Va Form 21-0960m-4 - Elbow And Forearm Conditions Disability Benefits Questionnaire Page 2
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SECTION IV - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS
4C. LEFT 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
4D. LEFT 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
(for reasons other than an
4E. IF ROM DOES NOT CONFORM TO THE NORMAL RANGE OF MOTION IDENTIFIED ABOVE BUT IS NORMAL FOR THIS VETERAN
elbow condition, such as age, body habitus, neurologic disease)
, EXPLAIN:
SECTION V - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING
5A. IS THE VETERAN ABLE TO PERFORM REPETITIVE-USE TESTING WITH 3 REPETITIONS?
YES
NO
IF UNABLE, PROVIDE REASON:
IF VETERAN IS UNABLE TO PERFORM REPETITIVE-USE TESTING, SKIP TO SECTION VI.
IF VETERAN IS ABLE TO TO PERFORM REPETITIVE-USE TESTING, MEASURE AND REPORT ROM AFTER A MINIMUM OF 3 REPETITIONS:
5B. RIGHT ELBOW POST-TEST ROM
Select where post-test 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 post-test 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
5C. LEFT ELBOW POST-TEST ROM
Select where post-test 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 post-test 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
SECTION VI - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION IN ROM
NOTE: The following section addresses reasons for functional loss, if present, and additional loss of ROM after repetitive-use testing, if present. The VA defines
functional loss as the inability to perform normal working movements of the body with normal excursion, strength, speed, coordination and/or endurance.
6A. DOES THE VETERAN HAVE ADDITIONAL LIMITATION IN ROM OF THE ELBOW AND FOREARM FOLLOWING REPETITIVE-USE TESTING?
YES
NO
6B. DOES THE VETERAN HAVE ANY FUNCTIONAL LOSS AND/OR FUNCTIONAL IMPAIRMENT OF THE ELBOW AND FOREARM?
YES
NO
Page 2
VA FORM 21-0960M-4, OCT 2012
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