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Respondent Burden: 30 minutes
ELBOW AND FOREARM 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 ELBOW OR FOREARM CONDITION?
YES
NO
(If "Yes," complete Item 1C) (If "No," complete Item 1B)
1B. PROVIDE RATIONALE (e.g. veteran does not currently have any known elbow or forearm condition)
1C. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO ELBOW AND FOREARM CONDITIONS
DIAGNOSIS # 1 -
ICD CODE -
DATE OF DIAGNOSIS -
SIDE AFFECTED
DIAGNOSIS # 2 -
ICD CODE -
DATE OF DIAGNOSIS -
SIDE AFFECTED
DIAGNOSIS # 3 -
ICD CODE -
DATE OF DIAGNOSIS -
SIDE AFFECTED
RIGHT
RIGHT
RIGHT
LEFT
BOTH
LEFT
BOTH
LEFT
BOTH
1D. IF ADDITIONAL DIAGNOSIS PERTAINING TO ELBOW AND FOREARM CONDITION, LIST USING ABOVE FORMAT
SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S ELBOW AND FOREARM CONDITION (brief summary)
2B. DOMINANT HAND
RIGHT
AMBIDEXTROUS
LEFT
2C. 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 ELBOW ROM
Check box at which flexion ends (normal endpoint is 145 degrees):
0
5
10
15
20
25
75
80
85
90
95
100
30
35
105
40
110
45
115
50
120
55
60
125
65
130
70
135
140
145 or greater
140
145 or greater
Check box at which extension ends:
0 or any degree of hyperextension (no limitation of extension)
Unable to fully extend; extension ends at:
5
10
15
20
25
30
75
80
85
90
95
100
35
40
105
45
50
55
60
65
50
55
60
70
110 or greater
B. LEFT ANKLE ROM
Check box at which flexion ends (normal endpoint is 145 degrees):
0
5
10
15
20
25
75
80
85
90
95
100
30
35
105
40
110
45
115
120
125
65
130
70
135
Check box at which extension ends:
0 or any degree of hyperextension (no limitation of extension)
Unable to fully extend; extension ends at:
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110 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 elbow condition, such as age, body
habitus, neurologic disease), explain:
VA FORM
JAN 2011
21-0960M-4
Page 1
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.
4. ROM MEASUREMENTS AFTER REPETITIVE USE TESTING
A. RIGHT ELBOW POST-TEST ROM
Check box at which post-test flexion ends:
0
5
10
15
20
75
80
85
90
95
25
30
35
105
100
40
110
45
50
115
55
120
60
125
65
130
70
135
140
145 or greater
140
145 or greater
Check box at which post-test extension ends
0 or any degree of hyperextension (no limitation of extension)
Unable to fully extend; extension ends at:
5
10
15
20
25
75
80
85
90
95
30
35
100
40
105
45
50
55
60
50
55
65
70
110 or greater
B. LEFT ELBOW POST-TEST ROM
Check box at which post-test flexion ends:
0
5
10
15
20
75
80
85
90
95
25
30
100
35
105
40
110
45
115
120
60
125
65
130
70
135
Check box at which post-test extension ends
0 or any degree of hyperextension (no limitation of extension)
Unable to fully extend; extension ends at:
5
10
15
20
25
75
80
85
90
95
30
100
35
40
105
45
50
55
60
65
70
110 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 ELBOW AND FOREAREM?
YES
NO
5B. DOES THE VETERAN HAVE ADDITIONAL LIMITATION IN ROM OF THE ELBOW AND FOREAREM FOLLOWING REPETITIVE-USE TESTING?
YES
NO
5C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT AND/OR ADDITIONAL LIMITATION OF ROM OF THE ELBOW AND FOREARM AFTER
REPETITIVE USE, INDICATE THE CONTRIBUTING FACTORS OF DISABILITY BELOW (check all that apply and indicate side affected):
No functional loss for right upper extremity
No functional loss for left upper extremity
Less movement than normal
Right
Left
More movement than normal
Right
Left
Both
Both
Weakened movement
Right
Left
Both
Excess fatigability
Right
Left
Both
Incoordination, impaired ability to execute skilled movements smoothly
Pain on movement
Right
Left
Both
Swelling
Right
Left
Both
Right
Left
Both
SECTION VI - PAINFUL MOTION, TENDERNESS AND STRENGTH TESTING
6A. IS THERE OBJECTIVE EVIDENCE OF PAINFUL MOTION FOR EITHER ELBOW (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 ELBOW OR FOREARM?
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
Elbow flexion:
Elbow 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
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
VA FORM 21-0960M-4, JAN 2011
Page 2
SECTION VII - ADDITIONAL CONDITIONS
7. DOES THE VETERAN HAVE ANKYLOSIS OF THE ELBOW JOINT, FLAIL JOINT, JOINT FRACTURE AND/OR IMPAIRMENT OF SUPINATION OR PRONATION?
YES
NO
(If "Yes," complete the questions below):
A. Does the veteran have ankylosis of the elbow?
YES
NO
(If "Yes," indicate side affected and severity):
At an angle between 90 and 70 degrees
Right
Left
Both
At an angle of more than 90 degrees
Right
Left
Both
At an angle between 70 and 50 degrees
Right
Left
Both
At an angle of less than 50 degrees
Right
Left
Both
Complete loss of supination or pronation
Right
Left
Both
(If "Yes," indicate side affected):
Right
B. Does the veteran have flail joint of the elbow?
YES
NO
Left
Both
C. Does the veteran have interarticular fracture (joint fracture or humeral fracture) with marked varus or valgus deformity?
YES
NO
(If "Yes," indicate side affected):
Right
Left
Both
D. Does the veteran have interarticular fracture (joint fracture) with ununited fracture of the head of the radius?
YES
NO
(If "Yes," indicate side affected):
Right
Left
Both
E. Does the veteran have impairment of supination or pronation?
YES
NO
(If "Yes," indicate severity and side affected)
Supination limited to 30 degrees or less
Right
Left
Both
Limited pronation with motion lost
beyond the last quarter of the arc; hand
does not approach full pronation
Right
Left
Both
Limited pronation with motion lost
beyond the middle of the arc
Right
Left
Both
Hand is fixed near the middle of the arc
or moderate pronation due to bone fusion
Right
Left
Both
Hand is fixed in full pronation due to
bone fusion
Right
Left
Both
Hand is fixed in supination or
hyperpronation due to bone fusion
Right
Left
Both
SECTION VIII - JOINT REPLACEMENT AND/OR OTHER SURGICAL PROCEDURES
8A. HAS THE VETERAN HAD A TOTAL ELBOW JOINT REPLACEMENT?
YES
NO
(If "Yes," indicate side and severity of residuals)
Right elbow
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 elbow
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:
8B. HAS THE VETERAN HAD ARTHROSCOPIC OR OTHER ELBOW SURGERY?
YES
NO
Right
(If "Yes," indicate side affected)
Left
Both
Date of surgery:
8C. DOES THE VETERAN HAVE ANY RESIDUAL SIGNS AND/OR SYMPTOMS DUE TO ARTHROSCOPIC OR OTHER ELBOW SURGERY?
YES
NO
Right
(If "Yes," indicate side affected)
Left
Both
If "Yes," describe symptoms:
VA FORM 21-0960M-4, JAN 2011
Page 3
SECTION IX - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
9. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS?
YES
NO
(If "Yes," describe):
NOTE - In all forearm injuries, if there are impaired finger movements due to tendon, muscle or nerve injuries, also complete the appropriate disability questionnaire(s),
such as the VA Form 21-0960M-7, Hand and Finger Disability Benefits Questionnaire, the VA Form 21-0960C-10, Peripheral Nerve Conditions Disability Benefits
Questionnaire, and the VA Form 21-0960M-10, Muscle Injuries Disability Benefits Questionnaire.
SECTION X - ASSISTIVE DEVICES AND REMAINING FUNCTION OF THE EXTREMITIES
10A. DOES THE VETERAN USE ANY ASSISTIVE DEVICES?
YES
NO
(If "Yes," identify assistive device(s) used (check all that apply and indicate frequency):
Brace(s)
Frequency of use:
Occasional
Regular
Constant
Other:
Frequency of use:
Occasional
Regular
Constant
(If "Yes," identify and describe each condition(s) causing the need for assistive device(s)):
10B. 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 XI - 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.
11A. HAVE IMAGING STUDIES OF THE ELBOW BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES
NO
(If "Yes," is arthritis documented?)
YES
NO
(If "Yes," indicate elbow)
Right
Left
Both
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 21-0960M-4, JAN 2011
Page 4
SECTION XII - FUNCTIONAL IMPACT AND REMARKS
12. DOES THE VETERAN'S ELBOW/FOREARM CONDITION IMPACT HIS OR HER ABILITY TO WORK?
YES
NO
(If "Yes," describe the impact of each of the veteran's conditions 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 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.
PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal
Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States,
litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration)
as identified in the VA system of records, 58/VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register.
Your obligation to respond is required to obtain or retain benefits. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with
your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for
refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is
considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to
verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this information. We estimate that
you will need an average of 30 minutes to review the instructions, find the information, and complete the 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 21-0960M-4, JAN 2011
Page 5
| File Type | application/pdf |
| File Title | VA Form 21-0960M-4 |
| Subject | Elbow and Forearm - Disability Benefits Questionnaire |
| Author | N. Kessinger |
| File Modified | 2011-01-31 |
| File Created | 2011-01-31 |