Va Form 21-0960m-10 - Muscle Injuries Disability Benefits Questionnaire Page 4

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SECTION V - MUSCLE INJURY EXAM (Continued)

CARDINAL SIGNS AND SYMPTOMS OF MUSCLE DISABILITY

10. DOES THE VETERAN HAVE ANY OF THE FOLLOWING SIGNS AND/OR SYMPTOMS ATTRIBUTABLE TO ANY MUSCLE INJURIES?

YES

(If "Yes," check all that apply, and indicate side affected, muscle group and frequency/severity):

Loss of power

(If checked, indicate side affected):

Right

Left

Both

(Indicate muscle group(s) affected (I-XXIII) if possible):

(Indicate frequency/severity):

Occasional

Consistent

Consistent at a more severe level

Weakness

(If checked, indicate side affected):

Right

Left

Both

(Indicate muscle group(s) affected (I-XXIII) if possible):

(Indicate frequency/severity):

Occasional

Consistent

Consistent at a more severe level

Lowered threshold of fatigue

(If checked, indicate sided affected):

Right

Left

Both

(Indicate muscle group(s) affected (I-XXIII) if possible):

(Indicate frequency/severity):

Occasional

Consistent

Consistent at a more severe level

Fatigue-pain

(If checked, indicate side affected):

Right

Left

Both

(Indicate muscle group(s) affected (I-XXIII) if possible):

(Indicate frequency/severity):

Occasional

Consistent

Consistent at a more severe level

Impairment of coordination

(If checked, indicate side affected):

Right

Left

Both

(Indicate muscle group(s) affected (I-XXIII) if possible):

(Indicate frequency/severity):

Occasional

Consistent

Consistent at a more severe level

Uncertainty of movement

(If checked, indicate side affected):

Right

Left

Both

(Indicate muscle group(s) affected (I-XXIII) if possible):

(Indicate frequency/severity):

Occasional

Consistent

Consistent at a more severe level

If further clarification is needed due to injuries of multiple muscle groups, describe which findings, signs and/or symptoms are attributable to each muscle injury:

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VA FORM 21-0960M-10, OCT 2012