Va Form 21-0960m-5 - Flatfoot (Pes Planus) Disability Benefits Questionnaire Page 2
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4SECTION III - SIGNS AND SYMPTOMS (Continued)
3C. IS THERE INDICATION OF SWELLING ON USE?
YES
NO
Left
Both
Right
If "Yes," indicate side affected:
3D. DOES THE VETERAN HAVE CHARACTERISTIC CALLUSES (OR ANY CALLUSES CAUSED BY THE FLATFOOT CONDITION)?
YES
NO
Right
Left
Both
If "Yes," indicate side affected:
3E. ARE THE VETERAN'S SYMPTOMS RELIEVED BY ARCH SUPPORTS (OR BUILT UP SHOES OR ORTHOTICS)?
YES
NO
If "No," indicate side that remains symptomatic despite arch supports or orthotics:
Right
Left
Both
3F. DOES THE VETERAN HAVE EXTREME TENDERNESS OF PLANTAR SURFACES ON ONE OR BOTH FEET?
YES
NO
Right
Left
Both
If "Yes," indicate side affected:
Is the tenderness improved by orthopedic shoes or appliances?
YES
NO
SECTION IV - ALIGNMENT AND DEFORMITY
4A. DOES THE VETERAN HAVE DECREASED LONGITUDINAL ARCH HEIGHT ON WEIGHT-BEARING?
YES
NO
If "Yes," indicate side affected:
Right
Left
Both
(pronation, abduction etc.)
4B. IS THERE OBJECTIVE EVIDENCE OF MARKED DEFORMITY OF THE FOOT
?
YES
NO
If "Yes," indicate side affected:
Right
Left
Both
4C. IS THERE MARKED PRONATION OF THE FOOT?
YES
NO
Right
Left
Both
If "Yes," indicate side affected:
if "Yes," is the condition improved by orthopedic shoes or appliances?
YES
NO
4D. DOES THE WEIGHT-BEARING LINE FALL OVER OR MEDIAL TO THE GREAT TOE?
YES
NO
If "Yes," indicate side affected:
Right
Left
Both
4E. IS THERE A LOWER EXTREMITY DEFORMITY OTHER THAN PES PLANUS, CAUSING ALTERATION OF THE WEIGHT-BEARING LINE?
YES
NO
Right
Left
Both
If "Yes," indicate side affected:
Describe lower extremity deformity other than pes planus causing alteration of the weight bearing line:
(i.e., hindfoot valgus, with lateral deviation of the heel)
4F. DOES THE VETERAN HAVE "INWARD" BOWING OF THE ACHILLES' TENDON
?
YES
NO
If "Yes," indicate side affected:
Right
Left
Both
(rigid hindfoot)
4G. DOES THE VETERAN HAVE MARKED INWARD DISPLACEMENT AND SEVERE SPASM OF THE ACHILLES' TENDON
ON MANIPULATION?
YES
NO
Right
Left
Both
If "Yes," indicate side affected:
Is the marked inward displacement and severe spasm of the Achilles tendon improved by orthopedic shoes or appliances?
YES
NO
If "Yes," indicate side improved by orthopedic shoes or appliances:
Right
Left
Both
SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
(surgical or otherwise)
5A. DOES THE VETERAN HAVE ANY SCARS
RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
SECTION I, DIAGNOSIS?
YES
NO
IF YES, ARE ANY OF THE SCARS PAINFUL AND/OR UNSTABLE, OR IS THE TOTAL AREA OF ALL RELATED SCARS GREATER THAN OR EQUAL TO 39 SQUARE CM
(6 square inches)
?
YES
NO
IF YES, ALSO COMPLETE A VAF 21-0960F-1 Scars/Disfigurement Disability Benefits Questionnaire.
Page 2
VA FORM 21-0960M-5, OCT 2012
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