Va Form 21-0960m-13 - Neck (Cervical Spine) Disability Benefits Questionnaire Page 4
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6SECTION IX - SENSORY EXAM
(dermatomes)
9. SENSORY EXAM - PROVIDE RESULTS FOR SENSATION TO LIGHT TOUCH
TESTING:
ALL NORMAL
Shoulder area (C5)
Right
Normal
Decreased
Absent
Left
Normal
Decreased
Absent
Inner/Outer forearm (C6/T1)
Right
Normal
Decreased
Absent
Left
Normal
Decreased
Absent
Hand/fingers (C6-C8)
Right
Normal
Decreased
Absent
Left
Normal
Decreased
Absent
OTHER SENSORY FINDINGS, IF ANY:
SECTION X - RADICULOPATHY HISTORY AND NEUROLOGIC EXAM
10A. DOES THE VETERAN HAVE RADICULAR PAIN OR ANY OTHER SIGNS OR SYMPTOMS DUE TO RADICULOPATHY?
(If "Yes," complete this section, check all that apply) (If "No," skip to section XI)
YES
NO
(may be excruciating at times)
CONSTANT PAIN
Right upper extremity:
None
Mild
Moderate
Severe
Left upper extremity:
None
Mild
Moderate
Severe
(usually dull)
INTERMITTENT PAIN
Right upper extremity:
None
Mild
Moderate
Severe
Left upper extremity:
None
Mild
Moderate
Severe
PARESTHESIAS AND/OR DYSESTHESIAS
Right upper extremity:
None
Mild
Moderate
Severe
Left upper extremity:
None
Mild
Moderate
Severe
NUMBNESS
Right upper extremity:
None
Mild
Moderate
Severe
Left upper extremity:
None
Mild
Moderate
Severe
10B. DOES THE VETERAN HAVE ANY OTHER SIGNS OR SYMPTOMS OF RADICULOPATHY?
(If "Yes," describe):
YES
NO
(Check all that apply)
10C. INDICATE NERVE ROOTS INVOLVED:
(upper radicular group)
Involvement of C5/C6 nerve roots
(middle radicular group)
Involvement of C7 nerve roots
(lower radicular group)
Involvement of C8/T1 nerve roots
10D. INDICATE SEVERITY OF RADICULPATHY AND SIDE AFFECTED:
(NOTE: For VA purposes, when the involvement is wholly sensory, the evaluation should be for the mild, or at most, the moderate degree)
Right
Not affected
Mild
Moderate
Severe
Left
Not affected
Mild
Moderate
Severe
SECTION XI - OTHER NEUROLOGIC ABNORMALITIES
(neck)
(such as bowel or bladder
11. DOES THE VETERAN HAVE ANY OTHER NEUROLOGIC ABNORMALITIES RELATED TO A CERVICAL SPINE
CONDITION
problems due to cervical myelopathy)?
YES
NO
(If "Yes," describe
).
Also complete the appropriate questionnaire, if indicated)
(IVDS)
SECTION XII - INTERVERTEBRAL DISC SYNDROME
12A. DOES THE VETERAN HAVE IVDS OF THE CERVICAL SPINE?
(If "Yes," complete Item 12B)
YES
NO
12B. HAS THE VETERAN HAD ANY INCAPACITATING EPISODES OVER THE PAST 12 MONTHS DUE TO IVDS?
(If "Yes," complete Item 12C)
YES
NO
Note: for VA purposes, an incapacitating episode is a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician.
12C. PROVIDE THE TOTAL DURATION OVER THE PAST 12 MONTHS:
Less than 1 week
At least 1 week but less than 2 weeks
At least 2 weeks but less than 4 weeks
At least 4 weeks but less than 6 weeks
At least 6 weeks
Page 4
VA FORM 21-0960M-13, OCT 2012
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