Va Form 21-0960m-14 - Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire
Download a blank fillable Va Form 21-0960m-14 - Back (Thoracolumbar Spine) 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-14 - Back (Thoracolumbar Spine) 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.
ADVERTISEMENT
1
2
3
4
5
6OMB Approved No. 2900-0779
Respondent Burden: 45 minutes
BACK (THORACOLUMBAR SPINE) 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 THIS 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
(back)
1A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER BEEN DIAGNOSED WITH A THORACOLUMBAR SPINE
CONDITION?
YES
NO
(back)
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO THORACOLUMBAR SPINE
CONDITIONS:
Diagnosis # 1 -
ICD code -
Date of diagnosis -
Diagnosis # 2 -
ICD code -
Date of diagnosis -
Diagnosis # 3 -
ICD code-
Date of diagnosis -
(back)
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO THORACOLUMBAR SPINE
CONDITIONS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
(back)
(brief summary)
2. DESCRIBE THE HISTORY
OF THE VETERAN'S THORACOLUMBAR SPINE
CONDITION
SECTION III - FLARE-UPS
(back)
3. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE THORACOLUMBAR SPINE
?
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
4. MEASURE ROM WITH A GONIOMETER, ROUNDING EACH MEASUREMENT TO THE NEAREST 5 DEGREES. DURING THE MEASUREMENTS, OBSERVE THE POINT
AT WHICH PAINFUL MOTION BEGINS, EVIDENCE BY VISIBLE BEHAVIOR SUCH AS FACIAL EXPRESSION, WINCING, ETC. REPORT INITIAL MEASUREMENTS BELOW.
NOTE: Following the initial assessment of ROM, perform repetitive-use testing. For VA purposes, repetitive-use testing must be included in all exams. The VA has
determined that 3 repetitions of ROM (at 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.
(normal endpoint is 90)
A. SELECT WHERE FORWARD FLEXION ENDS
:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90 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 or greater
(normal endpoint is 30)
B. SELECT WHERE EXTENSION ENDS
:
0
5
10
15
20
25
30 or greater
SELECT WHERE OBJECTIVE EVIDENCE OF PAINFUL MOTION BEGINS:
No objective evidence of painful motion
0
5
10
15
20
25
30 or greater
(normal endpoint is 30)
C. SELECT WHERE RIGHT LATERAL FLEXION ENDS
:
0
5
10
15
20
25
30 or greater
SELECT WHERE OBJECTIVE EVIDENCE OF PAINFUL MOTION BEGINS:
No objective evidence of painful motion
0
5
10
15
20
25
30 or greater
VA FORM
21-0960M-14
Page 1
SUPERSEDES VA FORM 21-0960M-14, DEC 2010,
OCT 2012
WHICH WILL NOT BE USED.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal