Va Form 21-0960m-8 - Hip And Thigh Conditions Disability Benefits Questionnaire
Download a blank fillable Va Form 21-0960m-8 - Hip And Thigh Conditions Disability Benefits Questionnaire in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Va Form 21-0960m-8 - Hip And Thigh Conditions Disability Benefits Questionnaire with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6OMB Approved No. 2900-0776
Respondent Burden: 30 minutes
HIP AND THIGH 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
SECTION I - DIAGNOSIS
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.
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER HAD A HIP AND/OR THIGH CONDITION?
(If "Yes," complete Item 1B)
YES
NO
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO HIP AND/OR THIGH CONDITIONS:
Diagnosis # 1 -
ICD code -
Date of diagnosis -
SIDE AFFECTED
RIGHT
LEFT
BOTH
Diagnosis # 2 -
ICD code -
Date of diagnosis -
SIDE AFFECTED
RIGHT
LEFT
BOTH
Diagnosis # 3 -
ICD code -
Date of diagnosis -
SIDE AFFECTED
RIGHT
LEFT
BOTH
1C. IF THERE ARE ADDITIONAL DIAGNOSES PERTAINING TO HIP AND/OR THIGH CONDITIONS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
(Brief summary):
2. DESCRIBE THE HISTORY
OF THE VETERAN'S CURRENT HIP AND/OR THIGH CONDITION(S)
SECTION III - FLARE-UPS
3. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE HIP AND/OR THIGH?
(If "Yes," document the veteran's description of the impact of flare-ups in his or her own words):
YES
NO
SECTION IV - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS
MEASURE ROM WITH A GONIOMETER, ROUNDING EACH MEASUREMENT TO THE NEAREST 5 DEGREES. 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 REPTITIONS. REPORT POST-TEST MEASUREMENTS IN SECTION 5.
4A. RIGHT HIP FLEXION
Select where flexion ends (normal endpoint is 125 degrees):
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125 or greater
Select where objective evidence of painful motion begins:
No objective evidence of painful motion
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125 or greater
4B. RIGHT HIP EXTENSION
Select where extension ends:
0
5
Greater than 5
Select where objective evidence of painful motion begins:
No objective evidence of painful motion
0
5
Greater than 5
Is abduction lost beyond 10 degrees?
YES
NO
Is adduction limited such that the Veteran cannot cross legs?
YES
NO
Is rotation limited such that the Veteran cannot toe-out more than 15 degrees?
YES
NO
VA FORM
SUPERSEDES VA FORM 21-0960M-8, JAN 2011,
21-0960M-8
Page 1
OCT 2012
WHICH WILL NOT BE USED.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal