Va Form 21-0960m-3 - Non-Degenerative Arthritis (Including Inflammatory, Autoimmune, Crystalline And Infectious Arthritis) And Dysbaric Osteonecrosis Disability Benefits Questionnaire Page 2

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SECTION II - MEDICAL HISTORY (Continued)
2D. DOES THE VETERAN HAVE ANEMIA DUE TO THIS ARTHRITIS CONDITION?
YES
NO
IF YES, DOES THE VETERAN'S ANEMIA ATTRIBUTABLE TO THIS ARTHRITIS CONDITION CAUSE IMPAIRMENT OF HEALTH?
YES
NO
(also provide CBC under diagnostic testing section #9):
IF YES, DESCRIBE THE IMPAIRMENT
SECTION III - JOINT INVOLVEMENT
(with or without joint movement)
3A. DOES THE VETERAN HAVE PAIN
ATTRIBUTABLE TO THIS ARTHRITIS CONDITION?
YES
NO
(check all that apply):
IF YES, INDICATE AFFECTED JOINTS
CERVICAL SPINE
THORACOLUMBAR SPINE
SACROILIAC JOINTS
RIGHT:
SHOULDER
ELBOW
WRIST
HAND/FINGERS
HIP
KNEE
ANKLE
FOOT/TOES
LEFT:
SHOULDER
ELBOW
WRIST
HAND/FINGERS
HIP
KNEE
ANKLE
FOOT/TOES
(brief summary).
FOR ALL CHECKED JOINTS, DESCRIBE INVOLVEMENT
ALSO COMPLETE A QUESTIONNAIRE FOR EACH AFFECTED JOINT, IF INDICATED.
3B. DOES THE VETERAN HAVE ANY LIMITATION OF JOINT MOVEMENT ATTRIBUTABLE TO THIS ARTHRITIS CONDITION?
YES
NO
(check all that apply):
IF YES, INDICATE AFFECTED JOINTS
CERVICAL SPINE
THORACOLUMBAR SPINE
SACROILIAC JOINTS
RIGHT:
SHOULDER
ELBOW
WRIST
HAND/FINGERS
HIP
KNEE
ANKLE
FOOT/TOES
LEFT:
SHOULDER
ELBOW
WRIST
HAND/FINGERS
HIP
KNEE
ANKLE
FOOT/TOES
(brief summary).
FOR ALL CHECKED JOINTS, DESCRIBE LIMITATION OF MOVEMENT
ALSO COMPLETE A QUESTIONNAIRE FOR EACH AFFECTED JOINT, IF
INDICATED.
3C. DOES THE VETERAN HAVE ANY JOINT DEFORMITIES ATTRIBUTABLE TO THIS ARTHRITIS CONDITION?
YES
NO
(check all that apply):
IF YES, INDICATE AFFECTED JOINTS
CERVICAL SPINE
THORACOLUMBAR SPINE
SACROILIAC JOINTS
RIGHT:
SHOULDER
ELBOW
WRIST
HAND/FINGERS
HIP
KNEE
ANKLE
FOOT/TOES
LEFT:
SHOULDER
ELBOW
WRIST
HAND/FINGERS
HIP
KNEE
ANKLE
FOOT/TOES
(brief summary).
FOR ALL CHECKED JOINTS, DESCRIBE DEFORMITIES
ALSO COMPLETE A QUESTIONNAIRE FOR EACH AFFECTED JOINT, IF INDICATED.
SECTION IV - SYSTEMIC INVOLVEMENT OTHER THAN JOINTS
4. DOES THE VETERAN HAVE ANY INVOLVEMENT OF ANY SYSTEMS, OTHER THAN JOINTS, ATTRIBUTABLE TO THIS ARTHRITIS CONDITION?
YES
NO
(check all that apply):
IF YES, INDICATE SYSTEMS INVOLVED
OPHTHALMOLOGICAL
SKIN AND MUCOUS MEMBRANES
HEMATOLOGIC
PULMONARY
CARDIAC
NEUROLOGIC
RENAL
GASTROINTESTINAL
VASCULAR
(brief summary).
FOR ALL CHECKED SYSTEMS, DESCRIBE INVOLVEMENT
ALSO COMPLETE THE APPROPRIATE QUESTIONNAIRE IF INDICATED.
Page 2
VA FORM 21-0960M-3, OCT 2012

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