Va Form 21-0960m-11 - Osteomyelitis Disability Benefits Questionnaire Page 3
Download a blank fillable Va Form 21-0960m-11 - Osteomyelitis 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-11 - Osteomyelitis 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
4SECTION IV - SIGNS, SYMPTOMS AND FINDINGS (continued)
4B. DOES THE VETERAN CURRENTLY HAVE ANY SYMPTOMS ATTRIBUTABLE TO OSTEOMYELITIS OR TREATMENT FOR OSTEOMYELITIS?
YES
NO
(If "Yes," check all that apply):
(If checked, describe severity, duration and location)
Pain
:
(If checked, describe severity, duration and location)
Swelling
:
(If checked, describe severity, duration and location)
Tenderness
:
(If checked, describe severity, duration and location)
Erythema
:
(If checked, describe severity, duration and location)
Warmth
:
(If checked, describe symptoms and duration)
Malaise
:
Other Symptoms, describe:
SECTION V - AMPUTATION
5. HAS THE VETERAN HAD AN AMPUTATION DUE TO OSTEOMYELITIS?
YES
NO
(If "Yes," also complete VA Form 21-0960M-1 Amputations Disability Benefits Questionnaire)
SECTION VI - ASSISTIVE DEVICES
6A. DOES THE VETERAN USE ANY ASSISTIVE DEVICES AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS
MAY BE POSSIBLE?
YES
NO
(If "Yes," identify assistive devices used (check all that apply and indicate frequency):
Wheelchair
Frequency of use:
Occasional
Regular
Constant
Brace(s)
Frequency of use:
Occasional
Regular
Constant
Crutch(es)
Frequency of use:
Occasional
Regular
Constant
Cane(s)
Frequency of use:
Occasional
Regular
Constant
Walker
Frequency of use:
Occasional
Regular
Constant
Other:
Frequency of use:
Occasional
Regular
Constant
(If the veteran uses any assistive devices, specify the condition and identify the assitive device used for each condition):
SECTION VII - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
7. DUE TO THE VETERAN'S OSTEOMYELITIS OR RESIDUALS OF TREATMENTS, IS THERE FUNCTIONAL IMPAIRMENT OF AN EXTREMITY SUCH THAT NO
(Functions of the
EFFECTIVE FUNCTION REMAINS OTHER THAN THAT WHICH WOULD BE EQUALLY WELL SERVED BY AN AMPUTATION WITH PROSTHESIS?
upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.)
YES, FUNCTIONING IS SO DIMINISHED THAT AMPUTATION WITH PROSTHESIS WOULD EQUALLY SERVE THE VETERAN
NO
(If "Yes," indicate extremities for which this applies):
Right upper
Left upper
Right lower
Left lower
(brief summary)
For each checked extremity, identify the condition causing loss of function, describe loss of effective function and provide specific examples
VA FORM 21-0960M-11, OCT 2012
Page 3
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal