VA Form 21-0960C-1 Peripheral Nerve Conditions (Not including diabetic sens

OMB Control No. 2900-XXXX
Respondent Burden: 45 minutes
PERIPHERAL NERVE CONDITIONS (NOT INCLUDING DIABETIC SENSORY- MOTOR PERIPHERAL
NEUROPATHY) 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 THIS FORM.
NAME OF PATIENT/VETERAN

PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

NOTE TO PHYSICIAN - The veteran has applied to the Department of Veterans Affairs (VA) for disability benefits. Please complete this questionnaire,
which VA needs for review of the veteran's application.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN HAVE A PERIPHERAL NERVE CONDITION AND/OR PERIPHERAL NEUROPATHY?
YES

NO

(If "No," complete Item 1B)

(If "Yes," complete Item 1C)

1B. PROVIDE RATIONALE (e.g., veteran does not currently have any known peripheral nerve condition(s))

1C. PROVIDE DIAGNOSES THAT PERTAIN TO A PERIPHERAL NERVE CONDITION AND/OR PERIPHERAL NEUROPATHY
DIAGNOSIS # 1 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 2 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 3 -

ICD CODE -

DATE OF DIAGNOSIS -

1D. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO A PERIPHERAL NERVE CONDITION AND/OR PERIPHERAL NEUROPATHY, LIST USING ABOVE
FORMAT

DEFINITIONS FOR VA PURPOSES: Neuralgia indicates a condition characterized by a dull and intermittent pain of typical distribution so as to identify
the nerve, while neuritis is characterized by loss of reflexes, muscle atrophy, sensory disturbances and constant pain, at time excruciating.
SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including cause, onset and course) OF THE VETERAN'S PERIPHERAL NERVE CONDITION(S)

2B. DOMINANT HAND
RIGHT

LEFT

AMBIDEXTROUS

SECTION III - SYMPTOMS
3. DOES THE VETERAN HAVE ANY SYMPTOMS DUE TO ANY PERIPHERAL NERVE CONDITION?
YES

NO

(If "Yes," indicate symptoms, location, and degree of severity) (Check all that apply)
A. CONSTANT PAIN (may be excruciating at times)
RIGHT UPPER EXTREMITY

NONE

MILD

MODERATE

SEVERE

LEFT UPPER EXTREMITY

NONE

MILD

MODERATE

SEVERE

RIGHT LOWER EXTREMITY

NONE

MILD

MODERATE

SEVERE

LEFT LOWER EXTREMITY

NONE

MILD

MODERATE

SEVERE

RIGHT UPPER EXTREMITY

NONE

MILD

MODERATE

SEVERE

LEFT UPPER EXTREMITY

NONE

MILD

MODERATE

SEVERE

RIGHT LOWER EXTREMITY

NONE

MILD

MODERATE

SEVERE

LEFT LOWER EXTREMITY

NONE

MILD

MODERATE

SEVERE

B. INTERMITTENT PAIN

C. DULL PAIN
RIGHT UPPER EXTREMITY

NONE

MILD

MODERATE

SEVERE

LEFT UPPER EXTREMITY

NONE

MILD

MODERATE

SEVERE

RIGHT LOWER EXTREMITY

NONE

MILD

MODERATE

SEVERE

LEFT LOWER EXTREMITY

NONE

MILD

MODERATE

SEVERE

VA FORM
DEC 2010

21-0960C-10

Page 1

SECTION III - SYMPTOMS (CONTINUED)
D. PARESTHESIAS AND/OR DYSESTHESIAS
RIGHT UPPER EXTREMITY

NONE

MILD

MODERATE

SEVERE

LEFT UPPER EXTREMITY

NONE

MILD

MODERATE

SEVERE

RIGHT LOWER EXTREMITY

NONE

MILD

MODERATE

SEVERE

LEFT LOWER EXTREMITY

NONE

MILD

MODERATE

SEVERE
SEVERE

E. NUMBNESS
RIGHT UPPER EXTREMITY

NONE

MILD

MODERATE

LEFT UPPER EXTREMITY

NONE

MILD

MODERATE

SEVERE

RIGHT LOWER EXTREMITY

NONE

MILD

MODERATE

SEVERE

LEFT LOWER EXTREMITY

NONE

MILD

MODERATE

SEVERE

F. OTHER SYMPTOMS (describe symptoms, location and severity)

SECTION IV - NEUROLOGIC EXAM
4A. STRENGTH - RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE:
0/5 No muscle movement
1/5 Visible muscle movement, but no joint movement
2/5 No movement against gravity
3/5 No movement against resistance
4/5 Less than normal strength
5/5 Normal strength
ELBOW FLEXION:

RIGHT:

5/5

4/5

3/5

2/5

1/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

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

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

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

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

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

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

ANKLE PLANTAR
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

ANKLE DORSIFLEXION:

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:
WRIST FLEXION:
WRIST EXTENSION:
GRIP:
PINCH

(thumb to index finger)
KNEE EXTENSION:

0/5

4B. DEEP TENDON REFLEXES (DTRs) - RATE REFLEXES ACCORDING TO THE FOLLOWING SCALE:
0 - Absent
1+ Decreased
2+ Normal
3+ Increased without clonus
4+ Increased with clonus
Biceps

RIGHT:

0

1+

2+

3+

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+

Knee
Ankle

4+

LEFT:

0

1+

2+

3+

4+

RIGHT:

0

1+

2+

3+

4+

LEFT:

0

1+

2+

3+

4+

RIGHT:

0

1+

2+

3+

4+

LEFT:

0

1+

2+

3+

4+

VA FORM 21-0960C-10, DEC 2010

Page 2

SECTION IV - NEUROLOGIC EXAM (Continued)
4C. SENSATION TESTING RESULTS (Indicate results for sensation testing for light touch):
SHOULDER AREA (C5)
INNER/OUTER FOREARM

(C6/T1)

HAND/FINGERS (C6-8)
THIGH/KNEE (L3/4)
LOWER LEG/ANKLE (L4/L5/S1)
FOOT/TOES (L5)

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

4D. DOES THE VETERAN HAVE MUSCLE ATROPHY?
YES

NO

(If muscle atrophy is present, indicate location:
and when possible, provide difference measured in cm between normal and atrophied side, measured at maximum muscle bulk:

cm).

4E. DOES THE VETERAN HAVE TROPHIC CHANGES (characterized by loss of extremity hair, smooth, shiny skin, etc.) ATTRIBUTABLE TO PERIPHERAL
NEUROPATHY?
YES

NO

(If "Yes," describe):

4F. DOES THE VETERAN HAVE ANY OTHER SIGNIFICANT SIGNS AND/OR SYMPTOMS OF A PERIPHERAL NERVE CONDITION?
YES

NO

(If "Yes," describe):

SECTION V - GAIT
5. IS THE VETERAN'S GAIT NORMAL?
YES

NO

(If "No," is abnormal gait due to a peripheral nerve condition?)
YES

NO

(If "Yes," describe the abnormal gait):

SECTION VI - NERVES AFFECTED
6A. INDICATE THE NERVES AFFECTED BY THE VETERAN'S CONDITION:
UPPER EXTREMITY NERVES - Check all that apply and complete Section VII for each checked nerve and/or radicular group
Radial nerve
Median
Ulnar
Musculocutaneous
Circumflex
Long thoracic
Radicular groups
6B. INDICATE THE NERVES AFFECTED BY THE VETERAN'S CONDITION:
LOWER EXTREMITY NERVES - Check all that apply and complete Section VII I for each checked nerve and/or radicular group
Sciatic
External popliteal (common peroneal)
Musculocutaneous (superficial peroneal)
Tibial (internal popliteal)
Posterior tibial
Femoral nerve (anterior crural)
Internal saphenous
Obturator
External cutaneous nerve of the thigh
Ilioinguinal
VA FORM 21-0960C-10, DEC 2010

Page 3

SECTION VII - SEVERITY OF PERIPHERAL NERVE CONDITION FOR UPPER EXTREMITY NERVES AND RADICULAR GROUPS
NOTE: For VA purposes, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the description of complete paralysis that
is given with each nerve.
If the nerve is completely paralyzed, check the box for "complete paralysis." If the nerve is not completely paralyzed, check the box for "incomplete paralysis" and
indicate severity.
Base assessment of severity on findings and symptoms described in Sections V and VI. For VA purposes, when nerve impairment is wholly sensory, the evaluation
should be mild, or at most, moderate.
7A. RADIAL NERVE
INCOMPLETE PARALYSIS OF RADIAL NERVE
RIGHT:

Not affected

Mild

Moderate

Severe

LEFT:

Not affected

Mild

Moderate

Severe

COMPLETE PARALYSIS (hand and fingers drop, wrist and fingers flexed; cannot extend hand at wrist, extend proximal phalanges

of fingers, extend thumb or make lateral movement of wrist; supination of hand, elbow extension and flexion weak, hand grip impaired)
RIGHT:

Not affected

Complete paralysis

LEFT:

Not affected

Complete paralysis

7B. MEDIAN NERVE
SPECIAL TESTS FOR MEDIAN NERVE:
Test not performed (not indicated for Veteran's condition)

PHALEN'S SIGN:

RIGHT:

Positive

Negative

LEFT:

Positive

Negative

Test not performed (not indicated for Veteran's condition)

TINEL'S SIGN:

RIGHT:

Positive

Negative

LEFT:

Positive

Negative

INCOMPLETE PARALYSIS OF MEDIAN NERVE
RIGHT:

Not affected

Mild

Moderate

Severe

LEFT:

Not affected

Mild

Moderate

Severe

COMPLETE PARALYSIS (hand inclined to the ulnar side, index and middle fingers extended, atrophy of thenar eminence, cannot make a fist,
defective opposition of thumb, cannot flex distal phalanx of thumb; wrist flexion weak)
RIGHT:

Not affected

Complete paralysis

LEFT:

Not affected

Complete paralysis

7C. ULNAR NERVE
INCOMPLETE PARALYSIS OF ULNAR NERVE
RIGHT:

Not affected

Mild

Moderate

Severe

LEFT:

Not affected

Mild

Moderate

Severe

COMPLETE PARALYSIS ("griffin claw" deformity, atrophy in dorsal interspaces, thenar and hypothenar eminences; cannot extend ring and little

finger, cannot spread fingers, cannot adduct the thumb; wrist flexion weakened)
RIGHT:

Not affected

Complete paralysis

LEFT:

Not affected

Complete paralysis

7D. MUSCULOCUTANEOUS NERVE
INCOMPLETE PARALYSIS OF MUSCULOCUTANEOUS NERVE
RIGHT:

Not affected

Mild

Moderate

Severe

LEFT:

Not affected

Mild

Moderate

Severe

COMPLETE PARALYSIS (weakened flexion of elbow and supination of forearm)
RIGHT:

Not affected

Complete paralysis

LEFT:

Not affected

Complete paralysis

7E. CIRCUMFLEX NERVE
INCOMPLETE PARALYSIS OF CIRCUMFLEX NERVE
RIGHT:

Not affected

Mild

Moderate

Severe

LEFT:

Not affected

Mild

Moderate

Severe

COMPLETE PARALYSIS (innervates deltoid and teres minor; cannot abduct arm, outward rotation is weakened)
RIGHT:

Not affected

Complete paralysis

LEFT:

Not affected

Complete paralysis

7F. LONG THORACIC NERVE
INCOMPLETE PARALYSIS OF LONG THORACIC NERVE
RIGHT:

Not affected

Mild

Moderate

Severe

LEFT:

Not affected

Mild

Moderate

Severe

COMPLETE PARALYSIS (inability to raise arm above shoulder level, winged scapula deformity)
RIGHT:

Not affected

Complete paralysis

LEFT:

Not affected

Complete paralysis

VA FORM 21-0960C-10, DEC 2010

Page 4

SECTION VII - SEVERITY OF PERIPHERAL NERVE CONDITION FOR UPPER EXTREMITY NERVES AND RADICULAR GROUPS (Continued)
7G. UPPER RADICULAR GROUP
INCOMPLETE PARALYSIS OF UPPER RADICULAR GROUP
RIGHT:

Not affected

Mild

Moderate

Severe

LEFT:

Not affected

Mild

Moderate

Severe

COMPLETE PARALYSIS (all shoulder and elbow movements lost; hand and wrist movements not affected)
RIGHT:

Not affected

Complete paralysis

LEFT:

Not affected

Complete paralysis

7H. MIDDLE RADICULAR GROUP
INCOMPLETE PARALYSIS OF MIDDLE RADICULAR GROUP
RIGHT:

Not affected

Mild

Moderate

Severe

LEFT:

Not affected

Mild

Moderate

Severe

COMPLETE PARALYSIS (adduction, abduction, rotation of arm, flexion of elbow and extension of wrist lost)
RIGHT:

Not affected

Complete paralysis

LEFT:

Not affected

Complete paralysis

7I. LOWER RADICULAR GROUP
INCOMPLETE PARALYSIS OF LOWER RADICULAR GROUP
RIGHT:

Not affected

Mild

Moderate

Severe

LEFT:

Not affected

Mild

Moderate

Severe

COMPLETE PARALYSIS (intrinsic hand muscles, wrist and finger flexors paralyzed; substantial loss of use of hand)
RIGHT:

Not affected

Complete paralysis

LEFT:

Not affected

Complete paralysis

7J. ALL RADICULAR GROUPS
INCOMPLETE PARALYSIS OF LOWER RADICULAR GROUP
RIGHT:

Not affected

Mild

Moderate

Severe

LEFT:

Not affected

Mild

Moderate

Severe

COMPLETE PARALYSIS (loss of use of all radicular groups)
RIGHT:

Not affected

Complete paralysis

LEFT:

Not affected

Complete paralysis

SECTION VIII - SEVERITY OF PERIPHERAL NERVE CONDITION FOR LOWER EXTREMITY NERVES
NOTE: For VA purposes, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the description of complete paralysis that
is given with each nerve.
If the nerve is completely paralyzed, check the box for "complete paralysis." If the nerve is not completely paralyzed, check the box for "incomplete paralysis" and
indicate severity.
Base assessment of severity on findings and symptoms described in Sections V and VI. For VA purposes, when nerve impairment is wholly sensory,
the evaluation should be mild, or at most, moderate.
8A. SCIATIC NERVE
INCOMPLETE PARALYSIS OF SCIATIC NERVE
RIGHT:

Not affected

Mild

Moderate

Severe

LEFT:

Not affected

Mild

Moderate

Severe

COMPLETE PARALYSIS (foot dangles and drops, no active movement of muscles below the knee, flexion of knee weakened or lost)
RIGHT:

Not affected

Complete paralysis

LEFT:

Not affected

Complete paralysis

8B. EXTERNAL POPLITEAL (common peroneal) NERVE
INCOMPLETE PARALYSIS OF EXTERNAL POPLITEAL (common peroneal) NERVE
RIGHT:

Not affected

Mild

Moderate

Severe

LEFT:

Not affected

Mild

Moderate

Severe

COMPLETE PARALYSIS (foot drop, cannot dorsiflex foot or extend toes; dorsum of foot and toes are numb)
RIGHT:

Not affected

Complete paralysis

LEFT:

Not affected

Complete paralysis

8C. MUSCULOCUTANEOUS NERVE
INCOMPLETE PARALYSIS OF MUSCULOCUTANEOUS NERVE
RIGHT:

Not affected

Mild

Moderate

Severe

LEFT:

Not affected

Mild

Moderate

Severe

COMPLETE PARALYSIS (eversion of foot weakened)
RIGHT:

Not affected

Complete paralysis

LEFT:

Not affected

Complete paralysis

VA FORM 21-0960C-10, DEC 2010

Page 5

SECTION VIII - SEVERITY OF PERIPHERAL NERVE CONDITION FOR LOWER EXTREMITY NERVES (Continued)
8D. ANTERIOR TIBIAL (deep peroneal) NERVE
INCOMPLETE PARALYSIS OF SCIATIC NERVE
RIGHT:

Not affected

Mild

Moderate

Severe

LEFT:

Not affected

Mild

Moderate

Severe

COMPLETE PARALYSIS (foot dangles and drops, no active movement of muscles below the knee, flexion of knee weakened or lost)
RIGHT:

Not affected

Complete paralysis

LEFT:

Not affected

Complete paralysis

8E. INTERNAL POPLITEAL (tibial) NERVE
INCOMPLETE PARALYSIS OF INTERNAL POPLITEAL (tibial) NERVE
RIGHT:

Not affected

Mild

Moderate

Severe

LEFT:

Not affected

Mild

Moderate

Severe

COMPLETE PARALYSIS (plantar flexion lost, flexion and separation of toes abolished)
RIGHT:

Not affected

Complete paralysis

LEFT:

Not affected

Complete paralysis

8F. POSTERIOR TIBIAL NERVE
INCOMPLETE PARALYSIS OF POSTERIOR TIBIAL NERVE
RIGHT:

Not affected

Mild

Moderate

Severe

LEFT:

Not affected

Mild

Moderate

Severe

COMPLETE PARALYSIS (paralysis of all muscles of sole of foot, frequently with painful paralysis of a causalgic nature;

loss of toe flexion; adduction weakened; plantar flexion impaired)
RIGHT:

Not affected

Complete paralysis

LEFT:

Not affected

Complete paralysis

8G. ANTERIOR CRURAL (femoral) NERVE
INCOMPLETE PARALYSIS OF ANTERIOR CRURAL (femoral) NERVE
RIGHT:

Not affected

Mild

Moderate

Severe

LEFT:

Not affected

Mild

Moderate

Severe

COMPLETE PARALYSIS (paralysis of quadriceps extensor muscles)
RIGHT:

Not affected

Complete paralysis

LEFT:

Not affected

Complete paralysis

8H. INTERNAL SAPHENOUS NERVE
INCOMPLETE PARALYSIS OF INTERNAL SAPHENOUS NERVE
RIGHT:

Not affected

Mild

Moderate

Severe

LEFT:

Not affected

Mild

Moderate

Severe

COMPLETE PARALYSIS
RIGHT:

Not affected

Complete paralysis

LEFT:

Not affected

Complete paralysis

8I. OBTURATOR NERVE
INCOMPLETE PARALYSIS OF OBTURATOR NERVE
RIGHT:

Not affected

Mild

Moderate

Severe

LEFT:

Not affected

Mild

Moderate

Severe

COMPLETE PARALYSIS
RIGHT:

Not affected

Complete paralysis

LEFT:

Not affected

Complete paralysis

8J. EXTERNAL CUTANEOUS NERVE OF THE THIGH
INCOMPLETE PARALYSIS OF EXTERNAL CUTANEOUS NERVE OF THE THIGH
RIGHT:

Not affected

Mild

Moderate

Severe

LEFT:

Not affected

Mild

Moderate

Severe

COMPLETE PARALYSIS
RIGHT:

Not affected

Complete paralysis

LEFT:

Not affected

Complete paralysis

8K. ILLIOINGUINAL NERVE
INCOMPLETE PARALYSIS OF ILLIOINGUINAL NERVE
RIGHT:

Not affected

Mild

Moderate

Severe

LEFT:

Not affected

Mild

Moderate

Severe

COMPLETE PARALYSIS
RIGHT:

Not affected

Complete paralysis

LEFT:

Not affected

Complete paralysis

VA FORM 21-0960C-10, DEC 2010

Page 6

SECTION IX - ASSISTIVE DEVICES AND REMAINING FUNCTION OF THE EXTREMITIES
9A. DOES THE VETERAN USE ANY ASSISTIVE DEVICE(S) AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS
MAY BE POSSIBLE?
YES

NO

(If "Yes," identify assistive device(s) used (check all that apply and indicate frequency)
WHEELCHAIR

Frequency of use:

Occasional

Regular

Constant

BRACE(S)

Frequency of use:

Occasional

Regular

Constant

CRUTCH(ES)

Frequency of use:

Occasional

Regular

Constant

CANE(S)

Frequency of use:

Occasional

Regular

Constant

WALKER

Frequency of use:

Occasional

Regular

Constant

Frequency of use:

Occasional

Regular

Constant

OTHER:
9B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:

9C. DUE TO PERIPHERAL NERVE CONDITIONS, IS THERE FUNCTIONAL IMPAIRMENT OF AN EXTREMITY SUCH THAT NO EFFECTIVE FUNCTION REMAINS OTHER
THAN THAT WHICH WOULD BE EQUALLY WELL SERVED BY AN AMPUTATION WITH PROSTHESIS? (Functions of the upper extremity include grasping,

manipulation, etc. while functions for the lower extremity include balance and propulsion, etc.)

YES, FUNCTIONING IS SO DIMINISHED THAT AMPUTATION WITH PROSTHESIS COULD EQUALLY SERVE THE VETERAN
NO

(If "Yes," indicate extremity(ies)) (Check all extremities for which this applies)
Right upper

Left upper

Right lower

Left lower

SECTION X - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
10. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, SIGNS AND/OR SYMPTOMS?
YES

NO

(If "Yes," describe) (brief summary):

SECTION XI - DIAGNOSTIC TESTING
NOTE: For the purpose of this examination, electromyography (EMG) studies are usually rarely required to diagnose specific peripheral nerve conditions in the
appropriate clinical setting. If EMG studies are in the medical record and reflect the veteran's current condition, repeat studies are
not indicated.
11A. HAVE EMG STUDIES BEEN PERFORMED?
YES

NO

(Extremities tested):
RIGHT UPPER EXTREMITY

Results:

Normal

Abnormal

Date:

LEFT UPPER EXTREMITY

Results:

Normal

Abnormal

Date:

RIGHT LOWER EXTREMITY

Results:

Normal

Abnormal

Date:

LEFT LOWER EXTREMITY

Results:

Normal

Abnormal

Date:

If abnormal describe:
11B. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES

NO

(If "Yes," provide type of test or procedure, date and results (brief summary)):

VA FORM 21-0960C-10, DEC 2010

Page 7

SECTION XII - FUNCTIONAL IMPACT AND REMARKS
12. DOES THE VETERAN'S PERIPHERAL NERVE CONDITION AND/OR PERIPHERAL NEUROPATHY IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe impact of each of the veteran's peripheral nerve and/or peripheral neuropathy condition(s), providing one or more examples):

13. REMARKS (If any)

SECTION XIII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
14A. PHYSICIAN'S SIGNATURE

14D. PHYSICIAN'S PHONE NUMBER

14B. PHYSICIAN'S PRINTED NAME

14E. PHYSICIAN'S MEDICAL LICENSE NUMBER

14C. DATE SIGNED

14F. PHYSICIAN'S ADDRESS

NOTE - VA may obtain additional medical information, including an examination, if necessary to complete VA's review of the veteran's application.

IMPORTANT - Physician please fax the completed form to
(VA Regional Office FAX No.)

NOTE - A list of VA Regional Office FAX Numbers can be found at www.vba.va.gov/disabilityexams or obtained by calling 1-800-827-1000.
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information. We estimate that you will need an average of 45 minutes to review the instructions, find the information, and complete a form. VA cannot conduct or sponsor
a collection of information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed.
Valid OMB control numbers can be located on the OMB Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get
information on where to send comments or suggestions about this form.
VA FORM 21-0960C-10, DEC 2010

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