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Click ‘Get Form’ to open it in the editor.
Begin by entering the veteran's name and Social Security number at the top of the form. This information is crucial for identification purposes.
In Section I, diagnose any thoracolumbar spine conditions. If applicable, provide detailed diagnoses along with ICD codes and dates of diagnosis.
Proceed to Section II to summarize the medical history related to the thoracolumbar spine condition, including any flare-ups that impact functionality.
For Section III, measure and record initial range of motion (ROM) using a goniometer. Ensure you document each measurement accurately.
Continue through Sections IV to XII, filling out details regarding functional loss, pain assessment, radiculopathy history, and any diagnostic testing results as required.
Finally, ensure that a physician certifies and signs the form in Section XIV before submission.

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