Va Form 21-0960m-12 - Shoulder And Arm Conditions Disability Benefits Questionnaire Page 5
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6SECTION XIII - JOINT REPLACEMENT AND/OR OTHER SURGICAL PROCEDURES
13A. HAS THE VETERAN HAD A TOTAL SHOULDER JOINT REPLACEMENT?
YES
NO
IF YES, INDICATE SIDE AND SEVERITY OF RESIDUALS:
RIGHT SHOULDER
DATE OF SURGERY:
RESIDUALS:
NONE
INTERMEDIATE DEGREES OF RESIDUAL WEAKNESS, PAIN AND/OR LIMITATION OF MOTION
CHRONIC RESIDUALS CONSISTING OF SEVERE PAINFUL MOTION AND/OR WEAKNESS
(Describe):
OTHER
LEFT SHOULDER
DATE OF SURGERY:
RESIDUALS:
NONE
INTERMEDIATE DEGREES OF RESIDUAL WEAKNESS, PAIN AND/OR LIMITATION OF MOTION
CHRONIC RESIDUALS CONSISTING OF SEVERE PAINFUL MOTION AND/OR WEAKNESS
(Describe):
OTHER
13B. HAS THE VETERAN HAD ARTHROSCOPIC OR OTHER SHOULDER SURGERY?
YES
NO
IF YES, INDICATE SIDE AFFECTED:
Right
Left
Both
DATE AND TYPE OF SURGERY:
13C. DOES THE VETERAN HAVE ANY RESIDUAL SIGNS AND/OR SYMPTOMS DUE TO ARTHROSCOPIC OR OTHER SHOULDER SURGERY?
YES
NO
IF YES, INDICATE SIDE AFFECTED:
Right
Left
Both
IF YES, DESCRIBE RESIDUALS:
SECTION XIV - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
(surgical or otherwise)
14A. DOES THE VETERAN HAVE ANY SCARS
RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
SECTION 1, DIAGNOSIS?
YES
NO
IF YES, ARE ANY OF THE SCARS PAINFUL/OR UNSTABLE, OR IS THE TOTAL AREA OF ALL RELATED SCARS GREATER THAN OR EQUAL TO 39 SQUARE CM
(6 square inches)
?
YES
NO
IF YES, ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT DISABILITY BENEFITS QUESTIONNAIRE.
14B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN SECTION 1, DIAGNOSIS?
(Brief summary)
YES
NO
IF YES, DESCRIBE
:
SECTION XV - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
15. DUE TO THE VETERAN'S SHOULDER AND/OR ARM CONDITIONS, IS THERE FUNCTIONAL IMPAIRMENT OF AN EXTREMITY SUCH THAT NO EFFECTIVE
(Functions of the upper
FUNCTION REMAINS OTHER THAN THAT WHICH WOULD BE EQUALLY WELL SERVED BY AN AMPUTATION WITH PROSTHESIS?
extremity include grasping, manipulation, etc)
YES, FUNCTIONING IS SO DIMINISHED THAT AMPUTATION WITH PROSTHESIS WOULD EQUALLLY SERVE THE VETERAN.
NO
(check all extremities for which this applies):
IF YES, INDICATE EXTREMITY(IES)
Right upper
Left upper
FOR EACH CHECKED EXTREMITY, DESCRIBE LOSS OF EFFECTIVE FUNCTION, IDENTIFY THE CONDITION CAUSING LOSS OF FUNCTION, AND PROVIDE
(brief summary)
SPECIFIC EXAMPLES
:
Page 5
VA FORM 21-0960M-12, OCT 2012
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