Va Form 21-0960c-10 - Peripheral Nerves Conditions (Not Including Diabetic Sensory- Motor Peripheral Neuropathy) Disability Benefits Questionnaire Page 4

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SECTION X - NERVES AFFECTED: Severity Evaluation for Upper Extremity Nerves and Radicular Groups (Continued)
NOTE: INDICATE THE AFFECTED NERVES, SIDE AFFECTED AND SEVERITY OF CONDITION.
(musculospiral nerve)
10A. Radial nerve
(hand and fingers drop, wrist and fingers flexed; cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb or
Note: Complete paralysis
make lateral movement of wrist; supination of hand, elbow extension and flexion weak, hand grip impaired)
Normal
Incomplete paralysis
Complete paralysis
Right:
If Incomplete paralysis is checked, indicate severity:
Mild
Moderate
Severe
Left:
Normal
Incomplete paralysis
Complete paralysis
If Incomplete paralysis is checked, indicate severity:
Mild
Moderate
Severe
10B. Median nerve
(hand inclined to the ulnar side, index and middle fingers extended, atrophy of thenar eminence, cannot make fist, defective opposition
Note: Complete paralysis
of thumb, cannot flex distal phalanx of thumb; wrist flexion weak)
Normal
Incomplete paralysis
Complete paralysis
Right:
If Incomplete paralysis is checked, indicate severity:
Mild
Moderate
Severe
Left:
Normal
Incomplete paralysis
Complete paralysis
If Incomplete paralysis is checked, indicate severity:
Mild
Moderate
Severe
10C. Ulnar nerve
("griffin claw" deformity, atrophy in dorsal interspaces, thenar and hypothenar eminences; cannot extend ring and little finger, cannot
Note: Complete paralysis
spread fingers, cannot adduct the thumb; wrist flexion weakened)
Normal
Incomplete paralysis
Complete paralysis
Right:
If Incomplete paralysis is checked, indicate severity:
Mild
Moderate
Severe
Left:
Normal
Incomplete paralysis
Complete paralysis
If Incomplete paralysis is checked, indicate severity:
Mild
Moderate
Severe
10D. Musculocutaneous nerve
(weakened flexion of elbow and supination of forearm)
Note: Complete paralysis
Normal
Incomplete paralysis
Complete paralysis
Right:
If Incomplete paralysis is checked, indicate severity:
Mild
Moderate
Severe
Left:
Normal
Incomplete paralysis
Complete paralysis
If Incomplete paralysis is checked, indicate severity:
Mild
Moderate
Severe
10E. Circumflex nerve
(innervates deltoid and teres minor; cannot abduct arm, outward rotation is weakened)
Note: Complete paralysis
Complete paralysis
Right:
Normal
Incomplete paralysis
If Incomplete paralysis is checked, indicate severity:
Mild
Moderate
Severe
Left:
Normal
Incomplete paralysis
Complete paralysis
If Incomplete paralysis is checked, indicate severity:
Mild
Moderate
Severe
10F. Long thoracic nerve
(inability to raise arm above shoulder level, winged scapula deformity)
Note: Complete paralysis
Normal
Incomplete paralysis
Complete paralysis
Right:
If Incomplete paralysis is checked, indicate severity:
Mild
Moderate
Severe
Left:
Normal
Incomplete paralysis
Complete paralysis
If Incomplete paralysis is checked, indicate severity:
Mild
Moderate
Severe
VA FORM 21-0960C-10, OCT 2012
Page 4

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