Va Form 21-0960m-11 - Osteomyelitis Disability Benefits Questionnaire Page 2
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4SECTION II - MEDICAL HISTORY (continued)
2D. HAS THE VETERAN HAD SURGICAL TREATMENT FOR OSTEOMYELITIS?
YES
NO
(If "Yes," indicate surgical procedure and date (if multiple procedures, indicate below)):
Procedure #1:
Date:
Facility:
Procedure #2:
Date:
Facility:
If additional surgical procedures, list using above format:
2E. PROVIDE STATUS OF THE VETERAN'S CURRENT OSTEOMYELITIS CONDITION:
ACUTE
SUBACUTE
CHRONIC
INACTIVE
RESOLVED
OTHER describe:
SECTION III - RECURRENT INFECTIONS
3A. HAS THE VETERAN HAD ANY ADDITIONAL EPISODES OR RECURRING INFECTIONS OF OSTEOMYELITIS FOLLOWING THE INITIAL INFECTION?
(If "Yes," complete questions 3B and 3C) (If "No," skip to Section IV)
YES
NO
(If "Yes," indicate number of additional episodes):
1
2
3
4
5 or more
(check all that apply)
3B. LOCATION OF RECURRENT INFECTIONS
:
PELVIS
CERVICAL VERTEBRAE
THORACOLUMBAR VERTEBRAE
Right
Left
LONG BONES OF UPPER EXTREMITY
Side affected:
Right
Left
LONG BONES OF LOWER EXTREMITY
Side affected:
FINGER(S):
Right digit(s) affected:
Left digit(s) affected:
TOE(S):
Right digit(s) affected:
Left digit(s) affected:
OTHER, Specify:
EXTENSION INTO JOINTS
(If checked, indicate joints affected)
:
Right:
Shoulder
Elbow
Wrist
Hip
Knee
Ankle
Multiple hand joints
Multiple foot joints
Left:
Shoulder
Elbow
Wrist
Hip
Knee
Ankle
Multiple hand joints
Multiple foot joints
OTHER, Specify:
3C. DATES OF RECURRENT INFECTION
Indicate dates of recurrences:
Date of recurrence #1:
Site of recurrent infection:
Date of recurrence #2:
Site of recurrent infection:
Date of recurrence #3:
Site of recurrent infection:
If there are additional recurrences, list using above format:
SECTION IV - SIGNS, SYMPTOMS AND FINDINGS
4A. DOES THE VETERAN CURRENTLY HAVE ANY SIGNS OR FINDINGS ATTRIBUTABLE TO OSTEOMYELITIS OR TREATMENT FOR OSTEOMYELITIS?
(If "Yes," check all that apply):
YES
NO
Involucrum
Sequestrum
Discharging sinus
Amyloidosis secondary to chronic infection
Anemia
(If checked, provide CBC results in diagnostic testing section).
Decreased joint function or range of motion due to osteomyelitis or residuals of treatment
If checked, indicate affected joints and ALSO complete appropriate Questionnaire for each affected joint and/or spinal segment.
Right:
Shoulder
Elbow
Wrist
Hip
Knee
Ankle
Single foot joint
Multiple hand joints
Multiple foot joints
Single hand joint
Left:
Shoulder
Elbow
Wrist
Hip
Knee
Ankle
Single foot joint
Multiple hand joints
Multiple foot joints
Single hand joint
Cervical vertebral joint(s)
Thoracolumbar vertebral joint(s) Specific vertebral joint(s) affected
VA FORM 21-0960M-11, OCT 2012
Page 2
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