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

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SECTION V - INCAPACITATING AND NON-INCAPACITATING EXACERBATIONS
5A. DUE TO THE ARTHRITIS CONDITION, DOES THE VETERAN HAVE EXACERBATIONS WHICH ARE NOT INCAPACITATING?
YES
NO
IF YES, INDICATE FREQUENCY OF NON-INCAPACITATING EXACERBATIONS PER YEAR:
0
1
2
3
4 OR MORE
Date of most recent non-incapacitating exacerbation:
Duration of most recent non-incapacitating exacerbation:
Describe non-incapacitating exacerbation:
5B. DUE TO THE ARTHRITIS CONDITION, DOES THE VETERAN HAVE EXACERBATIONS WHICH ARE INCAPACITATING?
YES
NO
IF YES, DESCRIBE:
INDICATE FREQUENCY OF INCAPACITATING EXACERBATIONS PER YEAR:
0
1
2
3
4 OR MORE
Date of most recent incapacitating exacerbation:
Duration of most recent incapacitating exacerbation:
Describe incapacitating exacerbation:
5C. DUE TO THE ARTHRITIS CONDITION, DOES THE VETERAN HAVE CONSTITUTIONAL MANIFESTATIONS ASSOCIATED WITH ACTIVE JOINT INVOLVEMENT
WHICH ARE TOTALLY INCAPACITATING?
YES
NO
IF YES, HAS THE VETERAN BEEN TOTALLY INCAPACITATED DUE TO THIS DURING THE PAST 12 MONTHS?
YES
NO
IF YES, INDICATE THE TOTAL DURATION OF INCAPACITATION OVER THE PAST 12 MONTHS:
< 1 WEEK
1 WEEK TO < 2 WEEKS
2 WEEKS TO < 4 WEEKS
4 WEEKS TO < 6 WEEKS
6 WEEKS OR MORE
DESCRIBE CONSTITUTIONAL MANIFESTATIONS AND THE MANNER IN WHICH THOSE MANIFESTATIONS CAUSE INCAPACITATION:
SECTION VI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
(surgical or otherwise)
6A. DOES THE VETERAN HAVE ANY SCARS
RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
SECTION I, DIAGNOSIS?
YES
NO
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)
?
YES
NO
IF YES, ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT DISABILITY BENEFITS QUESTIONNAIRE.
6B. 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
NO
(brief summary):
IF YES, DESCRIBE
SECTION VII - ASSISTIVE DEVICES
7A. DOES THE VETERAN USE ANY ASSISTIVE DEVICE(S) AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS
MAY BE POSSIBLE?
YES
NO
(check all that apply and indicate frequency):
IF YES, IDENTIFY ASSISTIVE DEVICE(S) USED
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
Page 3
VA FORM 21-0960M-3, OCT 2012

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