Va Form 21-0960m-2 - Ankle Conditions Disability Benefits Questionnaire
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6OMB Approved No. 2900-0776
Respondent Burden: 30 minutes
ANKLE CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE
IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE
PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION
BEFORE COMPLETING FORM.
NAME OF PATIENT/VETERAN
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
NOTE TO PHYSICIAN - Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you
provide on this questionnaire as part of their evaluation in processing the veteran's claim.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER HAD AN ANKLE CONDITION?
(If "Yes," complete Item 1B)
YES
NO
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO ANKLE CONDITION(S):
SIDE AFFECTED
DIAGNOSIS # 1 -
ICD CODE -
DATE OF DIAGNOSIS -
RIGHT
LEFT
BOTH
SIDE AFFECTED
DIAGNOSIS # 2 -
ICD CODE -
DATE OF DIAGNOSIS -
RIGHT
LEFT
BOTH
SIDE AFFECTED
DIAGNOSIS # 3 -
ICD CODE -
DATE OF DIAGNOSIS -
RIGHT
LEFT
BOTH
1C. IF THERE ARE ADDITIONAL DIAGNOSES PERTAINING TO ANKLE CONDITIONS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
(brief summary):
2. DESCRIBE THE HISTORY
OF THE VETERAN'S ANKLE CONDITION
SECTION III - FLARE-UPS
3. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE ANKLE?
YES
NO
IF YES, DOCUMENT THE VETERAN'S DESCRIPTION OF THE IMPACT OF FLARE-UPS IN HIS OR HER OWN WORDS:
SECTION IV - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS
MEASURE ROM WITH A GONIOMETER, ROUNDING EACH MEASUREMENT TO THE NEAREST 5 DEGREES. DURING THE MEASUREMENTS, DOCUMENT THE
POINT AT WHICH PAINFUL MOTION BEGINS, EVIDENCED BY VISIBLE BEHAVIOR SUCH AS FACIAL EXPRESSION, WINCING, ETC. REPORT INITIAL
MEASUREMENTS BELOW.
FOLLOWING THE INITIAL ASSESSMENT OF ROM, PERFORM REPETITIVE USE TESTING. FOR VA PURPOSES, REPETITIVE USE TESTING MUST BE INCLUDED IN
(at a minimum)
ALL JOINT EXAMS. THE VA HAS DETERMINED THAT 3 REPETITIONS OF ROM
CAN SERVE AS A REPRESENTATIVE TEST OF THE EFFECT
OF REPETITIVE USE. AFTER THE INITIAL MEASUREMENT, REASSESS ROM AFTER 3 REPETITIONS. REPORT POST-TEST MEASUREMENTS IN SECTION 5.
4A. RIGHT ANKLE PLANTAR FLEXION
(normal endpoint is 45 degrees):
SELECT WHERE PLANTAR FLEXION ENDS
0
5
10
15
20
25
30
35
40
45 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 or greater
(extension)
4B. RIGHT ANKLE DORSIFLEXION
(extension)
(normal endpoint is 20 degrees):
SELECT WHERE DORSIFLEXION
ENDS
0
5
10
15
20 or greater
SELECT WHERE OBJECTIVE EVIDENCE OF PAINFUL MOTION BEGINS:
NO OBJECTIVE EVIDENCE OF PAINFUL MOTION
0
5
10
15
20 or greater
21-0960M-2
SUPERSEDES VA FORM 21-0960M-2, JAN 2011,
VA FORM
Page 1
WHICH WILL NOT BE USED.
OCT 2012
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