Va Form 21-0960m-6 - Foot Miscellaneous (Other Than Flatfoot/pes Planus) Disability Benefits Questionnaire Page 3

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SECTION IX - FOOT INJURIES

9. DOES THE VETERAN HAVE ANY OTHER FOOT INJURIES?

YES

If "Yes," describe:

If "Yes," indicate severity and side affected:

Moderate

Right

Left

Both

Moderately severe

Left

Both

Right

Severe

Right

Left

Both

SECTION X - BILATERAL WEAK FOOT

NOTE - For VA purposes, bilateral weak foot is a symptomatic condition secondary to many constitutional conditions characterized by atrophy of the musculature,

disturbed circulation, and weakness.

10. IS THERE EVIDENCE OF BILATERAL WEAK FOOT?

YES

If "Yes," describe and report underlying condition:

SECTION XI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS

11A. DOES THE VETERAN HAVE ANY SCARS (SURGICAL OR OTHERWISE) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS

LISTED IN SECTION I, DIAGNOSIS?

YES

(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)?)

(If "Yes," ALSO complete VA Form 21-0960F-1, Scars/Disability Benefits Questionnaire)

YES

11B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY

CONDITIONS LISTED IN SECTION I, DIAGNOSIS?

YES

If "Yes," describe - brief summary:

SECTION XII - ASSISTIVE DEVICES

12A. DOES THE VETERAN USE ANY ASSISTIVE DEVICES AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER

METHODS MAY BE POSSIBLE?

YES

If "Yes," identify assistive devices used (Check all that apply and indicate frequency):

Wheelchair

Frequency of use:

Occasional

Regular

Constant

Brace(s)

Frequency of use:

Occasional

Regular

Constant

Crutch(es)

Frequency of use:

Occasional

Regular

Constant

Cane(s)

Frequency of use:

Occasional

Regular

Constant

Walker

Frequency of use:

Occasional

Regular

Constant

Other:

Frequency of use:

Occasional

Regular

Constant

12B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE FOR EACH CONDITION:

SECTION XIII - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES

13. DUE TO THE VETERAN'S FOOT CONDITION, IS THERE FUNCTIONAL IMPAIRMENT OF AN EXTREMITY SUCH THAT NO EFFECTIVE FUNCTION REMAINS

OTHER THAN THAT WHICH WOULD BE EQUALLY WELL SERVED BY AN AMPUTATION WITH PROSTHESIS? (Functions for the lower extremity include balance and

propulsion, etc.)

Yes, functioning is so diminished that amputation with prosthesis would equally serve the veteran

If "Yes," indicate extremities for which this applies:

Right lower

Left lower

For each checked extremity, describe loss of effective function, identify the condition causing loss of function, and provide specific examples (brief summary):

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VA FORM 21-0960M-6, OCT 2012