When a Veteran claims peripheral neuropathy from diabetes, this 9-page questionnaire documents each affected nerve separately. The clinician records pain, paresthesias and numbness by limb, a full neurologic exam, then grades the radial, median, ulnar, sciatic and femoral nerves on each side from normal to complete paralysis, plus assistive devices and any loss of effective limb function.
The Veteran's treating or examining clinician completes all sections and signs the Section 12 examiner's certification, including NPI and license number. The Veteran completes no part of the form.
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Diabetic Peripheral Neuropathy Disability Benefits Questionnaire
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No. The form says EMG studies are rarely required, because diabetic peripheral neuropathy can be diagnosed in the right clinical setting from characteristic pain or sensory changes in a stocking-glove pattern and objective exam findings. If EMG has been done, item 9A records the limbs tested, results and dates.
In the upper extremities the radial, median and ulnar nerves; in the lower extremities the sciatic and femoral nerves. Each side is marked normal, incomplete paralysis or complete paralysis, and incomplete paralysis is graded by severity, with the sciatic nerve also allowing moderately severe and severe with marked muscular atrophy.