Va Form 21-0960m-1 - Amputations Disability Benefits Questionnaire Page 2
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SECTION V - AMPUTATION(S) OF THE UPPER EXTREMITY(IES) (NOT INCLUDING FINGERS)
5B. IS THERE AN AMPUTATION OF EITHER FOREARM?
(If "Yes," check all that apply)
YES
NO
LEFT
RIGHT
Amputation resulting in loss of use of the hand
Amputation resulting in loss of use of hand
Amputation below insertion of pronator teres
Amputation below insertion of pronator teres
Amputation above insertion of pronator teres
Amputation above insertion of pronator teres
Does the amputation site allow the use of a suitable
Does the amputation site allow the use of a suitable
prosthetic appliance?
prosthetic appliance?
YES
NO
YES
NO
SECTION VI - AMPUTATION(S) OF FINGER(S)
6A. IS THERE AN AMPUTATION OF EITHER THUMB?
(If "Yes," check all that apply)
YES
NO
LEFT
RIGHT
Amputation at the distal joint or through the distal phalanx
Amputation at the distal joint or through the distal phalanx
Amputation at the metacarpophalangeal joint or through
Amputation at the metacarpophalangeal joint or through
the proximal phalanx
the proximal phalanx
Amputation with metacarpal resection
Amputation with metacarpal resection
6B. IS THERE AN AMPUTATION OF EITHER INDEX FINGER?
(If "Yes," check all that apply)
YES
NO
LEFT
RIGHT
Amputation through the long phalanx or at the distal joint
Amputation through the long phalanx or at the distal joint
Amputation without metacarpal resection, at the proximal
Amputation without metacarpal resection, at the proximal
interphalangeal joint or proximal thereto
interphalangeal joint or proximal thereto
Amputation with metacarpal resection (more than one-half
Amputation with metacarpal resection (more than one-half
the bone lost)
the bone lost)
6C. IS THERE AN AMPUTATION OF EITHER LONG FINGER?
(If "Yes," check all that apply)
YES
NO
LEFT
RIGHT
Amputation without metacarpal resection, at the proximal
Amputation without metacarpal resection, at the proximal
interphalangeal joint or proximal thereto
interphalangeal joint or proximal thereto
Amputation with metacarpal resection (more than one-half
Amputation with metacarpal resection (more than one-half
the bone lost)
the bone lost)
6D. IS THERE AN AMPUTATION OF EITHER RING FINGER?
(If "Yes," check all that apply)
YES
NO
LEFT
RIGHT
Amputation without metacarpal resection, at the proximal
Amputation without metacarpal resection, at the proximal
interphalangeal joint or proximal thereto
interphalangeal joint or proximal thereto
Amputation with metacarpal resection (more than one-half
Amputation with metacarpal resection (more than one-half
the bone lost)
the bone lost)
6E. IS THERE AN AMPUTATION OF EITHER LITTLE FINGER?
(If "Yes," check all that apply)
YES
NO
LEFT
RIGHT
Amputation without metacarpal resection, at the proximal
Amputation without metacarpal resection, at the proximal
interphalangeal joint or proximal thereto
interphalangeal joint or proximal thereto
Amputation with metacarpal resection (more than one-half
Amputation with metacarpal resection (more than one-half
the bone lost)
the bone lost)
SECTION VII - AMPUTATION(S) OF THE LOWER EXTREMITY(IES) (NOT INCLUDING THE TOES)
7A. IS THERE AN AMPUTATION ABOVE EITHER KNEE?
(If "Yes," check all that apply)
YES
NO
LEFT
RIGHT
Amputation of the middle or lower third
Amputation of the middle or lower third
Amputation of the upper third, one-third of the distance from
Amputation of the upper third, one-third of the distance from
the perineum to the knee joint, measured from the perineum
the perineum to the knee joint, measured from the perineum
Disarticulation with loss of extrinsic pelvic girdle muscles
Disarticulation with loss of extrinsic pelvic girdle muscles
Does the amputation site allow the use of a suitable prosthetic appliance?
Does the amputation site allow the use of a suitable prosthetic appliance?
YES
NO
YES
NO
Page 2
VA FORM 21-0960M-1, OCT 2012
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