Va Form 21-0960m-13 - Neck (Cervical Spine) Disability Benefits Questionnaire

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OMB Control No. 2900-0779

Respondent Burden: 45 minutes

NECK (CERVICAL SPINE) 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 THIS 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

(neck)

1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH A CERVICAL SPINE

CONDITION?

YES

(neck)

1B. PROVIDE DIAGNOSES THAT PERTAIN TO CERVICAL SPINE

CONDITION(S):

DIAGNOSIS # 1 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 2 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 3 -

ICD CODE -

DATE OF DIAGNOSIS -

(neck)

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO CERVICAL SPINE

CONDITIONS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY

(including onset and course)

(neck)

(brief summary):

2A. DESCRIBE THE HISTORY

OF THE VETERAN'S CERVICAL SPINE

CONDITION

(neck)

2B. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE CERVICAL SPINE

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

YES

(ROM)

SECTION III - INITIAL RANGE OF MOTION

MEASUREMENTS

3. MEASURE ROM WITH A GONIOMETER, ROUNDING EACH MEASUREMENT TO THE NEAREST 5 DEGREES. DURING THE MEASUREMENTS, OBSERVE THE

POINT AT WHICH PAINFUL MOTION BEGINS, EVIDENCED BY VISIBLE BEHAVIOR SUCH AS FACIAL EXPRESSION, WINCING, ETC. REPORT INITIAL

MEASUREMENTS BELOW.

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

determined that 3 repetitions of ROM 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.

(normal endpoint is 45 degrees)

A. SELECT WHERE FORWARD FLEXION ENDS

45 or greater

SELECT WHERE OBJECTIVE EVIDENCE OF PAINFUL MOTION BEGINS:

NO OBJECTIVE EVIDENCE OF PAINFUL MOTION

45 or greater

(normal endpoint is 45 degrees)

B. SELECT WHERE EXTENSION ENDS

45 or greater

SELECT WHERE OBJECTIVE EVIDENCE OF PAINFUL MOTION BEGINS:

NO OBJECTIVE EVIDENCE OF PAINFUL MOTION