Va Form 21-0960c-5 - Central Nervous System And Neuromuscular Diseases Disability Benefits Questionnaire Page 5

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SECTION III - CONDITIONS, SIGNS, AND SYMPTOMS (Continued)
(if male)
3K. DOES THE VETERAN
HAVE ERECTILE DYSFUNCTION?
YES
NO
IF YES, IS THE ERECTILE DYSFUNCTION AS LIKELY AS NOT (AT LEAST 50% PROBABILITY) ATTRIBUTABLE TO A CNS DISEASE (INCLUDING TREATMENT OR
RESIDUALS OF TREATMENT?
YES
NO
IF NO, PROVIDE THE ETIOLOGY OF THE ERECTILE DYSFUNCTION:
IF YES, IS THE VETERAN ABLE TO ACHIEVE AN ERECTION (WITHOUT MEDICATION) SUFFICIENT FOR PENETRATION AND EJACULATION?
YES
NO
IF NO, IS THE VETERAN ABLE TO ACHIEVE AN ERECTION (WITH MEDICATION) SUFFICIENT FOR PENETRATION AND EJACULATION?
YES
NO
SECTION IV - NEUROLOGIC EXAM
4A. SPEECH
NORMAL
ABNORMAL
If speech is abnormal, describe:
4B. GAIT
NORMAL
ABNORMAL, DESCRIBE:
If gait is abnormal and the veteran has more than one medical condition contributing to the abnormal gait, identify the conditions and describe each condition's contribution to
the abnormal gait:
4C. STRENGTH - Rate strength according to the following scale:
0/5 No muscle movement
1/5 Visible muscle movement, but no joint movement
2/5 No movement against gravity
3/5 No movement against resistance
4/5 Less than normal strength
5/5 Normal strength
ALL NORMAL
Elbow 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
Elbow extension:
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 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:
5/5
4/5
3/5
2/5
1/5
0/5
Grip:
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
Pinch (thumb to
RIGHT:
5/5
4/5
3/5
2/5
1/5
0/5
index finger):
LEFT:
5/5
4/5
3/5
2/5
1/5
0/5
RIGHT:
5/5
4/5
3/5
2/5
1/5
0/5
Knee extension:
LEFT:
5/5
4/5
3/5
2/5
1/5
0/5
RIGHT:
5/5
4/5
3/5
2/5
1/5
0/5
Ankle plantar flexion:
LEFT:
5/5
4/5
3/5
2/5
1/5
0/5
RIGHT:
5/5
4/5
3/5
2/5
1/5
0/5
Ankle dorsiflexion:
LEFT:
5/5
4/5
3/5
2/5
1/5
0/5
Page 5
VA FORM 21-0960C-5, OCT 2012

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