OMB Control No. 2900-0776
Respondent Burden: 15 minutes
TEMPOROMANDIBULAR JOINT (TMJ) 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 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 A TEMPOROMANDIBULAR JOINT CONDITION?
(If "Yes," complete Item 1B)
YES
NO
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO TEMPOROMANDIBULAR JOINT CONDITIONS:
Diagnosis # 1:
ICD code:
Date of diagnosis:
Diagnosis # 2:
ICD code:
Date of diagnosis:
Diagnosis # 3:
ICD code:
Date of diagnosis:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO TEMPOROMANDIBULAR JOINT CONDITIONS LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
(Brief summary):
2. DESCRIBE THE HISTORY
OF THE VETERAN'S TEMPOROMANDIBULAR JOINT CONDITION
SECTION III - FLARE-UPS
3. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE TEMPOROMANDIBULAR JOINT?
YES
NO
IF YES, DOCUMENT THE VETERAN'S DESCRIPTION OF THE IMPACT OF FLARE-UPS ON FUNCTION IN HIS OR HER OWN WORDS:
SECTION IV - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS
Measure ROM. During the measurements, document the point at which painful motion begins, evidenced by visible behavior such as facial expression, wincing, etc.
Report initial measurements below.
Following the initial assessment of ROM, perform repetitive use testing. For VA purposes, repetitive use testing must be included in all joint exams. The VA has determined
that 3 repetitions of ROM (at a 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 V.
4A. ROM FOR LATERAL EXCURSION:
Greater than 4 mm
0 to 4 mm
SELECT WHERE EVIDENCE OF PAINFUL MOTION BEGINS:
No objective evidence of painful motion
Greater than 4 mm
0 to 4 mm
4B. ROM FOR OPENING MOUTH, MEASURED BY INTER-INCISAL DISTANCE:
Greater than 40 mm
31 to 40 mm
21 to 30 mm
11 to 20 mm
0 to 10 mm
VA FORM
SUPERSEDES VA FORM 21-0960M-15, JAN 2011,
21-0960M-15
Page 1
OCT 2012
WHICH WILL NOT BE USED.