Peripheral Nerves

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

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Comment on:

1. Onset and course - 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. Paresthesias, dysesthesias, other sensory abnormalities.
4. Describe extent to which condition interferes with daily activity.
5. Specify nerves involved.

C. Physical Examination (Objective Findings):

Address each of the following and fully describe current findings:

1. If the disability is the result of brain disease or injury, spinal cord disease or injury, cervical disc disease, or trauma to the nerve roots themselves:

1. Report sensory and motor impairment by reference to the distribution of the affected groups as paralysis, neuritis or neuralgia.
2. Report each affected extremity separately.

2. If disability is NOT from the above:

1. Identify the specific major nerve involved, localize the lesion and describe specific impairment of motor and sensory function, fine motor control, etc.
2. Characterize as paralysis, neuritis or neuralgia, and indicate whether any muscle wasting or atrophy represents direct effect of nerve damage or merely disuse.
3. Report each affected extremity separately.

3. For each joint that is affected:

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.

D. Diagnostic and Clinical Tests:

1. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

1. State etiology.