Va Form 21-0960m-8 - Hip And Thigh Conditions Disability Benefits Questionnaire Page 4
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6SECTION X - ADDITIONAL CONDITIONS
10. DOES THE VETERAN HAVE MALUNION OR NONUNION OF FEMUR, FLAIL HIP JOINT OR LEG LENGTH DISCREPANCY?
YES
NO
(If "Yes," indicate condition and complete the appropriate sections below):
MALUNION OR NONUNION OF THE FEMUR
If checked, indicate condition and complete the appropriate sections below.
Malunion with slight hip disability
Right
Left
Both
Malunion with moderate hip disability
Right
Left
Both
Malunion with marked hip disability
Right
Left
Both
Fracture of surgical neck with false joint
Right
Left
Both
(anatomical)
Fracture of shaft or neck
,
Right
Left
Both
resulting in nonunion without loose motion;
weight-bearing preserved with
aid of a brace
(anatomical)
Fracture of shaft or neck
, with
Right
Left
Both
(spiral or
nonunion with loose motion;
oblique fracture)
NOTE: If impairment of the femur causes knee disability, also complete VA Form 21-0960M-9, Knee and Lower Leg Conditions
Disability Benefits Questionnaire.
FLAIL HIP JOINT
If checked, indicate hip affected:
Right
Left
Both
(shortening of any bones of the lower extremity)
LEG LENGTH DISCREPANCY
If checked, provide length of each lower extremity in inches (to the nearest 1/4 inch) or centimeters, measuring from the anterior superior
iliac spine to the internal malleolus of the tibia.
Measurements: Right leg:
cm
inches
Left leg:
cm
inches
SECTION XI - JOINT REPLACEMENT AND OTHER SURGICAL PROCEDURES
11A. HAS THE VETERAN HAD A TOTAL HIP JOINT REPLACEMENT?
(If "Yes," indicate side and severity of residuals):
YES
NO
Right hip
Date of surgery:
Residuals:
None
Intermediate degrees of residual weakness, pain and/or limitation of motion
Chronic residuals consisting of severe painful motion and/or weakness
Other, describe:
Left hip
Date of surgery:
Residuals:
None
Intermediate degrees of residual weakness, pain and/or limitation of motion
Chronic residuals consisting of severe painful motion and/or weakness
Other, describe:
11B. HAS THE VETERAN HAD ARTHROSCOPIC OR OTHER HIP SURGERY?
(If "Yes," indicate side affected):
YES
NO
Right
Left
Both
Date and type of surgery:
11C. DOES THE VETERAN HAVE ANY RESIDUAL SIGNS AND/OR SYMPTOMS DUE TO ARTHROSCOPIC OR OTHER HIP SURGERY?
(If "Yes," indicate side affected):
YES
NO
Right
Left
Both
(If "Yes," describe residuals):
SECTION XII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
(surgical or otherwise)
12A. DOES THE VETERAN HAVE ANY SCARS
RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED
IN SECTION I, DIAGNOSIS?
YES
NO
(If "Yes," are any of the scars painful and/or unstable, or is the total area of all related scars greater than or equal to 39 square cm (6 square inches?))
YES
NO
(If "Yes," also complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)
Page 4
VA FORM 21-0960M-8, OCT 2012
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