VA Form 21-0960C-4 Diabetic Peripheral Neuropathy (Diabetic Sensory-Motor P

OMB Control No. 2900-XXXX
Respondent Burden: 30 minutes
DIABETIC PERIPHERAL NEUROPATHY (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 DIABETIC 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 diabetic peripheral neuropathy condition(s))

1C. PROVIDE DIAGNOSES THAT PERTAIN TO DIABETIC 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 DIABETIC PERIPHERAL NEUROPATHY, LIST USING ABOVE FORMAT

SECTION II - MEDICAL HISTORY
2A. DOES THE VETERAN HAVE DIABETES MELLITUS TYPE I OR TYPE II?
YES

NO

2B. DESCRIBE THE HISTORY (including cause, onset and course) OF THE VETERAN'S DIABETIC PERIPHERAL NEUROPATHY

2C. DOMINANT HAND
RIGHT

LEFT

AMBIDEXTROUS

SECTION III - SYMPTOMS
3. INDICATE SYMPTOMS DUE TO DIABETIC PERIPHERAL NEUROPATHY, INCLUDING LOCATION AND SEVERITY (Check all that apply)
THE VETERAN DENIES ANY SYMPTOMS ATTRIBUTABLE TO DIABETIC PERIPHERAL NEUROPATHY
RIGHT UPPER EXTREMITY (Check all that apply)
NO SYMPTOMS

NUMBNESS

PARESTHESIAS

DULL AND INTERMITTENT PAIN

CONSTANT PAIN, AT TIMES EXCRUCIATING

PARESTHESIAS

DULL AND INTERMITTENT PAIN

CONSTANT PAIN, AT TIMES EXCRUCIATING

PARESTHESIAS

DULL AND INTERMITTENT PAIN

CONSTANT PAIN, AT TIMES EXCRUCIATING

PARESTHESIAS

DULL AND INTERMITTENT PAIN

CONSTANT PAIN, AT TIMES EXCRUCIATING

LEFT UPPER EXTREMITY (Check all that apply)
NO SYMPTOMS

NUMBNESS

RIGHT LOWER EXTREMITY (Check all that apply)
NO SYMPTOMS

NUMBNESS

LEFT LOWER EXTREMITY (Check all that apply)
NO SYMPTOMS

NUMBNESS

OTHER SYMPTOMS (Describe the symptoms, their location and severity):

VA FORM
DEC 2010

21-0960C-4

Page 1

SECTION IV - NEUROLOGIC EXAM
4A. STRENGTH - RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE:
0/5 No muscle movement

2/5 No movement against gravity

4/5 Less than normal strength

1/5 Visible muscle movement, but no joint movement

3/5 No movement against resistance

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

Wrist Extension

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

Grip

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

Elbow Extension
Wrist Flexion

Pinch

(thumb to index finger)
Knee Extension

Ankle Plantar Flexion
Ankle Dorsiflexion

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

4B. DEEP TENDON REFLEXES (DTRs) - RATE REFLEXES ACCORDING TO THE FOLLOWING SCALE:
0 - Absent

2+ Normal

1+ Decreased

3+ Increased without clonus

Biceps
Triceps
Brachioradialis
Knee
Ankle

4+ Increased with clonus

RIGHT:

0

1+

2+

3+

LEFT:

0

1+

2+

3+

4+
4+

RIGHT:

0

1+

2+

3+

4+
4+

LEFT:

0

1+

2+

3+

RIGHT:

0

1+

2+

3+

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+

4C. LIGHT TOUCH/MONOFILAMENT TESTING RESULTS
Shoulder area
Inner/outer forearm
Hand/fingers
Knee/thigh
Ankle/lower leg
Foot/toes

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. POSITION SENSE (grasp index finger/great toe on sides and ask patient to identify up and down movement)
Not tested
RIGHT UPPER EXTREMITY

Normal

Decreased

LEFT UPPER EXTREMITY

Normal

Decreased

Absent

RIGHT LOWER EXTREMITY

Normal

Decreased

Absent

LEFT LOWER EXTREMITY

Normal

Decreased

Absent

VA FORM 21-0960C-4, DEC 2010

Absent

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SECTION IV - NEUROLOGIC EXAM (Continued)
4E. VIBRATION SENSATION (place low-pitched tuning fork over DIP joint of index finger/IP joint of great toe)
Not tested
RIGHT UPPER EXTREMITY

Normal

Decreased

Absent

LEFT UPPER EXTREMITY

Normal

Decreased

Absent

RIGHT LOWER EXTREMITY

Normal

Decreased

Absent

LEFT LOWER EXTREMITY

Normal

Decreased

Absent

4F. COLD SENSATION (test distal extremities for cold sensation with side of tuning fork)
Not tested
RIGHT UPPER EXTREMITY

Normal

Decreased

Absent

LEFT UPPER EXTREMITY

Normal

Decreased

Absent

RIGHT LOWER EXTREMITY

Normal

Decreased

Absent

LEFT LOWER EXTREMITY

Normal

Decreased

Absent

4G. DOES THE VETERAN HAVE MUSCLE ATROPHY?
YES

NO

(If muscle atrophy is present, indicate location):

(If possible, provide difference measured in cm between normal and atrophied side, measured at maximum muscle bulk:

cm)

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

NO

(If "Yes," describe):

SECTION V - SEVERITY
NOTE: For VA purposes, when the involvement is wholly sensory, the evaluation should be for the mild, or at most, the moderate degree of severity. Based on
symptoms and findings from Sections IV and V, complete Items 5A and 5B to provide an evaluation of the severity of the Veteran's diabetic peripheral neuropathy.
5A. DOES THE VETERAN HAVE AN UPPER EXTREMITY DIABETIC PERIPHERAL NEUROPATHY?
YES

NO

(If "Yes," indicate severity and side affected)
RIGHT

Not affected

Mild

Moderate

Severe

LEFT

Not affected

Mild

Moderate

Severe

(Indicate nerves affected (check all that apply; checked nerves include terminal branches))
Radial nerve

Median nerve

Ulnar nerve

5B. DOES THE VETERAN HAVE A LOWER EXTREMITY DIABETIC PERIPHERAL NEUROPATHY?
YES

NO

(If "Yes," indicate severity and side affected)
RIGHT

Not affected

Mild

Moderate

Moderately Severe

Severe, with marked muscular atrophy

LEFT

Not affected

Mild

Moderate

Moderately Severe

Severe, with marked muscular atrophy

(Indicate nerves affected (check all that apply; checked nerves include terminal branches))
Sciatic

Femoral nerve

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

NO

(If "Yes," describe):

VA FORM 21-0960C-4, DEC 2010

Page 3

SECTION VII - DIAGNOSTIC TESTING
NOTE: For purposes of this examination, electromyography (EMG) studies are rarely required to diagnose diabetic peripheral neuropathy. The diagnosis of diabetic
peripheral neuropathy can be made in the appropriate clinical setting by a history of characteristic pain and/or sensory changes in a stocking/glove distribution and
objective clinical findings, which may include symmetrical lost/decreased reflexes, decreased strength, lost/decreased sensation for cold, vibration and/or position sense,
and/or lost/decreased sensation to monofilament testing
7A. 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):
7B. IF THERE ARE OTHER SIGNIFICANT FINDINGS OR DIAGNOSTIC TEST RESULTS, PROVIDE DATES AND DESCRIBE

SECTION VIII - FUNCTIONAL IMPACT AND REMARKS
8. DOES THE VETERAN'S DIABETIC PERIPHERAL NEUROPATHY IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

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

9. REMARKS (If any)

SECTION IX - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
10A. PHYSICIAN'S SIGNATURE

10D. PHYSICIAN'S PHONE NUMBER

10B. PHYSICIAN'S PRINTED NAME

10E. PHYSICIAN'S MEDICAL LICENSE NUMBER

10C. DATE SIGNED

10F. 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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VA FORM 21-0960C-4, DEC 2010

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