VA Form 21-0960M-2 Ankle Conditions DBQ

OMB Approved No. 2900-XXXX
Respondent Burden: 30 minutes

ANKLE 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 ON REVERSE 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 HAVE AN ANKLE CONDITION?
YES

(If "Yes," complete Item 1C)

NO

(If "No," complete Item 1B)

1B. PROVIDE RATIONALE (e.g. veteran does not currently have any known ankle conditions)

1C. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO ANKLE CONDITIONS
DIAGNOSIS # 1 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 2 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 3 -

ICD CODE -

DATE OF DIAGNOSIS -

1D. IF ADDITIONAL DIAGNOSIS PERTAINING TO ANKLE CONDITIONS, LIST USING ABOVE FORMAT

SECTION II - MEDICAL HISTORY

2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S ANKLE CONDITION (brief summary)

2B. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE AFFECTED JOINT(S)?
YES

NO

(If "Yes," document the veteran's description of the impact of flare-ups in his or her own words)

SECTION III - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS
3. MEASURE ROM WITH A GONIOMETER, ROUNDING EACH MEASUREMENT TO THE NEAREST 5 DEGREES. REPORT INITIAL MEASUREMENTS BELOW
A. RIGHT ANKLE ROM
Check box at which plantar flexion ends (normal endpoint is 45 degrees):

0

5

10

15

20

25

30

35

40

45 or greater

Check box at which dorsiflexion (extension) ends (normal endpoint is 20 degrees):

0

5

10

15

20 or greater

B. LEFT ANKLE ROM
Check box at which plantar flexion ends (normal endpoint is 45 degrees):

0

5

10

15

20

25

30

35

40

45 or greater

Check box at which dorsiflexion (extension) ends (normal endpoint is 20 degrees):

0

5

10

15

20 or greater

C. If ROM does not conform to the normal range of motion identified above but is normal for this veteran (for reasons other than an ankle condition, such as age, body habitus,
neurologic disease), explain:

VA FORM
JAN 2011

21-0960M-2

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SECTION IV- ROM MEASUREMENTS AFTER REPETITIVE USE TESTING
NOTE - FOR VA PURPOSES, REPETITIVE - USE TESTING MUST ALSO BE PERFORMED. THE VA HAS DETERMINED THAT 3 REPETITIONS, AT
MINIMUM, CAN SERVE AS A REPRESENTATIVE TEST FOR THE EFFECT OF REPETITIVE USE. FOLLOWING INITIAL ROM ASSESSMENT, THE
CLINICIAN MUST PERFORM REPETITIVE - USE TESTING AND REPORT POST - TEST MEASUREMENTS.
A. Is the veteran able to perform repetitive-use testing with 3 repetitions?
YES

(If unable, provide reason:)

NO

NOTE: If veteran is unable to perform repetitive-use testing, skip to Section 5.
NOTE: If veteran is able to perform repetitive-use testing, measure and report ROM after a minimum of 3 repetitions in Items 4B and 4C below.
B. RIGHT ANKLE POST-TEST ROM
Check box at which post-test plantar flexion ends:

0

5

10

15

20

25

30

35

40

45 or greater

35

40

45 or greater

Check box at which post-test dorsiflexion (extension) ends

0

5

10

15

20 or greater

C. LEFT ANKLE POST-TEST ROM
Check box at which post-test plantar flexion ends:

0

5

10

15

20

30

25

Check box at which post-test dorsiflexion (extension) ends

0

5

10

15

20 or greater
SECTION V- FUNCTIONAL LOSS AND ADDITIONAL LIMITATION IN ROM

5A. DOES THE VETERAN HAVE ANY FUNCTIONAL LOSS AND/OR FUNCTIONAL IMPAIRMENT OF THE ANKLE?

YES
NO
5B. DOES THE VETERAN HAVE ADDITIONAL LIMITATION IN ROM OF THE ANKLE FOLLOWING REPETITIVE-USE TESTING?
YES

NO

5C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT AND/OR ADDITIONAL LIMITATION OF ROM OF THE ANKLE AFTER REPETITIVE USE,
INDICATE THE CONTRIBUTING FACTORS OF DISABILITY BELOW (Check all that apply and indicate side affected)
No functional loss for right lower extremity
No functional loss for left lower extremity
Less movement than normal

Right

Left

Both

More movement than normal

Right

Left

Both

Weakened movement

Right

Left

Both

Excess fatigability

Left
Both
Right
Incoordination, impaired ability to execute skilled movements
Pain on movement

Right

Left

Both

Swelling

Right

Left

Both

Deformity

Right

Left

Both

Atrophy of disuse

Right

Left

Both

Instability of station

Right

Left

Both

Disturbance of locomotion

Left
Right
Interference with sitting, standing and weight-bearing

Right

Both
Right

Left

Both

Left

Both

SECTION VI - PAINFUL MOTION, TENDERNESS AND STRENGTH TESTING
6A. IS THERE OBJECTIVE EVIDENCE OF PAINFUL MOTION FOR EITHER ANKLE (evidenced by visible behavior, such as facial expression, wincing, etc.)?
YES

NO (If "Yes," indicate side affected):

Right

Left

Both

6B. DOES THE VETERAN HAVE LOCALIZED TENDERNESS OR PAIN TO PALPATION FOR JOINTS/SOFT TISSUE OF EITHER ANKLE?
YES

NO (If "Yes," indicate side affected):

Right

Left

Both

6C. STRENGTH TESTING - 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
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

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:

VA FORM 21-0960M-2, JAN 2011

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SECTION VII - JOINT STABILITY
7A. ANTERIOR DRAWER TEST - IS THERE LAXITY COMPARED WITH OPPOSITE SIDE?
YES

NO

UNABLE TO TEST

(If "Yes," which side demonstrates laxity?)

Right

Left

Both

7B. TALAR TILT TEST (inversion/eversion stress) - IS THERE LAXITY COMPARED WITH OPPOSITE SIDE?
YES

NO

UNABLE TO TEST

(If "Yes," which side demonstrates laxity?)

Right

Left

Both

SECTION VIII - ADDITIONAL CONDITIONS

8. DOES THE VETERAN HAVE "SHIN SPLINTS", STRESS FRACTURES, ACHILLES TENDONITIS, ACHILLES TENDON RUPTURE, ANKYLOSIS, MALUNION OF
CALCANEUS OR TALUS, OR HAS THE VETERAN HAD A TALECTOMY?
YES

NO

(If "Yes," complete the questions below):
A. Does the veteran now have or has he or she ever had "shin splints"?
YES

NO

(If "Yes," indicate side affected):

Right

Left

Both

Describe current symptoms:
B. Does the veteran now have or has he or she ever had stress fractures of the lower extremity(ies)?
YES

NO

(If "Yes," indicate side affected):

Right

Left

Both

Describe current symptoms:
C. Does the veteran now have or has he or she ever had Achilles tendonitis or Achilles tendon rupture?
YES

NO

(If "Yes," indicate side affected):

Right

Left

Both

Describe current symptoms:
D. Does the veteran now have ankylosis of the ankle, subtalar and/or tarsal joint?
YES

NO

(If "Yes," indicate severity of ankylosis and side affected (check all that apply)

In plantar flexion, less than 30º

Right

Left

Both

In plantar flexion, between 30º and 40º

Right

Left

Both

In plantar flexion, at more than 40º

Right

Left

Both

In dorsiflexion, between 0º and 10º

Right

Left

Both

In dorsiflexion at more than 10º

Right

Left

Both

With abduction, adduction, inversion or eversion deformity

Right

In good weight-bearing position

Right

Left

Both

In poor weight-bearing position

Right

Left

Both

Left

Both

E. Does the veteran have malunion of calcaneus or talus?
YES

NO

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

Moderate

Right

Left

Both

Marked deformity

Right

Left

Both

SECTION IX - JOINT REPLACEMENT AND/OR OTHER SURGICAL PROCEDURES
9A. HAS THE VETERAN HAD A TOTAL ANKLE JOINT REPLACEMENT?
YES

NO

(If "Yes," indicate side and severity of residuals)

Right ankle
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
Other, describe:
Left ankle
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
Other, describe:
VA FORM 21-0960M-2, JAN 2011

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SECTION IX - JOINT REPLACEMENT AND/OR OTHER SURGICAL PROCEDURES (Continued)
9B. HAS THE VETERAN HAD ARTHROSCOPIC OR OTHER ANKLE SURGERY?
YES

NO

(If "Yes," indicate side affected)

Right

Left

Both

Date and type of surgery:
9C. DOES THE VETERAN HAVE ANY RESIDUAL SIGNS AND/OR SYMPTOMS DUE TO ARTHROSCOPIC OR OTHER ANKLE SURGERY?
YES

NO

(If "Yes," indicate side affected)
(If "Yes," describe symptoms):

Right

Left

Both

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

NO

(If "Yes," describe):

SECTION XI - ASSISTIVE DEVICES AND REMAINING FUNCTION OF THE EXTREMITIES
11A. DOES THE VETERAN USE ANY ASSISTIVE DEVICES 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

OTHER:

(If "Yes," identify and describe each condition(s) causing the need for assistive device(s)):

11B. DUE TO THE SERVICE-CONNECTED DISABLING CONDITION(S), 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 would 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

Describe diminished function of each indicated extremity:

SECTION XII - DIAGNOSTIC TESTING
NOTE - The diagnosis of arthritis must be confirmed by imaging studies. Once arthritis has been documented, no further imaging studies are indicated, even if
arthritis has worsened.
12A. HAVE IMAGING STUDIES OF THE ANKLE BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

(If "Yes," is arthritis documented?)
YES

NO

(If "Yes," indicate ankle)
Right

Left

Both

12B. 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)):

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SECTION XIII - FUNCTIONAL IMPACT AND REMARKS
13. DOES THE VETERAN'S ANKLE CONDITION(S) IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

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

14. REMARKS (If any)

SECTION XIV - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
15A. PHYSICIAN'S SIGNATURE

15D. PHYSICIAN'S PHONE NUMBER

15B. PHYSICIAN'S PRINTED NAME

15E. PHYSICIAN'S MEDICAL LICENSE NUMBER

15C. DATE SIGNED

15F. PHYSICIAN'S ADDRESS

NOTE - VA may request additional medical information, including additional examinations, 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 21-0960M-2, JAN 2011

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