passively moveable? Is any muscle contraction felt?
10. If joint function is affected:

1. Using a goniometer, measure the passive and active range of motion, including movement against gravity and against strong resistance.
2. State to what extent (if any) and in which degrees (if possible) the range of motion or function is additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive use or during flare-ups. If more than one of these is present, state, if possible, which has the major functional impact.

D. Diagnostic and Clinical Tests:

1. If applicable, x-rays of joint(s) involved in two planes or anatomic area involved if not recorded in past (once taken, the x-rays do not need to be repeated).
2. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:

Date: