Va Form 21-0960m-5 - Flatfoot (Pes Planus) Disability Benefits Questionnaire

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OMB Approved No. 2900-0776

Respondent Burden: 30 minutes

FLATFOOT (PES PLANUS) 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 FLATFOOT (PES PLANUS)?

(If "Yes," complete Item 1B)

YES

1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO FLATFOOT:

DIAGNOSIS # 1 -

ICD CODE -

DATE OF DIAGNOSIS -

SIDE AFFECTED

BOTH

RIGHT

LEFT

DIAGNOSIS # 2 -

ICD CODE -

DATE OF DIAGNOSIS -

SIDE AFFECTED

BOTH

RIGHT

LEFT

DIAGNOSIS # 3 -

ICD CODE -

DATE OF DIAGNOSIS -

SIDE AFFECTED

BOTH

RIGHT

LEFT

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO FLATFOOT, LIST USING ABOVE FORMAT

NOTE - If the veteran has additional foot conditions other than flatfoot, (such as extreme tenderness on the plantar surfaces of the feet indicating plantar fasciitis),

complete a VAF 21-0960M-6 Foot (other than flatfoot) Disability Benefits Questionnaire.

SECTION II - MEDICAL HISTORY

(including onset and course)

(i.e., when did flatfoot first become

2. DESCRIBE THE HISTORY

OF THE VETERAN'S CURRENT FLATFOOT CONDITION

symptomatic?) (brief summary):

SECTION III - SIGNS AND SYMPTOMS

NOTE: INDICATE ALL SIGNS AND SYMPTOMS THAT APPLY TO THE VETERAN'S FLATFOOT CONDITION, REGARDLESS OF WHETHER SIMILAR SIGNS AND

SYMPTOMS APPEAR MORE THAN ONCE IN DIFFERENT SECTIONS

3A. DOES THE VETERAN HAVE PAIN ON USE OF THE FEET?

YES