Va Form 21-0960m-16 - Wrist Conditions Disability Benefits Questionnaire Page 3
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SECTION VI - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION IN ROM
6C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT AND/OR ADDITIONAL LIMITATION OF ROM OF THE WRIST AFTER REPETITIVE USE,
(Check all that apply and indicate side affected):
INDICATE THE CONTRIBUTING FACTORS OF DISABILITY BELOW
NO FUNCTIONAL LOSS FOR RIGHT UPPER EXTREMITY
NO FUNCTIONAL LOSS FOR LEFT UPPER EXTREMITY
LESS MOVEMENT THAN NORMAL
Right
Left
Both
MORE MOVEMENT THAN NORMAL
Right
Left
Both
WEAKENED MOVEMENT
Right
Left
Both
EXCESS FATIGABILITY
Right
Left
Both
INCOORDINATION (IMPAIRED ABILITY
Right
Left
Both
TO EXECUTE SKILLED MOVEMENTS
SMOOTHLY)
PAIN ON MOVEMENT
Right
Left
Both
SWELLING
Right
Left
Both
DEFORMITY
Right
Left
Both
ATROPHY OF DISUSE
Right
Left
Both
SECTION VII - PAIN (PAIN ON PALPATION)
7. DOES THE VETERAN HAVE LOCALIZED TENDERNESS OR PAIN ON PALPATION FOR JOINTS/SOFT TISSUE OF EITHER WRIST?
YES
NO
IF "YES," SIDE AFFECTED:
Right
Left
Both
SECTION VIII- MUSCLE STRENGTH TESTING
8. RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE:
0/5 No muscle movement
1/5 Palpable or visible muscle movement, 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
5/5
4/5
3/5
2/5
1/5
0/5
Wrist flexion:
Right:
5/5
4/5
3/5
2/5
1/5
0/5
Left:
5/5
4/5
3/5
2/5
1/5
0/5
Wrist extension:
Right:
5/5
4/5
3/5
2/5
1/5
0/5
Left:
SECTION IX- ANKYLOSIS
9. DOES THE VETERAN HAVE ANKYLOSIS OF EITHER WRIST JOINT?
YES
NO
IF "YES," INDICATE SEVERITY AND SIDE AFFECTED:
Right
Left
Both
Extremely unfavorable
Right
Left
Both
Unfavorable, with ulnar or radial deviation
Right
Left
Both
Unfavorable, in any degree of palmar flexion
Right
Left
Both
Any other position, except favorable
Right
Left
Both
Favorable in 20 degree to 30 degree dorsiflexion
SECTION X- JOINT REPLACEMENT AND/OR OTHER SURGICAL PROCEDURES
10A. HAS THE VETERAN HAD A TOTAL WRIST JOINT REPLACEMENT?
YES
NO
IF "YES," INDICATE SIDE AND SEVERITY OF RESIDUALS:
Right wrist
Date of surgery:
Residuals:
None
Intermediate degrees of residual weakness, pain and/or limitation of motion
Chronic residuals consisting of severe painful motion and/or weakness
Other, describe:
Page 3
VA FORM 21-0960M-16, OCT 2012
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