Va Form 21-0960m-10 - Muscle Injuries Disability Benefits Questionnaire

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OMB Approved No. 2900-0776

Respondent Burden: 30 minutes

MUSCLE INJURIES DISABILITY BENEFITS QUESTIONNAIRE

IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE

PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION

BEFORE COMPLETING FORM.

NAME OF PATIENT/VETERAN

PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

NOTE TO PHYSICIAN - Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you

provide on this questionnaire as part of their evaluation in processing the veteran's claim.

SECTION I - DIAGNOSIS

1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH A MUSCLE INJURY?

(If "Yes," complete Item 1B)

YES

1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO MUSCLE INJURIES:

SIDE AFFECTED

DIAGNOSIS #1 -

ICD CODE -

DATE OF DIAGNOSIS -

Right

Left

Both

SIDE AFFECTED

DIAGNOSIS #2 -

ICD CODE -

DATE OF DIAGNOSIS -

Right

Left

Both

SIDE AFFECTED

DATE OF DIAGNOSIS -

DIAGNOSIS #3 -

ICD CODE -

Right

Left

Both

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO MUSCLE INJURIES, LIST USING ABOVE FORMAT:

NOTE - If there are multiple muscle injuries, complete the assessment for all muscle injuries on this questionnaire, if possible. If unable to complete assessment for all

muscle injuries on this questionnaire, also complete an additional questionnaire for each additional injury. If the veteran has or has had a muscle injury that results in any

conditions that are not covered in this questionnaire, also complete any other appropriate questionnaires (e.g., if peripheral nerve injury also exists due to the muscle

injury, complete VA Form 21-0960C-10, Peripheral Nerve Conditions (not including diabetic sensory-motor peripheral neuropathy) Disability Benefits Questionnaire.

SECTION II - HISTORY OF MUSCLE INJURY

(such as a gunshot or shell fragment wound)

2A. DOES THE VETERAN HAVE A PENETRATING MUSCLE INJURY

YES

(such as a muscle strain, torn Achilles tendon or torn quadriceps muscle)

2B. DOES THE VETERAN HAVE A NON-PENETRATING MUSCLE INJURY

YES

(including onset and course)

(brief summary)

2C. DESCRIBE THE HISTORY

OF THE VETERAN'S MUSCLE INJURY

2D. DOMINANT HAND

RIGHT

LEFT

AMBIDEXTROUS

SECTION III - LOCATION OF MUSCLE INJURY

NOTE - For VA purposes, muscles are classified into groups I-XXIII. In this section, indicate the location of the veteran's muscle injury(ies) by checking the

muscle group(s) involved.

SHOULDER GIRDLE AND ARM

3. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD AN INJURY TO A MUSCLE GROUP OF THE SHOULDER GIRDLE OR ARM?

YES

(If "Yes," check muscle group(s) and side affected (check all that apply)

GROUP I: Extrinsic muscles of shoulder girdle: trapezius, levator scapulae, serratus magnus

Function: Upward rotation of scapula, elevation of arm above shoulder level

Right

Both

Side affected:

Left

GROUP II: Muscles of shoulder girdle: pectoralis major, latissimus dorsi and teres major, pectoralis minor, rhomboid