Va Form 21-0960m-8 - Hip And Thigh Conditions Disability Benefits Questionnaire Page 3
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6SECTION VI - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION IN ROM
NOTE: 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 INABLILITY 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 THE HIP AND THIGH FOLLOWING REPETITIVE-USE TESTING?
YES
NO
6B. DOES THE VETERAN HAVE ANY FUNCTIONAL LOSS AND/OR FUNCTIONAL IMPAIRMENT OF THE HIP AND THIGH?
YES
NO
6C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT AND/OR ADDITIONAL LIMITATION OF ROM OF THE HIP AND THIGH AFTER
(check all that apply and indicate side affected):
REPETITIVE USE, INDICATE THE CONTRIBUTING FACTORS OF DISABILITY BELOW
NO FUNCTIONAL LOSS FOR RIGHT LOWER EXTREMITY
NO FUNCTIONAL LOSS FOR LEFT LOWER EXTREMITY
LESS MOVEMENT THAN NORMAL
Right
Left
Both
MORE MOVEMENT THAN NORMAL
Right
Left
Both
WEAKENED MOVEMENT
Right
Left
Both
EXCESS FATIGABILITY
Right
Left
Both
Right
Left
Both
INCOORDINATION, IMPAIRED ABILITY
TO EXECUTE SKILLED MOVEMENTS
SMOOTHLY
PAIN ON MOVEMENT
Right
Left
Both
SWELLING
Right
Left
Both
DEFORMITY
Right
Left
Both
ATROPHY OF DISUSE
Right
Left
Both
INSTABILITY OF STATION
Right
Left
Both
DISTURBANCE OF LOCOMOTION
Right
Left
Both
INTERFERENCE WITH SITTING,
Right
Left
Both
STANDING AND OR WEIGHT-BEARING
SECTION VII - PAIN (PAIN ON PALPATION)
7. DOES THE VETERAN HAVE LOCALIZED TENDERNESS OR PAIN TO PALPATION FOR JOINTS/SOFT TISSUE OF EITHER HIP?
(If "Yes," side affected):
YES
NO
Right
Left
Both
SECTION VIII - MUSCLE STRENGTH TESTING
8. RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE:
0/5 No muscle movement
1/5 Palpable or visible muscle contraction, but no joint movement
2/5 Active movement with gravity eliminated
3/5 Active movement against gravity
4/5 Active movement against some resistance
5/5 Normal strength
Hip flexion:
Right:
5/5
4/5
3/5
2/5
1/5
0/5
Left:
5/5
4/5
3/5
2/5
1/5
0/5
Hip abduction:
Right:
5/5
4/5
3/5
2/5
1/5
0/5
Left:
5/5
4/5
3/5
2/5
1/5
0/5
Hip extension:
Right:
5/5
4/5
3/5
2/5
1/5
0/5
Left:
5/5
4/5
3/5
2/5
1/5
0/5
SECTION IX - ANKYLOSIS
9A. DOES THE VETERAN HAVE ANKYLOSIS OF EITHER HIP JOINT?
(If "Yes," complete Item 9B)
YES
NO
9B. INDICATE SEVERITY AND SIDE AFFECTED:
FAVORABLE, IN FLEXION AT AN ANGLE BETWEEN 20 AND 40 DEGREES, AND SLIGHT ADDUCTION OR ABDUCTION
Right
Left
Both
INTERMEDIATE, BETWEEN FAVORABLE AND UNFAVORABLE
Right
Left
Both
UNFAVORABLE, EXTREMELY UNFAVORABLE ANKYLOSIS, FOOT NOT REACHING GROUND, CRUTCHES NEEDED
Right
Left
Both
Page 3
VA FORM 21-0960M-8, OCT 2012
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