(Continued)
SECTION IV - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS
(Continued)
4B. ROM FOR OPENING MOUTH, MEASURED BY INTER-INCISAL DISTANCE
SELECT WHERE OBJECTIVE EVIDENCE OF PAINFUL MOTION BEGINS:
No objective evidence of painful motion
Greater than 40 mm
31 to 40 mm
21 to 30 mm
11 to 20 mm
0 to 10 mm
(for reasons other than a
4C. IF ROM DOES NOT CONFORM TO THE NORMAL RANGE OF MOTION IDENTIFIED ABOVE BUT IS NORMAL FOR THIS VETERAN
temporomandibular joint condition, such as age, body habitus, neurologic disease)
, EXPLAIN:
SECTION V - ROM MEASUREMENT AFTER REPETITIVE USE TESTING
5A. IS THE VETERAN ABLE TO PERFORM REPETITIVE-USE TESTING WITH 3 REPETITIONS?
YES
NO
IF UNABLE, PROVIDE REASON:
If veteran is unable to perform repetitive-use testing, skip to Section VI
If veteran is able to perform repetitive-use testing, measure and report ROM after a minimum of 3 repetitions.
5B. POST-TEST ROM FOR LATERAL EXCURSION:
0 to 4 mm
Greater than 4 mm
5C. POST-TEST 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
SECTION VI - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION IN ROM
The following section addresses reasons for functional loss, if present, and additional loss of ROM after repetitive-use testing, if present. The VA defines functional loss as the
inability to perform normal working movements of the body with normal excursion, strength, speed, coordination and/or endurance.
6A. DOES THE VETERAN HAVE ADDITIONAL LIMITATION IN ROM OF EITHER TMJ FOLLOWING REPETITIVE-USE TESTING?
YES
NO
6B. DOES THE VETERAN HAVE ANY FUNCTIONAL LOSS OR FUNCTIONAL IMPAIRMENT OF EITHER TMJ?
YES
NO
6C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT AND/OR ADDITIONAL LIMITATION OF ROM OF EITHER TMJ AFTER REPETITIVE USE,
(Check all that apply and indicate side affected):
INDICATE THE CONTRIBUTING FACTORS OF DISABILITY BELOW
Right
Left
Both
No functional loss for right TMJ
Right
Left
Both
No functional loss for left TMJ
Right
Left
Both
Less movement than normal
Right
Left
Both
More movement than normal
Weakened movement
Right
Left
Both
Pain on movement
Right
Left
Both
Right
Left
Both
Excess fatigability
Incoordination, impaired ability to execute
Right
Left
Both
skilled movements smoothly
Right
Left
Both
Swelling
Deformity
Right
Left
Both
SECTION VII - PAIN (PAIN ON PALPATION) AND CREPITUS
7A. DOES THE VETERAN HAVE LOCALIZED TENDERNESS OR PAIN ON PALPATION OF JOINTS OR SOFT TISSUES OF EITHER TMJ?
YES
NO
Right
Left
Both
IF YES, SIDE AFFECTED:
7B. DOES THE VETERAN HAVE CLICKING OR CREPITATION OF JOINTS OR SOFT TISSUES OF EITHER TMJ?
YES
NO
Right
Left
Both
IF YES, SIDE AFFECTED:
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VA FORM 21-0960M-15, OCT 2012
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