Shin Splints - Prolonged weight bearing exercise greater ...



???????Claimant Report – Prolonged weight bearing exercisegreater than 6 METSShin SplintsThis form is in connection with your claim for pension and medical treatment and the information you supply will assist in deciding eligibility for benefits under the Veterans' Entitlements Act 1986 and/or Military Rehabilitation and Compensation Act 2004. In the event of an appeal against a decision, this information may be provided to the Veterans' Review Board, Administrative Appeals Tribunal or Federal Court.Veteran's DetailsSurnameGiven NamesDVA File NumberReport Detail1.When were the symptoms of (_________________________) first noticed? (Please be as specific as possible)2.Is there a history of undertaking weight bearing exercise involving the affected leg(s) at a rate greater than 6 METs for at least 1 hour per day on more days than not (eg 4 days a week) for at least the three months before the development of the first symptoms of (_____________________________)?A “MET” is a unit of measurement of the level of physical exertion.In general this level of activity would require a large increase in breathing or heart rate (conversation is difficult or “broken”). Some examples of vigorous physical activity of greater than 6 METS are: jogging (8km/hr), participating in high-impact aerobic dancing, carrying more than 10 kg up a flight of stairs, standing or walking with more than 30 kg.?No ?Yes – Please give details overleaf of all periods IN THE THREE MONTHS BEFORE the development of first symptoms of shin splints, where weight bearing exercise to this extent occurred.Periods of weight bearing exercise as defined above in the 3 months before the first symptoms of shin splints:2.Is there a history of undertaking weight bearing exercise involving the affected leg(s) at a rate greater than 6 METs for at least 1 hour per day on more days than not (eg 4 days a week) for at least the six months before the development of the first symptoms of (____________________________________)?A “MET” is a unit of measurement of the level of physical exertion.In general this level of activity would require a large increase in breathing or heart rate (conversation is difficult or “broken”). Some examples of vigorous physical activity of greater than 6 METS are: jogging (8km/hr), participating in high-impact aerobic dancing, carrying more than 10 kg up a flight of stairs, standing or walking with more than 30 kg.?No ?Yes – Please give details overleaf of all periods IN THE 6 MONTHS BEFORE the development of first symptoms of shin splints, where weight bearing exercise to this extent occurred.Periods of weight bearing exercise as defined above in the 6 months before the first symptoms of shin splints:***Claims assessor - please use the first version of this question if the veteran has only operational service. If there is only eligible service, or operational service as well as eligible service, delete the first version and use the second version of the question.***PeriodNumber of days per week Description of activityFromTo/ // // // // // // // /3.Did (insert claimed condition) permanently worsen? (Please be as specific as possible)?No - Please sign the form and return it to the Department?Yes – Please provide details, including date of worsening / /4.Is there a history of undertaking weight bearing exercise involving the affected leg(s) at a rate greater than 6 METs for at least 1 hour per day on more days than not (eg 4 days a week) for at least the three months immediately before the permanent worsening of (insert claimed condition)??No - Please sign the form and return it to the Department?Yes – Please give details overleaf of all periods IN THE THREE MONTHS BEFORE the worsening of shin splints, where weight bearing exercise to this extent occurred.Periods of weight bearing exercise as defined above in the 3 months before the worsening of shin splints:4.Is there a history of undertaking weight bearing exercise involving the affected leg(s) at a rate greater than 6 METs for at least 1 hour per day on more days than not (eg 4 days a week) for at least the six months immediately before the permanent worsening of (insert claimed condition)??No - Please sign the form and return it to the Department?Yes – Please give details overleaf of all periods IN THE 6 MONTHS BEFORE the worsening of shin splints, where weight bearing exercise to this extent occurred.Periods of weight bearing exercise as defined above in the 6 months before the worsening of shin splints:***Claims assessor - please use the first version of this question if the veteran has only operational service. If there is only eligible service, or operational service as well as eligible service, delete the first version and use the second version of the question.***PeriodNumber of days per week Description of activityFromTo/ // // // // // // // /Claimant's SignatureYou are reminded that:The Declaration you signed on the claim form also covers the information you supply on this form.There are penalties for knowingly making false or misleading statements.// ................
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