Va Form 21-0960m-12 - Shoulder And Arm Conditions Disability Benefits Questionnaire Page 3
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SECTION V - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING
5C. LEFT SHOULDER POST-TEST ROM
Select where flexion ends:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
Select where abduction ends:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
SECTION VI - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION IN ROM
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.
6A. DOES THE VETERAN HAVE ADDITIONAL LIMITATION IN ROM OF THE SHOULDER AND ARM FOLLOWING REPETITIVE-USE TESTING?
YES
NO
6B. DOES THE VETERAN HAVE ANY FUNCTIONAL LOSS AND/OR FUNCTIONAL IMPAIRMENT OF THE SHOULDER AND ARM?
YES
NO
6C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT AND/OR ADDITIONAL LIMITATION OF ROM OF THE SHOULDER AND ARM AFTER
(check all that apply and indicate side affected):
REPETITIVE USE, INDICATE THE CONTRIBUTING FACTORS OF DISABILITY BELOW
NO FUNCTIONAL LOSS FOR RIGHT UPPER EXTREMITY
NO FUNCTIONAL LOSS FOR LEFT UPPER EXTREMITY
LESS MOVEMENT THAN NORMAL
Right
Left
Both
MORE MOVEMENT THAN NORMAL
Right
Left
Both
WEAKENED MOVEMENT
Right
Left
Both
EXCESS FATIGABILITY
Right
Left
Both
Right
Left
Both
INCOORDINATION, IMPAIRED ABILITY
TO EXECUTE SKILLED MOVEMENTS
SMOOTHLY
PAIN ON MOVEMENT
Right
Left
Both
SWELLING
Right
Left
Both
DEFORMITY
Right
Left
Both
ATROPHY OF DISUSE
Right
Left
Both
(pain on palpation)
SECTION VII - PAIN
7A. DOES THE VETERAN HAVE LOCALIZED TENDERNESS OR PAIN ON PALPATION OF JOINTS/SOFT TISSUE/BICEPS TENDON OF EITHER SHOULDER?
YES
NO
IF YES, SHOULDER AFFECTED:
Right
Left
Both
7B. DOES THE VETERAN HAVE GUARDING OF EITHER SHOULDER?
YES
NO
IF YES, SHOULDER AFFECTED:
Right
Left
Both
SECTION VIII - MUSCLE STRENGTH TESTING
8. 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
SHOULDER 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
SHOULDER FORWARD 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
SECTION IX - ANKYLOSIS
9. DOES THE VETERAN HAVE ANKYLOSIS OF THE GLENOHUMERAL ARTICULATION (SHOULDER JOINT)?
YES
NO
IF YES, INDICATE SEVERITY AND SIDE AFFECTED:
ABDUCTION TO 60 DEGREES; CAN REACH MOUTH AND HEAD
Right
Left
Both
ABDUCTION LIMITED TO BETWEEN 60 AND 25 DEGREES
Right
Left
Both
ABDUCTION LIMITED TO 25 DEGREES FROM THE SIDE
Right
Left
Both
VA FORM 21-0960M-12, OCT 2012
Page 3
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