VA Form 21-0960M-6 Foot Miscellaneous (Other than Flatfoot/Pes Planus) DBQ

OMB Approved No. 2900-XXXX
Respondent Burden: 15 minutes

FOOT MISCELLANEOUS (OTHER THAN FLATFOOT/PES PLANUS)
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 A FOOT CONDITION (OTHER THAN FLATFOOT)?
YES

NO

(If "Yes," complete Item 1C)

(If "No," complete Item 1B)

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

1C. INDICATE DIAGNOSIS/ES (Check all that apply) AND COMPLETE THE APPROPRIATE SECTION(S) OF THE FORM
MORTON'S NEUROMA

ICD CODE -

DATE OF DIAGNOSIS -

METATARSALGIA

ICD CODE -

DATE OF DIAGNOSIS -

HAMMER TOES

ICD CODE -

DATE OF DIAGNOSIS -

HALLUX VALGUS

ICD CODE -

DATE OF DIAGNOSIS -

HALLUX RIGIDUS

ICD CODE -

DATE OF DIAGNOSIS -

CLAW FOOT (PES CAVUS) ICD CODE -

DATE OF DIAGNOSIS -

MALUNION/NONUNION OF
TARSAL/METATARSAL
BONES

ICD CODE -

DATE OF DIAGNOSIS -

FOOT INJURIES (specify)

ICD CODE -

DATE OF DIAGNOSIS -

OTHER FOOT CONDITIONS ICD CODE -

DATE OF DIAGNOSIS -

(specify)

NOTE - If the veteran has flatfoot, also complete the VA Form 21-0960M-5, Flatfoot (Pes Planus) Disability Benefits Questionnaire.
SECTION II - MEDICAL HISTORY

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

SECTION III - MORTON'S NEUROMA (Morton's disease) AND /OR METATARSALGIA
3A. DOES THE VETERAN HAVE MORTON'S NEUROMA?
YES

NO

If "Yes," indicate affected side(s)

Right

Left

Both

Left

Both

3B. DOES THE VETERAN HAVE METATARSALGIA?
YES
NO
If "Yes," indicate affected side(s)

Right

SECTION IV - HAMMER TOE
4. DOES THE VETERAN HAVE HAMMER TOE(S)?
YES
NO
If "Yes," indicate which toes are affected on each side?
Right:

None

Great toe

Second toe

Third toe

Fourth toe

Little toe

Left:

None

Great toe

Second toe

Third toe

Fourth toe

Little toe

SECTION V - HALLUX VALGUS
5A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD HALLUX VALGUS?
YES

NO

If "Yes," indicate severity: (check all that apply))
Mild or moderate symptoms
Indicate side affected:

Right

Left

Both

Severe, with function equivalent to amputation of great toe
Indicate side affected:
VA FORM
JAN 2011

21-0960M-6

Right

Left

Both

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SECTION V - HALLUX VALGUS (Continued)
5B. HAS THE VETERAN HAD SURGERY FOR HALLUX VALGUS?
YES
NO
If "Yes," indicate type of surgery and side
Resection of metatarsal head
Date of surgery:
Side affected:

Left

Right

Both

Metatarsal osteotomy/metatarsal head osteotomy (equivalent to metatarsal head resection)
Date of surgery:
Side affected:

Left

Right

Both

Other surgery for hallux valgus, describe:
Date of surgery:
Side affected:

Left

Right

Both

SECTION VI - HALLUX RIGIDUS
6. DOES THE VETERAN HAVE HALLUX RIGIDUS?
YES
NO
If "Yes," indicate severity: (check all that apply)
Mild or moderate symptoms
Side affected:

Left

Right

Both

Severe, with function equivalent to amputation of great toe
Side affected:

Left

Right

Both

SECTION VII - PES CAVUS (CLAW FOOT)
7. DOES THE VETERAN HAVE ACQUIRED CLAW FOOT (PES CAVUS)?
YES
NO
If "Yes," complete the Items 7A through 7D
A. Toes (check all that apply)
Great toe dorsiflexed

Right

Left

Both

All toes tending to dorsiflexion

Right

Left

Both

All toes hammer toes

Right

Left

Both

None of the above

Right

Left

Both

B. Pain and tenderness (check all that apply)
Definite tenderness under metatarsal heads

Right

Left

Both

Marked tenderness under metatarsal heads

Right

Left

Both

Very painful callosities

Right

Left

Both

None of the above

Right

Left

Both

Right

Left

Both

Right

Left

Both

Right

Left

Both

C. Effect on plantar fascia (check all that apply)
Shortened plantar fascia
Marked contraction of plantar fascia with
dropped forefoot
None of the above
D.Dorsiflexion and varus deformity (check all that apply)
Some limitation of dorsiflexion at ankle

Right

Left

Both

Limitation of dorsiflexion at ankle to right angle

Right

Left

Both

Marked varus deformity

Right

Left

Both

Right

Left

Both

None of the above

SECTION VIII - MALUNION OR NONUNION OF TARSAL OR METATARSAL BONES
8. DOES THE VETERAN HAVE MALUNION OR NONUNION OF TARSAL OR METATARSAL BONES?
YES

NO

If "Yes," indicate severity and affected side(s):
Moderate

Left

Right

Moderately severe

Right

Severe

Left

Right

Both
Left

Both

Both

SECTION IX - FOOT INJURIES
9. DOES THE VETERAN HAVE ANY OTHER FOOT INJURIES?
YES
NO If "Yes," describe:
If "Yes," indicate severity and affected side(s):
Moderate
Left
Both
Right
Moderately severe

Right

Severe

Left

Right

VA FORM 21-0960M-6, JAN 2011

Left

Both

Both
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SECTION X - BILATERAL WEAK FOOT
NOTE - Bilateral weak foot is a symptomatic condition secondary to many constitutional conditions characterized by atrophy of the musculature, disturbed circulation,
and weakness.
10. IS THERE EVIDENCE OF BILATERAL WEAK FOOT?
YES

NO

If "Yes," describe:

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

NO

If "Yes," describe:

SECTION XII- ASSISTIVE DEVICES AND REMAINING FUNCTION OF THE EXTREMITIES
12A. 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:

Brace(s)

Frequency of use:

Crutch(es)

Frequency of use:

Cane(s)

Regular

Constant

Occasional

Regular

Constant

Occasional

Regular

Constant

Frequency of use:

Occasional

Regular

Constant

Walker

Frequency of use:

Occasional

Regular

Constant

Other:

Frequency of use:

Occasional

Regular

Constant

Occasional

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

12B. 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 lower
Left lower
Left upper
Right upper

SECTION XIII - 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.
13A. HAVE IMAGING STUDIES OF THE FEET BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

(If "Yes," is arthritis documented in multiple joints of the same foot?)
YES

NO

(If "Yes," indicate foot)
Right

Left

Both

13B. 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-6, JAN 2011

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SECTION XIV - FUNCTIONAL IMPACT AND REMARKS
14. DOES THE VETERAN'S FOOT CONDITION IMPACT HIS OR HER ABILITY TO WORK?
YES
NO
(If "Yes," describe the impact of each of the veteran's foot conditions providing one or more examples)

15. REMARKS (If any)

SECTION XV - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
16A. PHYSICIAN'S SIGNATURE

16D. PHYSICIAN'S PHONE NUMBER

16B. PHYSICIAN'S PRINTED NAME

16E. PHYSICIAN'S MEDICAL LICENSE NUMBER

16C. DATE SIGNED

16F. 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
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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
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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
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VA FORM 21-0960M-6, JAN 2011

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