Va Form 21-0960m-13 - Neck (Cervical Spine) Disability Benefits Questionnaire Page 2
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2
3
4
5
6(ROM)
(Continued)
SECTION III - INITIAL RANGE OF MOTION
MEASUREMENTS
(normal endpoint is 80 degrees)
E. SELECT WHERE RIGHT LATERAL ROTATION ENDS
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80 or greater
SELECT WHERE OBJECTIVE EVIDENCE OF PAINFUL MOTION BEGINS:
NO OBJECTIVE EVIDENCE OF PAINFUL MOTION
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80 or greater
(normal endpoint is 80 degrees)
F. SELECT WHERE LEFT LATERAL ROTATION ENDS
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80 or greater
SELECT WHERE OBJECTIVE EVIDENCE OF PAINFUL MOTION BEGINS:
NO OBJECTIVE EVIDENCE OF PAINFUL MOTION
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80 or greater
(for reasons other than a cervical spine (neck) condition, such as
G. If ROM does not conform to the normal range of motion identified above but is normal for this veteran
age, body habitus, neurologic disease)
, explain:
SECTION IV - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING
4.A. IS A VETERAN ABLE TO PERFORM REPETITIVE-USE TESTING WITH 3 REPETITIONS?
(If unable, provide reason):
YES
NO
(If veteran is unable to perform repetitive-use testing, skip to Section V)
(If veteran is able to perform repetitive-use testing, measure and report ROM after a minimum of 3 repetitions)
B. SELECT WHERE POST-TEST FORWARD FLEXION ENDS:
0
5
10
15
20
25
30
35
40
45 or greater
C. SELECT WHERE POST-TEST EXTENSION ENDS:
0
5
10
15
20
25
30
35
40
45 or greater
D. SELECT WHERE POST-TEST RIGHT LATERAL FLEXION ENDS:
0
5
10
15
20
25
30
35
40
45 or greater
E. SELECT WHERE POST-TEST LEFT LATERAL FLEXION ENDS:
0
5
10
15
20
25
30
35
40
45 or greater
F. SELECT WHERE POST-TEST RIGHT LATERAL ROTATION ENDS:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80 or greater
G. SELECT WHERE POST-TEST LEFT LATERAL ROTATION ENDS:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80 or greater
SECTION V - FUNCTIONAL LOSS
NOTE: The following section addresses reasons for functional loss, if present, and additional loss of ROM after repetitive-use testing, if present. The VA defines
functional loss as the inability to perform normal working movements of the body with normal excursion, strength, speed, coordination and/or endurance.
(neck)
5A. DOES THE VETERAN HAVE ADDITIONAL LIMITATION IN ROM OF THE CERVICAL SPINE
FOLLOWING REPETITIVE-USE TESTING?
YES
NO
(neck)?
5B. DOES THE VETERAN HAVE ANY FUNCTIONAL LOSS AND/OR FUNCTIONAL IMPAIRMENT OF THE CERVICAL SPINE
YES
NO
(neck)
5C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT AND/OR ADDITIONAL LIMITATION OF ROM OF THE CERVICAL SPINE
AFTER
REPETITIVE USE, INDICATE THE CONTRIBUTING FACTORS OF DISABILITY BELOW.
No
ITEM
YES
NO
1
Less movement than normal
2
More movement than normal
3
Weakened movement
4
Excess fatigability
5
Incoordination, impaired ability to execute skilled movements smoothly
6
Pain on movement
7
Swelling
8
Deformity
9
Atrophy of disuse
10
Instability of station
11
Disturbance of locomotion
12
Interference with sitting, standing and/or weight-bearing
13
Other, describe:
Page 2
VA FORM 21-0960M-13, OCT 2012
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