Va Form 21-0960m-16 - Wrist Conditions Disability Benefits Questionnaire Page 4

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(Continued)

SECTION X- JOINT REPLACEMENT AND/OR OTHER SURGICAL PROCEDURES

(Continued)

10A. HAS THE VETERAN HAD A TOTAL WRIST JOINT REPLACEMENT?

Left 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:

10B. HAS THE VETERAN HAD ARTHROSCOPIC OR OTHER WRIST SURGERY?

YES

Right

Left

Both

IF YES, INDICATE SIDE AFFECTED:

(Date and type of surgery):

10C. DOES THE VETERAN HAVE ANY RESIDUAL SIGNS AND/OR SYMPTOMS DUE TO ARTHROSCOPIC OR OTHER WRIST SURGERY?

YES

Right

Left

Both

IF YES, INDICATE SIDE AFFECTED:

IF YES, DESCRIBE RESIDUALS:

SECTION XI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS

(surgical or otherwise)

11A. DOES THE VETERAN HAVE ANY SCARS

RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN

THE SECTION I, DIAGNOSIS?

YES

IF "YES," ARE ANY OF THE SCARS PAINFUL AND/OR UNSTABLE, OR IS THE TOTAL AREA OF ALL RELATED SCARS GREATER THAN OR EQUAL TO 39 SQUARE

(6 square inches)?

YES

IF "YES," ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT DISABILITY BENEFITS QUESTIONNAIRE.

11B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS RELATED TO ANY

CONDITIONS LISTED IN SECTION I, DIAGNOSIS?

YES

(brief summary):

IF "YES," DESCRIBE

SECTION XII - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES

12. DUE TO THE VETERAN'S WRIST CONDITIONS, IS THERE FUNCTIONAL IMPAIRMENT OF AN EXTREMITY SUCH THAT NO EFFECTIVE FUNCTION REMAINS

(Functions of the upper extremity include grasping,

OTHER THAN THAT WHICH WOULD BE EQUALLY WELL SERVED BY AN AMPUTATION WITH PROSTHESIS?

manipulation, etc.)

YES, FUNCTIONING IS SO DIMINISHED THAT AMPUTATION WITH PROSTHESIS WOULD EQUALLY SERVE THE VETERAN

(check all extremities for which this applies):

IF "YES," INDICATE EXTREMITY(IES)

Right upper

Left upper

FOR EACH CHECKED EXTREMITY, DESCRIBE LOSS OF EFFECTIVE FUNCTION, IDENTIFY THE CONDITION CAUSING LOSS OF FUNCTION AND PROVIDE

(brief summary):

SPECIFIC EXAMPLES

SECTION XIII- DIAGNOSTIC TESTING

NOTE: The diagnosis of degenerative arthritis (osteoarthritis) or traumatic arthritis must be confirmed by imaging studies. Once arthritis has been documented, no

further imaging studies are indicated, even if arthritis has worsened.

13A. HAVE IMAGING STUDIES OF THE WRIST BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?

YES

IF "YES," IS DEGENERATIVE OR TRAUMATIC ARTHRITIS DOCUMENTED?

YES

IF "YES," INDICATE WRIST:

Right

Left

Both

Page 4

VA FORM 21-0960M-16, OCT 2012