Va Form 21-0960m-16 - Wrist Conditions Disability Benefits Questionnaire Page 2
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SECTION IV - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS
C. LEFT WRIST PALMAR FLEXION:
(endpoint of palmar flexion 80 degrees):
Select where palmar flexion ends
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80 or greater
Select where objective evidence of painful motion begins:
No objective evidence of painful motion
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70 or greater
(extension)
D. LEFT WRIST DORSIFLEXION
(extension)
(endpoint of dorsiflexion (extension) 70 degrees):
Select where dorsiflexion
ends
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80 or greater
Select where objective evidence of painful motion begins:
No objective evidence of painful motion
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70 or greater
(for reasons other than a wrist
E. 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 V - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING
5A. IS VETERAN ABLE TO PERFORM REPETITIVE-USE TESTING WITH 3 REPETITIONS?
YES
NO
IF UNABLE, PROVIDE REASON:
IF VETERAN IS UNABLE TO PERFORM REPETITIVE-USE TESTING, SKIP TO SECTION VI.
IF VETERAN IS ABLE TO PERFORM REPETITIVE-USE TESTING, MEASURE AND REPORT ROM AFTER A MINIMUM OF 3 REPETITIONS.
5B. RIGHT WRIST POST-TEST ROM
Select where palmar flexion ends:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80 or greater
Select where dorsiflexion (extension) ends:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70 or greater
5C. LEFT WRIST POST-TEST ROM
Select where palmar flexion ends:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80 or greater
Select where dorsiflexion (extension) ends:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70 or greater
SECTION VI - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION IN ROM
THE FOLLOWING SECTION ADDRESSES REASONS FOR FUNCTIONAL LOSS, IF PRESENT, AND ADDITIONAL LOSS OF ROM AFTER REPETITIVE-USE TESTING ,
IF PRESENT. THE VA DEFINES FUNCTIONAL LOSS AS THE INABILITY TO PERFORM NORMAL WORKING MOVEMENTS OF THE BODY WITH NORMAL
EXCURSION, STRENGTH, SPEED, COORDINATION AND/OR ENDURANCE.
6A. DOES THE VETERAN HAVE ADDITIONAL LIMITATION IN ROM OF THE WRIST FOLLOWING REPETITIVE-USE TESTING?
YES
NO
6B. DOES THE VETERAN HAVE ANY FUNCTIONAL LOSS AND/OR FUNCTIONAL IMPAIRMENT OF THE WRIST?
YES
NO
Page 2
VA FORM 21-0960M-16, OCT 2012
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