Va Form 21-0960c-4 - Diabetic Sensory-Motor Peripheral Neuropathy Disability Benefits Questionnaire Page 3

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SECTION IV - NEUROLOGIC EXAM

4C. LIGHT TOUCH/MONOFILAMENT TESTING RESULTS

All Normal

Shoulder area

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

Inner/outer forearm

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

Hand/fingers

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

Knee/thigh

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

Ankle/lower leg

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

Foot/toes

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

(grasp index finger/great toe on sides and ask patient to identify up and down movement)

4D. POSITION SENSE

Not tested

RIGHT UPPER EXTREMITY

Normal

Decreased

Absent

LEFT UPPER EXTREMITY

Normal

Decreased

Absent

RIGHT LOWER EXTREMITY

Normal

Decreased

Absent

LEFT LOWER EXTREMITY

Normal

Decreased

Absent

(place low-pitched tuning fork over DIP joint of index finger/IP joint of great toe)

4E. VIBRATION SENSATION

Not tested

RIGHT UPPER EXTREMITY

Normal

Decreased

Absent

LEFT UPPER EXTREMITY

Normal

Decreased

Absent

RIGHT LOWER EXTREMITY

Normal

Decreased

Absent

LEFT LOWER EXTREMITY

Normal

Decreased

Absent

(test distal extremities for cold sensation with side of tuning fork)

4F. COLD SENSATION

Not tested

RIGHT UPPER EXTREMITY

Normal

Decreased

Absent

LEFT UPPER EXTREMITY

Normal

Decreased

Absent

RIGHT LOWER EXTREMITY

Normal

Decreased

Absent

LEFT LOWER EXTREMITY

Normal

Decreased

Absent

4G. DOES THE VETERAN HAVE MUSCLE ATROPHY?

YES

(If muscle atrophy is present, indicate location):

(For each instance of muscle atrophy, provide measurements in cm between normal and atrophied side, measured at maximum muscle bulk:

cm.)

(characterized by loss of extremity hair, smooth, shiny skin, etc.)

4H. DOES THE VETERAN HAVE TROPHIC CHANGES

ATTRIBUTABLE TO DIABETIC PERIPHERAL

NEUROPATHY?

(If "Yes," describe):

YES

SECTION V - SEVERITY

NOTE: Based on symptoms and findings from Sections III and IV, complete Items 5a and 5b below to provide an evaluation of the severity of the veteran's diabetic peripheral neuropathy.

NOTE: For VA purposes, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the description of complete paralysis that is given with each

nerve. If the nerve is completely paralyzed, check the box for "complete paralysis". If the nerve is not completely paralyzed, check the box for "incomplete paralysis" and indicate severity.

For VA purposes, when nerve impairment is wholly sensory, the evaluation should be mild, or at most, moderate.

5A. DOES THE VETERAN HAVE AN UPPER EXTREMITY DIABETIC PERIPHERAL NEUROPATHY?

(If "Yes," indicate nerve affected, severity and side affected)

YES

RADIAL NERVE (musculospiral nerve)

(NOTE: Complete paralysis (hand and fingers drop, wrist and fingers flexed; cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb or

make lateral movement of wrist; supination of hand, elbow extension and flexion weak, hand grip impaired.)

Normal

Incomplete paralysis

Complete paralysis

RIGHT:

(If incomplete paralysis is checked, indicate severity):

Mild

Moderate

Severe

Page 3

VA FORM 21-0960C-4, OCT 2012