Form VA Form 21-0960M-8 VA Form 21-0960M-8 Hip and Thigh Conditions DBQ

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

HIP AND THIGH 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 A HIP AND THIGH 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 hip conditions)
1C. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO HIP/THIGH CONDITIONS, UNDER RIGHT AND/OR LEFT HAND(S)
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 THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO HIP/THIGH CONDITIONS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S HIP/THIGH CONDITION(S) (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 hip ROM
Check box at which flexion ends (normal endpoint is 125 degrees):
0

5

10

15

20

25

75

80

85

90

95

100

30

35

105

40
110

45
115

50
120

55

60

65

70

125 or greater

Check box at which extension ends (normal endpoint is 0 degrees):
0

5 or greater

Is adduction lost beyond 10 degrees?
YES

NO

Is adduction limited such that the veteran cannot cross legs?
NO

YES

Is rotation limited such that the veteran cannot toe-out more than 15 degrees?
YES

NO

B. Left hip ROM
Check box at which flexion ends (normal endpoint is 125 degrees):
0

5

10

15

20

25

75

80

85

90

95

100

30

35

105

40
110

45
115

50
120

55

60

65

70

125 or greater

Check box at which extension ends (normal endpoint is 0 degrees):
0

5 or greater

Is adduction lost beyond 10 degrees?
YES

NO

Is adduction limited such that the veteran cannot cross legs?
YES

NO

Is rotation limited such that the veteran cannot toe-out more than 15 degrees?
YES
NO
C. If ROM does not conform to the normal range of motion identified above but is normal for this veteran (for reasons other than a hip condition, such as age, body
habitus, neurologic disease), explain:

VA FORM
JAN 2011

21-0960M-8

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.
4A. IS VETERAN ABLE TO PERFORM REPETITIVE-USE TESTING WITH 3 REPETITIONS?
YES

NO

(If "No," provide reason):

(If "No," skip to section 5)
(If veteran is able to perform repetitive-use testing, measure and report ROM after a minimum of 3 repetitions.)
4B. RIGHT HIP 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

50

55

120

60

65

70

125 or greater

Check box at which post-test extension ends:
0

5 or greater

Is post-test adduction lost beyond 10 degrees?
YES

NO

Is post-test adduction limited such that the veteran cannot cross legs?
YES

NO

Is post-test rotation limited such that the veteran cannot toe-out more than 15 degrees?
YES

NO

4C. LEFT HIP 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

50
120

55

60

65

70

125 or greater

Check box at which post-test extension ends:
0

5 or greater

Is post-test adduction lost beyond 10 degrees?
YES

NO

Is post-test adduction limited such that the veteran cannot cross legs?
YES

NO

Is post-test rotation limited such that the veteran cannot toe-out more than 15 degrees?
YES

NO

SECTION V - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION IN ROM
5A. DOES THE VETERAN HAVE ANY FUNCTIONAL LOSS AND/OR FUNCTIONAL IMPAIRMENT OF THE HIP AND THIGH?
YES

NO

5B. DOES THE VETERAN HAVE ADDITIONAL LIMITATION IN ROM OF THE HIP AND THIGH FOLLOWING REPETITIVE-USE TESTING?
YES

NO

5C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT AND/OR ADDITIONAL LIMITATION OF ROM OF THE HIP AND THIGH 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

Right

Left

Both

INCOORDINATION, IMPAIRED ABILITY
TO EXECUTE SKILLED MOVEMENTS
SMOOTHLY

Right

Left

Both

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

Right

Left

Both

INTERFERENCE WITH SITTING,
STANDING AND OR WEIGHT-BEARING

Right

Left

Both

VA FORM 21-0960M-8, JAN 2011

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

NO

(If "Yes," side affected):

Right

Left

Both

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

NO

(If "Yes," 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
Hip flexion:
Hip abduction:
Hip 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

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

SECTION VII - ADDITIONAL CONDITIONS
7A. DOES THE VETERAN HAVE ANKYLOSIS, MALUNION OR NONUNION OF FEMUR, FLAIL HIP JOINT OR LEG LENGTH DISCREPANCY?
YES

NO

(If "Yes," complete Items 7B through 7E)

7B. DOES THE VETERAN HAVE ANKYLOSIS OF EITHER HIP JOINT?
YES

NO

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

Favorable, in flexion at an angle between 20 and 40 degrees, and slight adduction or abduction
Right

Left

Both

Intermediate, between favorable and unfavorable
Right

Left

Both

Unfavorable, extremely unfavorable ankylosis, foot not reaching ground, crutches needed
Right

Left

Both

7C. DOES THE VETERAN HAVE MALUNION OR NONUNION OF THE FEMUR?
YES

NO

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

Malunion with slight hip disability

Right

Left

Both

Malunion with moderate hip disability

Right

Left

Both

Malunion with marked hip disability

Right

Left

Both

Intertrochanteric fracture (surgical neck)
with false joint

Right

Left

Both

Fracture of shaft or neck (anatomical),
resulting in nonunion without loose motion;
weight-bearing preserved with
aid of a brace
Fracture of shaft or neck (anatomical), with
nonunion with loose motion; (spiral or

Right

Left

Both

Right

Left

Both

oblique fracture)

NOTE - If impairment of the femur causes knee disability(ies), also complete the VA Form 21-0960M-9, Knee and Lower Leg Conditions
Disability Benefits Questionnaire.
7D. DOES THE VETERAN HAVE A FLAIL HIP JOINT?
YES

NO

(If "Yes," indicate hip affected):

Right

Left

Both

7E. DOES THE VETERAN HAVE SHORTENING OF ANY BONES OF THE LOWER EXTREMITY (leg length discrepancy)?
YES

NO

(If "Yes," provide leg length in inches (to the nearest 1/4 inch) or centimeters, measuring each lower extremity from anterior superior iliac
spine to the internal malleolus of the tibia):
Measurements: Right leg:
VA FORM 21-0960M-8, JAN 2011

cm

inches

Left leg:

cm

inches

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SECTION VIII - JOINT REPLACEMENT AND/OR SURGICAL PROCEDURES
8A. HAS THE VETERAN HAD A TOTAL HIP JOINT REPLACEMENT?
YES

NO

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

Right hip
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 hip
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 HIP SURGERY?
YES

NO

(If "Yes," indicate side affected):

Right

Left

Both

Date and type of surgery:
8C. DOES THE VETERAN HAVE ANY RESIDUAL SIGNS AND/OR SYMPTOMS DUE TO ARTHROSCOPIC OR OTHER HIP SURGERY?
YES

NO

(If "Yes," indicate side affected):

Right

Left

Both

(If "Yes," describe symptoms):
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):

SECTION X - ASSISTIVE DEVICES AND REMAINING FUNCTION OF THE EXTREMITIES
10A. 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

Frequency of use:

Occasional

Regular

Constant

Other:

(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

VA FORM 21-0960M-8, JAN 2011

Right lower

Left lower

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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 HIP(S) BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

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

NO

(If "Yes," indicate hip)
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)):

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

NO

(If "Yes," describe the impact of each of the veteran's hip/thigh 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.
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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-8, JAN 2011

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