Form 21-0960m-16 - Wrist Conditions Disability Benefits Questionnaire Page 3
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8(ROM)
(Continued)
SECTION III - INITIAL RANGE OF MOTION
MEASUREMENTS
(Continued)
3A. INITIAL ROM MEASUREMENTS
If ROM testing is not indicated for the veteran's condition or not able to be performed,
Wrist
Joint Movement
ROM Measurement
please explain why, and then proceed to Section 5:
Palmar Flexion
Not indicated
(normal endpoint
= 80 degrees)
Not able to perform
Dorsiflexion
LEFT
(normal endpoint
Not indicated
WRIST
= 70 degrees)
Not able to perform
All Normal
Ulnar Deviation
Not indicated
(normal endpoint
= 45 degrees)
Not able to perform
Radial Deviation
Not indicated
(normal endpoint
= 20 degrees)
Not able to perform
3B. DO ANY ABNORMAL ROMs NOTED ABOVE CONTRIBUTE TO FUNCTIONAL LOSS?
(you will be asked to further describe these limitations in Section 6 below)
YES
NO, EXPLAIN WHY THE ABNORMAL ROMs DO NOT CONTRIBUTE:
(for reasons other than a wrist
3C. IF ROM DOES NOT CONFORM TO THE NORMAL RANGE OF MOTION IDENTIFIED ABOVE BUT IS NORMAL FOR THIS VETERAN
condition, such as age, body habitus, neurologic disease),
EXPLAIN:
SECTION IV - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING
4A. POST-TEST ROM MEASUREMENTS
Is there additional limitation in ROM
Post-test ROM
Wrist
Is the veteran able to perform repetitive-use testing?
Joint Movement
after repetitive-use testing?
Measurement
Yes
Yes
Palmar Flexion
No, there is no change in ROM
No
after repetitive testing
If yes, perform repetitive-use testing
Dorsiflexion
RIGHT
If yes, report ROM after a minimum
If no, provide reason below, then proceed to Section 5
WRIST
of 3 repetitions.
Ulnar Deviation
If no, documentation of ROM after
repetitive-use testing is not required.
Radial Deviation
Yes
Yes
Palmar Flexion
No, there is no change in ROM
No
after repetitive testing
If yes, perform repetitive-use testing
Dorsiflexion
LEFT
If yes, report ROM after a minimum
If no, provide reason below, then proceed to Section 5
WRIST
of 3 repetitions.
Ulnar Deviation
If no, documentation of ROM after
repetitive-use testing is not required.
Radial Deviation
4B. DO ANY POST-TEST ADDITIONAL LIMITATIONS OF ROMs NOTED ABOVE CONTRIBUTE TO FUNCTIONAL LOSS?
(you will be asked to further describe these limitations in Section 6 below)
YES
NO, EXPLAIN WHY THE POST-TEST ADDITIONAL LIMITATIONS OF ROMs DO NOT CONTRIBUTE:
VA FORM 21-0960M-16, MAY 2013
Page 3
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