Va Form 21-0960m-4 - Elbow And Forearm Conditions Disability Benefits Questionnaire Page 3
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SECTION VI - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION IN ROM
6C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT AND/OR ADDITIONAL LIMITATION OF ROM OF THE ELBOW AND FOREARM AFTER
(check all that apply and indicate side affected):
REPETITIVE USE, INDICATE THE CONTRIBUTING FACTORS OF DISABILITY BELOW
No functional loss for right upper extremity
No functional loss for left upper extremity
Less movement than normal
Right
Left
Both
More movement than normal
Right
Left
Both
Weakened movement
Right
Left
Both
Excess fatigability
Right
Left
Both
Incoordination, impaired ability to execute skilled movements smoothly
Right
Left
Both
Pain on movement
Right
Left
Both
Swelling
Right
Left
Both
Deformity
Right
Left
Both
Atrophy of disuse
Right
Left
Both
(pain on palpation)
SECTION VII - PAIN
7. DOES THE VETERAN HAVE LOCALIZED TENDERNESS OR PAIN ON PALPATION OF JOINTS/SOFT TISSUE OF EITHER ELBOW OR FOREARM?
YES
NO
IF YES, SIDE AFFECTED:
Right
Left
Both
SECTION VIII - MUSCLE STRENGTH TESTING
8. RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE:
0/5 No muscle movement
1/5 Palpable or visible muscle contraction, but no joint movement
2/5 Active movement with gravity eliminated
3/5 Active movement against gravity
4/5 Active movement against some resistance
5/5 Normal strength
Elbow flexion:
Right
5/5
4/5
3/5
2/5
1/5
0/5
Left
5/5
4/5
3/5
2/5
1/5
0/5
Elbow extension:
Right
5/5
4/5
3/5
2/5
1/5
0/5
Left
5/5
4/5
3/5
2/5
1/5
0/5
SECTION IX - ANKYLOSIS
9. DOES THE VETERAN HAVE ANKYLOSIS OF THE ELBOW?
YES
NO
IF YES, INDICATE SIDE AND SEVERITY:
At an angle of more than 90 degrees
Right
Left
Both
At an angle between 90 and 70 degrees
Right
Left
Both
At an angle between 70 and 50 degrees
Right
Left
Both
At an angle of less than 50 degrees
Right
Left
Both
SECTION X - ADDITIONAL CONDITIONS
10. DOES THE VETERAN HAVE FLAIL JOINT, JOINT FRACTURE AND/OR IMPAIRMENT OF SUPINATION OR PRONATION?
YES
NO
IF YES, INDICATE CONDITION AND COMPLETE THE APPROPRIATE SECTIONS BELOW.
A. FLAIL JOINT OF THE ELBOW.
If checked, indicate side:
Right
Left
Both
(joint fracture)
B. INTRA-ARTICULAR FRACTURE
WITH MARKED VARUS OR VALGUS DEFORMITY?
If checked, indicate side:
Right
Left
Both
(joint fracture)
C. INTRA-ARTICULAR FRACTURE
WITH UNUNITED FRACTURE OF THE HEAD OF THE RADIUS?
If checked, indicate side:
Right
Left
Both
D. IMPAIRMENT OF SUPINATION OR PRONATION
If checked, indicate severity and side
Supination limited to 30 degrees or less
Right
Left
Both
Limited pronation with motion lost beyond the last quarter of the arc;
Right
Left
Both
hand does not approach full pronation
Limited pronation with motion lost beyond the middle of the arc
Right
Left
Both
Hand is fixed near the middle of the arc or moderate pronation due to bone fusion
Right
Left
Both
Hand fixed in full pronation due to bone fusion
Right
Left
Both
Hand fixed in supination or hyperpronation due to bone fusion
Right
Left
Both
Page 3
VA FORM 21-0960M-4, OCT 2012
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