Form 21-0960m-16 - Wrist Conditions Disability Benefits Questionnaire Page 5
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8(Continued)
SECTION VI - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION OF ROM
6B. ARE ANY OF THE ABOVE FACTORS ASSOCIATED WITH LIMITATION OF MOTION?
(If yes, complete questions 6C and 6D)
YES
(If no, proceed to question 6D)
NO
6C. CONTRIBUTING FACTORS OF DISABILITY ASSOCIATED WITH LIMITATION OF MOTION
Can pain, weakness, fatigability, or
If there is a functional loss due to pain, during flare-ups and/or
If yes, please estimate ROM due to pain and/or
incoordination significantly limit functional
when the joint is used repeatedly over a period of time but the
Wrist
functional loss during flare-ups or when the
ability during flare-ups or when the joint is
limitation of ROM cannot be estimated, please describe
joint is used repeatedly over a period of time:
used repeatedly over a period of time?
the functional loss:
Palmar
Est. ROM is
Flexion
not feasible
Est. ROM is
Yes
No
Dorsiflexion
not feasible
RIGHT
WRIST
Ulnar
Est. ROM is
Deviation
not feasible
Radial
Est. ROM is
Deviation
not feasible
Palmar
Est. ROM is
Flexion
not feasible
Est. ROM is
Yes
No
Dorsiflexion
not feasible
LEFT
WRIST
Ulnar
Est. ROM is
Deviation
not feasible
Radial
Est. ROM is
Deviation
not feasible
6D. CONTRIBUTING FACTORS OF DISABILITY NOT ASSOCIATED WITH LIMITATION OF MOTION
(not associated with limitation of motion)
IS THERE ANY FUNCTIONAL LOSS
DURING FLARE-UPS OR WHEN THE JOINT IS USED REPEATEDLY OVER A
PERIOD OF TIME OR OTHERWISE?
RIGHT WRIST:
Yes
No
If yes, describe:
LEFT WRIST:
Yes
No
If yes, describe:
SECTION VII - MUSCLE STRENGTH TESTING
7A. MUSCLE STRENGTH - RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE:
0/5 No muscle movement
1/5 Palpable or visible muscle contraction, but no joint movement
2/5 Active movement with gravity eliminated
3/5 Active movement against gravity
4/5 Active movement against some resistance
5/5 Normal strength
Flexion
Rate
Is there a reduction in
If yes, is the reduction entirely due to the
If no (the reduction is not entirely due to the
Wrist
/Extension
Strength
muscle strength?
claimed condition in the Diagnosis section?
claimed condition), provide rationale:
RIGHT
Flexion
/5
WRIST
Yes
No
Yes
No
All Normal
Extension
/5
LEFT
Flexion
/5
WRIST
Yes
No
Yes
No
All Normal
/5
Extension
7B. DOES THE VETERAN HAVE MUSCLE ATROPHY?
YES
NO
IF YES, IS THE MUSCLE ATROPHY DUE TO THE CLAIMED CONDITION IN THE DIAGNOSIS SECTION?
YES
NO
IF NO, PROVIDE RATIONALE:
(Continued)
IF YES, CONTINUE ON PAGE 6, ITEM 7B
.
VA FORM 21-0960M-16, MAY 2013
Page 5
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