Va Form 21-0960m-4 - Elbow And Forearm Conditions Disability Benefits Questionnaire
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5OMB Approved No. 2900-0776
Respondent Burden: 30 minutes
ELBOW AND FOREARM CONDITIONS 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 HAD AN ELBOW OR FOREARM CONDITION?
(If "Yes," complete Item 1B)
YES
NO
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO ELBOW AND FOREARM CONDITION(S):
Diagnosis # 1 -
ICD code -
Date of diagnosis -
Side affected:
Right
Left
Both
Diagnosis # 2 -
ICD code -
Date of diagnosis -
Side affected:
Right
Left
Both
Diagnosis # 3 -
ICD code -
Date of diagnosis -
Side affected:
Right
Left
Both
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO ELBOW AND FOREARM CONDITIONS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
(brief summary)
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S ELBOW AND FOREARM CONDITION
2B. DOMINANT HAND
RIGHT
LEFT
AMBIDEXTROUS
SECTION III - FLARE-UPS
3. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE ELBOW AND/OR FOREARM?
YES
NO
IF YES, DOCUMENT THE VETERAN'S DESCRIPTION OF THE IMPACT OF FLARE-UPS IN HIS OR HER OWN WORDS:
SECTION IV - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS
NOTE: Measure ROM with a goniometer, rounding each measurement to the nearest 5 degrees. During the measurements, document the point at which painful motion
begins, evidenced by visible behavior such as facial expression, wincing, etc. Report initial measurements below.
Following the initial assessment of ROM, perform repetitive use testing. For VA purposes, repetitive use testing must be included in all joint exams. The VA has
determined that 3 repetitions of ROM (at a minimum) can serve as a representative test of the effect of repetitive use. After the initial measurement, reassess ROM after 3
repetitions. Report post-test measurements in Section 5.
4A. RIGHT ELBOW FLEXION
(normal endpoint is 145 degrees)
Select where flexion ends
:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145 or greater
Select where objective evidence of painful motion begins:
No objective evidence of painful motion
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145 or greater
4B. RIGHT ELBOW EXTENSION
Select where extension ends:
(no limitation of extension)
0 or any degree of hyperextension
Unable to fully extend; extension ends at:
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110 or greater
Select where objective evidence of painful motion begins:
No objective evidence of painful motion
(no limitation of extension)
0 or any degree of hyperextension
Unable to fully extend; extension ends at:
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110 or greater
21-0960M-4
VA FORM
SUPERSEDES VA FORM 21-0960M-4, JAN 2011,
Page 1
OCT 2012
WHICH WILL NOT BE USED.
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