Va Form 21-0960m-12 - Shoulder And Arm Conditions Disability Benefits Questionnaire
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6OMB Approved No. 2900-0776
Respondent Burden: 30 minutes
SHOULDER AND ARM 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 SHOULDER AND/OR ARM CONDITION?
(If "Yes," complete Item 1B)
YES
NO
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO SHOULDER AND/OR ARM CONDITIONS
DIAGNOSIS # 1 -
ICD CODE -
DATE OF DIAGNOSIS:
SIDE AFFECTED:
RIGHT
LEFT
BOTH
DIAGNOSIS # 2 -
ICD CODE -
DATE OF DIAGNOSIS:
SIDE AFFECTED:
RIGHT
LEFT
BOTH
DIAGNOSIS # 3 -
ICD CODE -
DATE OF DIAGNOSIS:
SIDE AFFECTED:
RIGHT
LEFT
BOTH
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO SHOULDER AND/OR ARM CONDITIONS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
(brief summary)
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S SHOULDER AND/OR ARM CONDITION
2B. DOMINANT HAND:
RIGHT
LEFT
AMBIDEXTROUS
SECTION III - FLARE-UPS
3. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE SHOULDER AND/OR ARM?
YES
NO
IF YES, DOCUMENT THE VETERAN'S DESCRIPTION OF THE IMPACT OF FLARE-UPS IN HIS OR HER OWN WORDS:
SECTION IV - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS
4. 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
(at a minimum)
IN ALL JOINT 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 5.
A. RIGHT SHOULDER FLEXION
(normal endpoint is 180 degrees):
Select where flexion ends
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Select where objective evidence of painful motion begins:
No objective evidence of painful motion
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VA FORM
SUPERSEDES VA FORM 21-0960M-12, JAN 2011,
21-0960M-12
Page 1
OCT 2012
WHICH WILL NOT BE USED.
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