Form 21-0960m-16 - Wrist Conditions Disability Benefits Questionnaire

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OMB Approved No. 2900-0805
Respondent Burden: 30 minutes
Expiration Date: 04-30-2017
WRIST CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE
IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE
PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION ON
REVERSE BEFORE COMPLETING FORM.
NAME OF PATIENT/VETERAN
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
NOTE TO PHYSICIAN - The veteran or service member is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the
information you provide on this questionnaire as part of their evaluation in processing the claim. VA reserves the right to confirm the authenticity of ALL DBQs
completed by private health care providers.
MEDICAL RECORD REVIEW
WAS THE VETERAN'S VA CLAIMS FILE REVIEWED?
YES
NO
IF YES, LIST ANY RECORDS THAT WERE REVIEWED BUT WERE NOT INCLUDED IN THE VETERAN'S VA CLAIMS FILE:
IF NO, CHECK ALL RECORDS REVIEWED:
Military service treatment records
Department of Defense Form 214 Separation Documents
(VA treatment records)
Veterans Health Administration medical records
Military service personnel records
Military enlistment examination
Civilian medical records
(family and others who have known the veteran before and after military service)
Military separation examination
Interviews with collateral witnesses
Military post-deployment questionnaire
Other:
No records were reviewed
SECTION I - DIAGNOSIS
NOTE: These are condition(s) for which an evaluation has been requested on an exam request form (Internal VA) or for which the Veteran has requested medical
evidence be provided for submission to VA.
1A. LIST THE CLAIMED CONDITION(S) THAT PERTAIN TO THIS DBQ:
NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed above. If there is no diagnosis, if the diagnosis is different
from a previous diagnosis for this condition, or if there is a diagnosis of a complication due to the claimed condition, explain your findings and reasons in comments
section. Date of diagnosis can be the date of the evaluation if the clinician is making the initial diagnosis, or an approximate date determined through record review or
reported history.
(Check all that apply)
1B. SELECT DIAGNOSES ASSOCIATED WITH THE CLAIMED CONDITION(S)
:
(Explain your findings and reasons in comments section.)
The Veteran does not have a current diagnosis associated with any claimed condition listed above.
Wrist Sprain, Chronic
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Tendinitis, wrist
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Ganglion cyst
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
(CMC)
Carpal metacarpal
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
arthritis
Osteoarthritis arthritis, wrist
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
deQuervain's syndrome
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Triangular fibrocartilaginous
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
(TFCC)
complex
injury
(intercalated
Carpal instability
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
segment/midcarpal/
scapholunate dissociation)
Avascular necrosis of carpal
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
bones
(total/ulnar
Wrist arthroplasty
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
head replacement)
Ankylosis of wrist
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
(specify)
Other
Other diagnosis #1:
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Other diagnosis #2:
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Other diagnosis #3:
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
21-0960M-16
VA FORM
SUPERSEDES VA FORM 21-0960M-16, OCT 2012,
Page 1
MAY 2013
WHICH WILL NOT BE USED.

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