Va Form 21-0960c-2 - Amyotrophic Lateral Sclerosis (Lou Gehrig'S Disease) Disability Benefits Questionnaire Page 4
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SECTION IV - NEUROLOGIC EXAM
4D. DEEP TENDON REFLEXES (DTRs) - RATE REFLEXES ACCORDING TO THE FOLLOWING SCALE:
3+ Increased without clonus
0 Absent
1+ Decreased
2+ Normal
4+ Increased with clonus
ALL NORMAL
Biceps:
RIGHT:
0
1+
2+
3+
4+
LEFT:
0
1+
2+
3+
4+
RIGHT:
0
1+
2+
3+
4+
Triceps:
LEFT:
0
1+
2+
3+
4+
Brachioradialis:
RIGHT:
0
1+
2+
3+
4+
LEFT:
0
1+
2+
3+
4+
RIGHT:
0
1+
2+
3+
4+
Knee:
LEFT:
0
1+
2+
3+
4+
Ankle:
RIGHT:
0
1+
2+
3+
4+
LEFT:
0
1+
2+
3+
4+
4E. PLANTAR (Babinski) REFLEX
RIGHT:
Plantar flexion (normal, or negative Babinski)
Dorsiflexion (abnormal, or positive Babinski)
LEFT:
Plantar flexion (normal, or negative Babinski)
Dorsiflexion (abnormal, or positive Babinski)
4F. DOES THE VETERAN HAVE MUSCLE ATROPHY ATTRIBUTABLE TO ALS?
(If muscle atrophy is present, indicate location):
YES
NO
(When possible, provide difference measured in cm between normal and atrophied side, measured at maximum muscle bulk:
cm.)
(check all that apply):
4G. SUMMARY OF MUSCLE WEAKNESS IN THE UPPER AND/OR LOWER EXTREMITIES ATTRIBUTABLE TO ALS
(no remaining function)
Right upper extremity muscle weakness:
None
Mild
Moderate
Severe
With atrophy
Complete
(no remaining function)
Left upper extremity muscle weakness:
None
Mild
Moderate
Severe
With atrophy
Complete
(no remaining function)
Right lower extremity muscle weakness:
None
Mild
Moderate
Severe
With atrophy
Complete
(no remaining function)
Left lower extremity muscle weakness:
None
Mild
Moderate
Severe
With atrophy
Complete
NOTE: If the Veteran has more than one medical condition contributing to the muscle weakness, identify the condition(s) and describe each condition's contribution to
the muscle weakness:
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)?
(If "Yes," ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)
Yes
No
5B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS RELATED TO ALS?
(If "Yes," describe, brief summary):
YES
NO
SECTION VI - MENTAL HEALTH MANIFESTATIONS DUE TO ALS OR ITS TREATMENT
6A. DOES THE VETERAN HAVE DEPRESSION, COGNITIVE IMPAIRMENT OR DEMENTIA, OR ANY OTHER MENTAL DISORDER ATTRIBUTABLE TO ALS
AND/OR ITS TREATMENT?
(If "Yes," complete Item 6B)
YES
NO
6B. DOES THE VETERAN'S MENTAL DISORDER, AS IDENTIFIED IN ITEM 6A, RESULT IN GROSS IMPAIRMENT IN THOUGHT PROCESSES OR COMMUNICATION?
(If "Yes," ALSO complete VA Form 21-0960P-2, Mental Disorders (Other than PTSD) Disability Benefits Questionnaire)
YES
NO
(Schedule with appropriate provider)
(If "Yes," briefly describe the veteran's mental disorder):
Page 4
VA FORM 21-0960C-2, OCT 2012
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