Va Form 21-0960m-4 - Elbow And Forearm Conditions Disability Benefits Questionnaire Page 4

Download a blank fillable Va Form 21-0960m-4 - Elbow And Forearm Conditions Disability Benefits Questionnaire in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Va Form 21-0960m-4 - Elbow And Forearm Conditions Disability Benefits Questionnaire with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

SECTION XI - JOINT REPLACEMENT AND/OR OTHER SURGICAL PROCEDURES

11A. HAS THE VETERAN HAD A TOTAL ELBOW JOINT REPLACEMENT?

YES

IF YES, INDICATE SIDE AND SEVERITY OF RESIDUALS

Right elbow

Date of surgery:

Residuals:

None

Intermediate degrees of residual weakness, pain and/or limitation of motion

Chronic residuals consisting of severe painful motion and/or weakness

Other, describe:

Left elbow

Date of surgery:

Residuals:

None

Intermediate degrees of residual weakness, pain and/or limitation of motion

Chronic residuals consisting of severe painful motion and/or weakness

Other, describe:

11B. HAS THE VETERAN HAD ARTHROSCOPIC OR OTHER ELBOW SURGERY?

YES

IF YES, INDICATE SIDE AFFECTED:

Right

Left

Both

Date of surgery:

11C. DOES THE VETERAN HAVE ANY RESIDUAL SIGNS AND/OR SYMPTOMS DUE TO ARTHROSCOPIC OR OTHER ELBOW SURGERY?

YES

IF YES, INDICATE SIDE AFFECTED:

Right

Left

Both

IF YES, DESCRIBE RESIDUALS:

SECTION XII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS

(surgical or otherwise)

12A. DOES THE VETERAN HAVE ANY SCARS

RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN

SECTION I, DIAGNOSIS?

YES

IF YES, ARE ANY OF THE SCARS PAINFUL/OR UNSTABLE, OR IS THE TOTAL AREA OF ALL RELATED SCARS GREATER THAN OR EQUAL TO 39 SQUARE cm

(6 square inches)

YES

IF YES, ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT DISABILITY BENEFITS QUESTIONNAIRE.

12B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY

CONDITIONS LISTED IN SECTION I, DIAGNOSIS?

(brief summary)

YES

IF YES, DESCRIBE

NOTE: In all forearm injuries, if there are impaired finger movements due to tendon, muscle or nerve injuries, also complete the appropriate disability Questionnaire

(s), such as the VA Form 21-0960M-7, Hand and/or Finger Conditions Disability Benefits Questionnaire or VA Form 21-0960C-10, Peripheral Nerves Conditions (Not

including Diabetic Sensory-Motor Peripheral Neuropathy) Disability Benefits Questionnaire.

SECTION XIII - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES

13. DUE TO THE SERVICE-CONNECTED DISABLING CONDITION(S), IS THERE FUNCTIONAL IMPAIRMENT OF AN EXTREMITY SUCH THAT NO EFFECTIVE

(Functions of the upper

FUNCTION REMAINS OTHER THAN THAT WHICH WOULD BE EQUALLY WELL SERVED BY AN AMPUTATION WITH PROSTHESIS?

extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.)

YES, functioning is so diminished that amputation with prosthesis would equally serve the veteran

IF YES, INDICATE EXTREMITIES FOR WHICH THIS APPLIES:

Right upper

Left upper

FOR EACH CHECKED EXTREMITY, IDENTIFY THE CONDITION CAUSING LOSS OF FUNCTION, DESCRIBE LOSS OF EFFECTIVE FUNCTION AND PROVIDE

(brief summary)