The CE provider will describe and discuss, as appropriate:
a. Signs of affected body systems, such as heart, lungs, kidneys, eyes, digestive
system, skin, etc.;
b. Any apparent abnormalities such as gait or the need for any type of assistive device;
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1. If the claimant uses an assistive device(s), note the type of, and medical need
for, the device.
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2. For lower extremity assistive devices, describe the claimant’s gait with and without
use of the device.
b. Ability to:
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1. Tandem walk;
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2. Walk on heels and toes;
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3. Bend;
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4. Squat;
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5. Get up from a seated position;
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6. Grasp or shake hands;
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7. Write; and
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8. Turn door handles.
c. Extremities and peripheral joints:
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1. If active range of motion is abnormal, describe passive range of motion and how
active range of motion differs from passive range of motion;
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2. Effusion;
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3. Periarticular swelling;
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4. Tenderness;
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5. Redness;
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6. Heat;
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7. Thickening;
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8. Structural deformities;
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9. Instability;
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10. Grip, pinch, and ability to fully close the fist (either by dynamometer or 0-5
scale);
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11. Extremity strength (either by dynamometer or 0-5 scale);
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12. Atrophy; and
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13. Ability to use, and effective use of, any orthoses.
d. Spine:
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1. Distribution of pain, tenderness, sensory or motor loss; and
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2. Active range of spinal motion;
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