Va Form 21-0960m-13 - Neck (Cervical Spine) Disability Benefits Questionnaire Page 3
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6(PAIN ON PALPATION, EFFECT OF MUSCLE SPASM ON GAIT)
SECTION VI - PAIN AND MUSCLE SPASM
(neck)?
6A. DOES THE VETERAN HAVE LOCALIZED TENDERNESS OR PAIN TO PALPATION FOR JOINTS/SOFT TISSUE OF THE CERVICAL SPINE
YES
NO
(neck)?
6B. DOES THE VETERAN HAVE GUARDING OR MUSCLE SPASM OF THE CERVICAL SPINE
(If "Yes," is it severe enough to result in): (Check all that apply)
YES
NO
Abnormal gait
Abnormal spinal contour
Guarding or muscle spasm is present, but do not result in abnormal gait or spinal contour
SECTION VII - MUSCLE STRENGTH
7A. MUSCLE STREGTH TRAINING - RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE:
0/5 No muscle movement
1/5 Palpable or visible muscle contraction, but no joint movement
2/5 Active movement with gravity eliminated
3/5 Active movement against gravity
4/5 Active movement against some resistance
5/5 Normal strength
ALL NORMAL
:
ELBOW FLEXION
Right
5/5
4/5
3/5
2/5
1/5
0/5
Left
5/5
4/5
3/5
2/5
1/5
0/5
:
ELBOW EXTENSION
Right
5/5
4/5
3/5
2/5
1/5
0/5
Left
5/5
4/5
3/5
2/5
1/5
0/5
WRIST FLEXION
Right
5/5
4/5
3/5
2/5
1/5
0/5
Left
5/5
4/5
3/5
2/5
1/5
0/5
:
WRIST EXTENSION
Right
5/5
4/5
3/5
2/5
1/5
0/5
Left
5/5
4/5
3/5
2/5
1/5
0/5
:
FINGER FLEXION
Right
5/5
4/5
3/5
2/5
1/5
0/5
Left
5/5
4/5
3/5
2/5
1/5
0/5
:
FINGER ABDUCTION
Right
5/5
4/5
3/5
2/5
1/5
0/5
Left
5/5
4/5
3/5
2/5
1/5
0/5
7B. DOES THE VETERAN HAVE MUSCLE ATROPHY?
YES
NO
(If muscle atrophy is present, indicate location:
and provide measurements in centimeters of normal side and atrophied side, measured at maximum muscle bulk: Normal side:
cm. Atrophied side:
cm.
SECTION VIII - REFLEX EXAM
(DTRs)
8. REFLEX EXAM - RATE DEEP TENDON REFLEXES
ACCORDING TO THE FOLLOWING SCALE:
0 Absent
1+ Hypoactive
2+ Normal
3+ Hyperactive without clonus
4+ Hyperactive with clonus
ALL NORMAL
BICEPS:
Right
0
1+
2+
3+
4+
Left
0
1+
2+
3+
4+
TRICEPS:
Right
0
1+
2+
3+
4+
Left
0
1+
2+
3+
4+
BRACHIORADIALIS:
Right
0
1+
2+
3+
4+
Left
0
1+
2+
3+
4+
Page 3
VA FORM 21-0960M-13, OCT 2012
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