Va Form 21-0960m-8 - Hip And Thigh Conditions Disability Benefits Questionnaire Page 2
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64C. LEFT 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
4D. LEFT 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
(for reasons other than a hip condition, such as age, body
4E. If ROM does not conform to the normal range of motion identified above but is normal for this veteran
habitus, neurologic disease)
, explain:
SECTION V - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING
5A. IS VETERAN ABLE TO PERFORM REPETITIVE-USE TESTING WITH 3 REPETITIONS?
(If unable, provide reason):
YES
NO
(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. RIGHT HIP POST-TEST ROM
Select where post-test flexion ends:
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 post-test extension ends:
0
5 or greater
Is post-test adduction lost beyond 10 degrees?
YES
NO
Is post-test adduction limited such that the veteran cannot cross legs?
YES
NO
Is post-test rotation limited such that the veteran cannot toe-out more than 15 degrees?
YES
NO
5C. LEFT HIP POST-TEST ROM
Select where post-test flexion ends:
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 post-test extension ends:
0
5 or greater
Is post-test adduction lost beyond 10 degrees?
YES
NO
Is post-test adduction limited such that the veteran cannot cross legs?
YES
NO
Is post-test rotation limited such that the veteran cannot toe-out more than 15 degrees?
YES
NO
Page 2
VA FORM 21-0960M-8, OCT 2012
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