Va Form 21-0960m-5 - Flatfoot (Pes Planus) Disability Benefits Questionnaire Page 3

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SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS (Continued)

5B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY

CONDITIONS LISTED IN SECTION 1, DIAGNOSIS?

YES

(brief summary):

IF YES, DESCRIBE

SECTION VI - ASSISTIVE DEVICES

(other than corrective shoes or orthotic inserts)

6A. DOES THE VETERAN USE ANY ASSISTIVE DEVICES

AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH

OCCASIONAL LOCOMOTION BY OTHER METHODS MAY BE POSSIBLE?

YES

(check all that apply and indicate frequency):

IF YES, IDENTIFY ASSISTIVE DEVICE(S) USED

Wheelchair

Frequency of use:

Occasional

Regular

Constant

Brace(s)

Frequency of use:

Occasional

Regular

Constant

Crutch(es)

Frequency of use:

Occasional

Regular

Constant

Cane(s)

Frequency of use:

Occasional

Regular

Constant

Walker

Frequency of use:

Occasional

Regular

Constant

Other:

Frequency of use:

Occasional

Regular

Constant

6B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:

SECTION VII - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES

7. DUE TO THE VETERAN'S FLATFOOT CONDITION, IS THERE FUNCTIONAL IMPAIRMENT OF AN EXTREMITY SUCH THAT NO EFFECTIVE FUNCTION REMAINS

(Functions for the lower extremity include balance and

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

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 LOWER

LEFT LOWER

(brief summary):

IDENTIFY THE CONDITION CAUSING LOSS OF FUNCTION, DESCRIBE LOSS OF EFFECTIVE FUNCTION AND PROVIDE SPECIFIC EXAMPLES

SECTION VIII - DIAGNOSTIC TESTING

NOTE - Plain or weight-bearing foot x-rays are not required to make the diagnosis of flatfoot. The diagnosis of degenerative arthritis (osteoarthritis) or traumatic

arthritis must be confirmed by imaging studies. Once such arthritis has been documented, no further imaging studies are required by VA, even if arthritis has worsened.

8A. HAVE IMAGING STUDIES OF THE FOOT BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?

YES

IF YES, IS DEGENERATIVE OR TRAUMATIC ARTHRITIS DOCUMENTED?

YES

IF YES, INDICATE FOOT:

Right

Left

Both

8B. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDING AND/OR RESULTS?

YES

(brief summary):

IF YES, PROVIDE TYPE OF TEST OR PROCEDURE, DATE AND RESULTS