Va Form 21-0960m-1 - Amputations Disability Benefits Questionnaire Page 3
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SECTION VII - AMPUTATION(S) OF THE LOWER EXTREMITY(IES) (NOT INCLUDING THE TOES)
7B. IS THERE AN AMPUTATION BELOW EITHER KNEE (TO INCLUDE FOREFOOT)?
(If "Yes," check all that apply)
YES
NO
LEFT
RIGHT
Amputation of the forefoot, which is proximal to the metatarsal
Amputation of the forefoot, which is proximal to the metatarsal
bones (more than one-half of metatarsal loss)
bones (more than one-half of metatarsal loss)
Amputation at a lower level (between the forefoot and knee),
Amputation at a lower level (between the forefoot and knee),
permitting prosthesis
permitting prosthesis
Amputation not improvable by prosthesis controlled by natural
Amputation not improvable by prosthesis controlled by natural
knee action
knee action
Amputation with defective stump and amputation of the thigh
Amputation with defective stump and amputation of the thigh
recommended
recommended
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
SECTION VIII - AMPUTATION(S) OF THE TOE(S)
8. IS THERE AN AMPUTATION OF A TOE(S) OF EITHER FOOT?
(If "Yes," check all that apply)
YES
NO
LEFT
RIGHT
Is there amputation of all toes without metatarsal loss?
Is there amputation of all toes without metatarsal loss?
YES
NO
YES
NO
Is there amputation of the great toe?
Is there amputation of the great toe?
YES
NO
YES
NO
(If "Yes," indicate which of the following apply):
(If "Yes," indicate which of the following apply):
Amputation without metatarsal involvement
Amputation without metatarsal involvement
Amputation with removal of the metatarsal head
Amputation with removal of the metatarsal head
Is there amputation of any lesser toe with removal of
Is there amputation of any lesser toe with removal of
the metatarsal head?
the metatarsal head?
YES
NO
YES
NO
(If "Yes," indicate which of the following apply):
(If "Yes," indicate which of the following apply):
Amputation of toes one or two
Amputation of toes one or two
Amputation without metatarsal involvement
Amputation without metatarsal involvement
Is there amputation of toes three or four without
Is there amputation of toes three or four without
metatarsal involvement?
metatarsal involvement?
YES
NO
YES
NO
(If "Yes," indicate which of the following apply):
(If "Yes," indicate which of the following apply):
Amputation not including great toe
Amputation not including great toe
Amputation including great toe
Amputation including great toe
SECTION IX - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
(SURGICAL OR OTHERWISE)
9A. DOES THE VETERAN HAVE ANY SCARS
RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS
LISTED IN SECTION I, DIAGNOSIS?
(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
NO
(If "Yes," also complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)
YES
NO
9B. 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
NO
Page 3
VA FORM 21-0960M-1, OCT 2012
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