Va Form 21-0960m-6 - Foot Miscellaneous (Other Than Flatfoot/pes Planus) Disability Benefits Questionnaire Page 2
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4SECTION V - HALLUX VALGUS (Continued)
5C. HAS THE VETERAN HAD SURGERY FOR HALLUX VALGUS?
YES
NO
If "Yes," indicate type and date of surgery and side affected:
Resection of metatarsal head
Date of surgery:
Side affected:
Left
Both
Right
Metatarsal osteotomy/metatarsal head osteotomy (equivalent to metatarsal head resection)
Date of surgery:
Side affected:
Left
Both
Right
Other surgery for hallux valgus, describe:
Date of surgery:
Side affected:
Left
Both
Right
SECTION VI - HALLUX RIGIDUS
6. DOES THE VETERAN HAVE HALLUX RIGIDUS?
YES
NO
If "Yes," does the veteran have symptoms due to hallux rigidus?
YES
NO
If "Yes," indicate severity and side affected:
Mild or moderate symptoms
Side affected:
Left
Both
Right
Severe symptoms, with function equivalent to amputation of great toe
Side affected:
Left
Both
Right
SECTION VII - PES CAVUS (CLAW FOOT)
7. DOES THE VETERAN HAVE ACQUIRED CLAW FOOT (PES CAVUS)?
YES
NO
If "Yes," complete the following:
A. Effect on toes due to pes cavus (check all that apply)
None
Left
Right
Both
Great toe dorsiflexed
Right
Left
Both
All toes tending to dorsiflexion
Left
Both
Right
Left
Both
All toes hammer toes
Right
Other, describe (if there is an effect on toes due to other etiology than pes cavus, indicate other etiology):
B. Pain and tenderness (check all that apply)
None
Left
Both
Right
Definite tenderness under metatarsal heads
Left
Right
Both
Marked tenderness under metatarsal heads
Right
Left
Both
Very painful callosities
Left
Both
Right
Other, describe (if the veteran has pain and tenderness due to other etiology than pes cavus, indicate other etiology):
C. Effect on plantar fascia (check all that apply)
None
Left
Both
Right
Shortened plantar fascia
Left
Both
Right
Marked contraction of plantar fascia with
Right
Left
Both
dropped forefoot
Other, describe (if there is an effect on plantar fascia due to other etiology than pes cavus, indicate other etiology):
D. Dorsiflexion and varus deformity (check all that apply)
None
Right
Left
Both
Some limitation of dorsiflexion at ankle
Right
Left
Both
Limitation of dorsiflexion at ankle to right angle
Right
Left
Both
Marked varus deformity
Right
Left
Both
Other, describe (if the veteran has dorsiflexion and varus deformity due to other etiology than pes cavus, indicate other etiology):
SECTION VIII - MALUNION OR NONUNION OF TARSAL OR METATARSAL BONES
8. DOES THE VETERAN HAVE MALUNION OR NONUNION OF TARSAL OR METATARSAL BONES?
YES
NO
If "Yes," indicate severity and side affected:
Moderate
Right
Left
Both
Moderately severe
Right
Left
Both
Severe
Right
Left
Both
VA FORM 21-0960M-6, OCT 2012
Page 2
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