Va Form 21-0960m-7 - Hand And Finger Conditions Disability Benefits Questionnaire

Download a blank fillable Va Form 21-0960m-7 - Hand And Finger Conditions 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-7 - Hand And Finger Conditions 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.

OMB Approved No. 2900-0776

Respondent Burden: 30 minutes

HAND AND FINGER CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE

IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE

PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION

BEFORE COMPLETING FORM.

NAME OF PATIENT/VETERAN

PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

NOTE TO PHYSICIAN: Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you

provide on this questionnaire as part of their evaluation in processing the veteran's claim.

SECTION I - DIAGNOSIS

1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER HAD A HAND OR FINGER CONDITION?

(If "Yes," provide only diagnoses that pertain to hand and finger conditions in Item 1B):

YES

1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO HAND AND FINGER CONDITION(S):

SIDE AFFECTED

DIAGNOSIS #1 -

ICD CODE -

DATE OF DIAGNOSIS -

Right

Left

Both

SIDE AFFECTED

DIAGNOSIS #2 -

ICD CODE -

DATE OF DIAGNOSIS -

Right

Left

Both

SIDE AFFECTED

DIAGNOSIS #3 -

ICD CODE -

DATE OF DIAGNOSIS -

Right

Left

Both

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO HAND AND FINGER CONDITIONS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY

(including onset and course)

(Brief summary

2A. DESCRIBE THE HISTORY

OF THE VETERAN'S HAND OR FINGER CONDITION(S)

2B. DOMINANT HAND

Right

Left

Ambidextrous

2C. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE HAND?

YES

If "Yes," document the veteran's description of the impact of flare-ups in his or her own words:

SECTION III - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS

NOTE: Measure ROM with a goniometer, rounding each measurement to the nearest 5 degrees. During the measurements, document the point at which painful motion

begins, evidenced by visible behavior such as facial expression, wincing, etc. Report initial measurements below.

Following the initial assessment of ROM, perform repetitive use testing. For VA purposes, repetitive use testing must be included in all joint exams. The VA has

determined that 3 repetitions of ROM (at a minimum) can serve as a representative test of the effect of repetitive use. After the initial measurement, reassess ROM

after 3 repetitions. Report post-test measurements in Section IV.

3A. IS THERE LIMITATION OF MOTION OR EVIDENCE OF PAINFUL MOTION FOR ANY FINGERS AND/OR THUMBS?

YES

If "No," skip to Section IV

If "Yes," indicate digit(s) affected: (check all that apply)

Right:

Thumb

Index finger

Long finger

Ring finger

Little finger

Left: