Va Form 21-0960m-9 - Knee And Lower Leg Conditions Disability Benefits Questionnaire Page 5

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SECTION XIII - JOINT REPLACEMENT AND OTHER SURGICAL PROCEDURES

(Continued)

13A. HAS THE VETERAN HAD A TOTAL KNEE JOINT REPLACEMENT?

Left knee

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:

13B. HAS THE VETERAN HAD ARTHROSCOPIC OR OTHER KNEE SURGERY NOT DESCRIBED ABOVE?

(If "Yes," indicate side affected)

YES

Right

Left

Both

Date and type of surgery:

13C. DOES THE VETERAN HAVE ANY RESIDUAL SIGNS AND/OR SYMPTOMS DUE TO ARTHROSCOPIC OR OTHER KNEE SURGERY NOT DESCRIBED ABOVE?

(If "Yes," indicate side affected):

YES

Right

Left

Both

(If "Yes," describe symptoms):

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

(surgical or otherwise)

14A. DOES THE VETERAN HAVE ANY SCARS

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

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 cm (6 square inches)?)

YES

(If "Yes," also complete VA Form 21-0960F-1, Scars/Disfigurement Questionnaire)

14B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY

CONDITIONS LISTED IN SECTION I, DIAGNOSIS?

If "Yes," describe (brief summary):

YES

SECTION XV - ASSISTIVE DEVICES

15A. DOES THE VETERAN USE ANY ASSISTIVE DEVICE(S) AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER

METHODS MAY BE POSSIBLE?

YES

(If "Yes," identify assistive device(s) used (check all that apply and indicate frequency):

Wheelchair