Va Form 21-0960c-4 - Diabetic Sensory-Motor Peripheral Neuropathy Disability Benefits Questionnaire Page 2

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SECTION III - SYMPTOMS (Continued)
(Continued)
3. DOES THE VETERAN HAVE ANY SYMPTOMS ATTRIBUTABLE TO DIABETIC PERIPHERAL NEUROPATHY?
PARESTHESIAS AND/OR DYSESTHESIAS
:
RIGHT UPPER EXTREMITY
None
Mild
Moderate
Severe
:
LEFT UPPER EXTREMITY
None
Mild
Moderate
Severe
:
RIGHT LOWER EXTREMITY
None
Mild
Moderate
Severe
:
LEFT LOWER EXTREMITY
None
Mild
Moderate
Severe
NUMBNESS
:
RIGHT UPPER EXTREMITY
None
Mild
Moderate
Severe
:
LEFT UPPER EXTREMITY
None
Mild
Moderate
Severe
:
RIGHT LOWER EXTREMITY
None
Mild
Moderate
Severe
:
LEFT LOWER EXTREMITY
None
Mild
Moderate
Severe
(Describe symptoms, location and severity):
OTHER SYMPTOMS
SECTION IV - NEUROLOGIC EXAM
4A. STRENGTH - RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE:
0/5 No muscle movement
2/5 No movement against gravity
4/5 Less than normal strength
1/5 Visible muscle movement, but no joint movement
3/5 No movement against resistance
5/5 Normal strength
All normal
Elbow Flexion
RIGHT:
5/5
4/5
3/5
2/5
1/5
0/5
LEFT:
5/5
4/5
3/5
2/5
1/5
0/5
Elbow Extension
RIGHT:
5/5
4/5
3/5
2/5
1/5
0/5
LEFT:
5/5
4/5
3/5
2/5
1/5
0/5
Wrist Flexion
RIGHT:
5/5
4/5
3/5
2/5
1/5
0/5
LEFT:
5/5
4/5
3/5
2/5
1/5
0/5
Wrist Extension
RIGHT:
5/5
4/5
3/5
2/5
1/5
0/5
LEFT:
5/5
4/5
3/5
2/5
1/5
0/5
Grip
RIGHT:
5/5
4/5
3/5
2/5
1/5
0/5
LEFT:
5/5
4/5
3/5
2/5
1/5
0/5
Pinch
RIGHT:
5/5
4/5
3/5
2/5
1/5
0/5
(thumb to index finger)
LEFT:
5/5
4/5
3/5
2/5
1/5
0/5
Knee Extension
RIGHT:
5/5
4/5
3/5
2/5
1/5
0/5
LEFT:
5/5
4/5
3/5
2/5
1/5
0/5
Knee Flexion
RIGHT:
5/5
4/5
3/5
2/5
1/5
0/5
LEFT:
5/5
4/5
3/5
2/5
1/5
0/5
Ankle Plantar Flexion
RIGHT:
5/5
4/5
3/5
2/5
1/5
0/5
LEFT:
5/5
4/5
3/5
2/5
1/5
0/5
Ankle Dorsiflexion
RIGHT:
5/5
4/5
3/5
2/5
1/5
0/5
LEFT:
5/5
4/5
3/5
2/5
1/5
0/5
4B. DEEP TENDON REFLEXES (DTRs) - RATE REFLEXES ACCORDING TO THE FOLLOWING SCALE:
0 - Absent
2+ Normal
4+ Increased with clonus
1+ Decreased
3+ Increased without clonus
All normal
Biceps
RIGHT:
0
1+
2+
3+
4+
LEFT:
0
1+
2+
3+
4+
Triceps
RIGHT:
0
1+
2+
3+
4+
LEFT:
0
1+
2+
3+
4+
Brachioradialis
RIGHT:
0
1+
2+
3+
4+
LEFT:
0
1+
2+
3+
4+
Knee
RIGHT:
0
1+
2+
3+
4+
LEFT:
0
1+
2+
3+
4+
Ankle
RIGHT:
0
1+
2+
3+
4+
LEFT:
0
1+
2+
3+
4+
Page 2

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