Va Form 21-0960m-3 - Non-Degenerative Arthritis (Including Inflammatory, Autoimmune, Crystalline And Infectious Arthritis) And Dysbaric Osteonecrosis Disability Benefits Questionnaire Page 4

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SECTION VII - ASSISTIVE DEVICES (Continued)
7B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION
SECTION VIII - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
8. DUE TO THE VETERAN'S INFLAMMATORY, AUTOIMMUNE, CRYSTALLINE OR INFECTIOUS ARTHRITIS OR DYSBARIC OSTEONECROSIS, IS THERE FUNCTIONAL
IMPAIRMENT OF AN EXTREMITY SUCH THAT NO EFFECTIVE FUNCTION REMAINS OTHER THAN THAT WHICH WOULD BE EQUALLY WELL SERVED BY AN
(Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and
AMPUTATION WITH PROSTHESIS?
propulsion, etc.)
YES, FUNCTIONING IS SO DIMINISHED THAT AMPUTATION WITH PROSTHESIS WOULD EQUALLY SERVE THE VETERAN
NO
IF YES, INDICATE EXTREMITIES FOR WHICH THIS APPLIES:
RIGHT UPPER
LEFT UPPER
RIGHT LOWER
LEFT LOWER
FOR EACH CHECKED EXTREMITY, IDENTIFY THE CONDITION CAUSING LOSS OF FUNCTION, DESCRIBE LOSS OF EFFECTIVE FUNCTION AND PROVIDE
(brief summary):
SPECIFIC EXAMPLES
SECTION IX - DIAGNOSTIC TESTING
NOTE - The diagnosis of degenerative arthritis (osteoarthritis) or traumatic arthritis must be confirmed by imaging studies. Once such arthritis has been documented, no
further imaging studies are required by VA, even if arthritis has worsened.
9A. HAVE IMAGING STUDIES BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES
NO
IF YES, INDICATE TYPE OF STUDY:
X-RAY
Area imaged:
Date:
Results:
OTHER, SPECIFY:
Area imaged:
Date:
Results:
9B. HAVE LABORATORY STUDIES BEEN PERFORMED?
NOTE: ONCE A DIAGNOSIS HAS BEEN CONFIRMED, LABORATORY STUDIES ARE NOT INDICATED FOR A DISABILITY EXAM.
YES
NO
IF YES, CHECK ALL THAT APPLY:
(ESR)
ERYTHROCYTE SEDIMENTATION RATE
Date of test:
Results:
C-REACTIVE PROTEIN
Date of test:
Results:
(RF)
RHEUMATOID FACTOR
Date of test:
Results:
ANTI-DNA ANTIBODIES
Date of test:
Results:
(ANA)
ANTINUCLEAR ANTIBODIES
Date of test:
Results:
ANTI-CYCLIC CITRULLINATED PEPTIDE (ANTI-CCP) ANTIBODIES
Date of test:
Results:
CBC
Date of test:
Hemoglobin:
Hematocrit:
White blood cell count:
Platelets:
URIC ACID TEST
Date of test:
Results:
OTHER, SPECIFY:
Date of test:
Results:
9C. HAS THE VETERAN HAD A JOINT ASPIRATION/SYNOVIAL FLUID ANALYSIS?
NOTE: ONCE A DIAGNOSIS HAS BEEN CONFIRMED, TESTING IS NOT INDICATED FOR A DISABILITY EXAM.
YES
NO
IF YES, INDICATE JOINT ASPIRATED, DATE AND RESULTS:
(e.g., skin, nerve, fat, rectum, kidney)?
9D. HAS THE VETERAN HAD A BIOPSY
NOTE: ONCE A DIAGNOSIS HAS BEEN CONFIRMED, TESTING IS NOT INDICATED FOR A DISABILITY EXAM.
YES
NO
IF YES, INDICATE AREA BIOPSIED, DATE AND RESULTS
9E. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES
NO
(brief summary):
IF YES, PROVIDE TYPE OF TEST OR PROCEDURE, DATE AND RESULTS
Page 4
VA FORM 21-0960M-3, OCT 2012

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