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Respondent Burden: 30 minutes
KNEE AND LOWER LEG 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 KNEE AND/OR LOWER LEG 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 knee and/or lower leg conditions)
1C. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO KNEE AND/OR LOWER LEG 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 THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO KNEE AND/OR LOWER LEG CONDITIONS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S KNEE AND/OR LOWER LEG CONDITION(S) (brief summary)
2B. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE KNEE AND/OR LOWER LEG CONDITION(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 knee ROM
Check box at which flexion ends (normal endpoint is 140 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 or greater
Check box at which extension ends:
0 or any degree of hyperextension (check this box if there is no limitation of extension)
Unable to fully extend; extension ends at:
5
10
15
20
25
30
35
40
45 or greater
B. Left knee ROM
Check box at which flexion ends (normal endpoint is 140 degrees):
0
5
10
15
20
25
75
80
85
90
95
100
30
35
105
40
110
45
115
50
120
55
125
60
65
130
70
135
140 or greater
Check box at which extension ends:
0 or any degree of hyperextension (check this box if there is no limitation of extension)
Unable to fully extend; extension ends at:
5
10
15
20
25
30
35
40
45 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 a knee and/or leg condition, such as age,
body habitus, neurologic disease), explain:
VA FORM
JAN 2011
21-0960M-9
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 posttest 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 KNEE 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
125
65
130
70
135
140 or greater
Check box at which post-test extension ends
0 or any degree of hyperextension (check this box if there is no limitation of extension)
Unable to fully extend; extension ends at:
5
10
15
20
25
30
35
25
30
40
45 or greater
4C. LEFT KNEE POST-TEST ROM
Check box at which post-test flexion ends:
0
5
10
15
20
75
80
85
90
95
100
35
105
40
110
45
115
50
120
55
60
125
65
130
70
135
140 or greater
Check box at which post-test extension ends
0 or any degree of hyperextension (check this box if there is no limitation of extension)
Unable to fully extend; extension ends at:
5
10
15
20
25
30
35
40
45 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 KNEE AND LOWER LEG?
YES
NO
5B. DOES THE VETERAN HAVE ADDITIONAL LIMITATION IN ROM OF THE KNEE AND LOWER LEG FOLLOWING REPETITIVE-USE TESTING?
YES
NO
5C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT AND/OR ADDITIONAL LIMITATION OF ROM OF THE KNEE AND LOWER LEG 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-9, JAN 2011
Page 2
SECTION VI - PAINFUL MOTION, TENDERNESS AND STRENGTH TESTING
6A. IS THERE OBJECTIVE EVIDENCE OF PAINFUL MOTION FOR EITHER KNEE (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 TENDERNESS OR PAIN TO PALPATION FOR JOINT LINE AND/OR SOFT TISSUES OF EITHER KNEE?
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
Knee 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
SECTION VII - JOINT STABILITY TESTS
7A. ANTERIOR INSTABILITY (Lachman test):
Unable to test:
Right
Left
Both
Right:
Normal
1+(0-5 millimeters)
2+(5-10 millimeters)
3+(10-15 millimeters)
Left:
Normal
1+(0-5 millimeters)
2+(5-10 millimeters)
3+(10-15 millimeters)
7B. POSTERIOR INSTABILITY (Posterior drawer test):
Right
Unable to test:
Left
Both
Right:
Normal
1+(0-5 millimeters)
2+(5-10 millimeters)
3+(10-15 millimeters)
Left:
Normal
1+(0-5 millimeters)
2+(5-10 millimeters)
3+(10-15 millimeters)
7C. MEDIAL-LATERAL INSTABILITY (Apply valgus/varus pressure to knee in extension and 30 degrees of flexion):
Right
Unable to test:
Left
Both
Right:
Normal
1+(0-5 millimeters)
2+(5-10 millimeters)
3+(10-15 millimeters)
Left:
Normal
1+(0-5 millimeters)
2+(5-10 millimeters)
3+(10-15 millimeters)
SECTION VIII - JOINT STABILITY/SUBLUXATION RESULTS
8A. IS THERE EVIDENCE OR HISTORY OF RECURRENT PATELLAR SUBLUXATION/DISLOCATION?
YES
NO
(If "Yes," indicate severity and side affected):
Right:
None
Slight
Moderate
Severe
Left:
None
Slight
Moderate
Severe
8B. IS THERE EVIDENCE OF INSTABILITY?
YES
NO
(If "Yes," indicate type of instability, severity and side affected):
Right:
None
Slight
Moderate
Severe
Left:
None
Slight
Moderate
Severe
SECTION IX - MENISCAL CONDITIONS, JOINT REPLACEMENT AND OTHER SURGICAL PROCEDURES
9A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER HAD A MENISCUS (semilunar cartilage) CONDITION?
YES
NO
(If "Yes," indicate severity and frequency of symptoms, and side affected):
No symptoms
Right
Left
Both
Meniscal dislocation
Right
Left
Both
Meniscal tear
Right
Left
Both
Frequent episodes of joint "locking"
Right
Left
Both
Frequent episodes of joint pain
Right
Left
Both
Frequent episodes of joint effusion
Right
Left
Both
9B. HAS THE VETERAN HAD A MENISCECTOMY?
YES
NO
(If "Yes," indicate side affected):
Right
Left
Both
Date of surgery:
Does the veteran have residual symptoms/signs?
NO (If "Yes," indicate side affected):
YES
(If "Yes," describe symptoms):
VA FORM 21-0960M-9, JAN 2011
Right
Left
Both
Page 3
SECTION IX - MENISCAL CONDITIONS, JOINT REPLACEMENT AND OTHER SURGICAL PROCEDURES (Continued)
9C. HAS THE VETERAN HAD A TOTAL KNEE JOINT REPLACEMENT?
YES
NO
(If "Yes," indicate side and severity of residuals)
Right knee
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 knee
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:
9D. HAS THE VETERAN HAD ARTHROSCOPIC OR OTHER KNEE SURGERY?
YES
NO
(If "Yes," indicate side affected)
Right
Left
Both
Date and type of surgery:
9E. DOES THE VETERAN HAVE ANY RESIDUAL SIGNS AND/OR SYMPTOMS DUE TO ARTHROSCOPIC OR OTHER KNEE SURGERY?
YES
NO
(If "Yes," indicate side affected):
Right
Left
Both
(If "Yes," describe symptoms):
SECTION X - ADDITIONAL CONDITIONS
10. DOES THE VETERAN HAVE "SHIN SPLINTS" (medial tibial stress syndrome), CHRONIC EXERTIONAL COMPARTMENT SYNDROME, STRESS FRACTURE OR
ANY OTHER TIBIAL AND/OR FIBULAR IMPAIRMENT?
YES
NO
(If "Yes," complete the following questions):
A. Does the veteran have "shin splints" (medial tibial stress syndrome)?
YES
NO
(If "Yes," indicate side affected):
Right
Left
Both
Right
Left
Both
Right
Left
Both
Describe current symptoms:
B. Does the veteran have chronic exertional compartment syndrome?
YES
NO
(If "Yes," indicate side affected):
Describe current symptoms:
C. Does the veteran have a stress fracture(s)?
YES
NO
(If "Yes," indicate side affected):
Describe location and current symptoms:
D. Does the veteran have evidence of acquired or traumatic genu recurvatum with weakness and insecurity in weight-bearing?
YES
NO
(If "Yes," indicate side affected):
Right
Left
Both
E. Does the veteran have leg length discrepancy or shortening of any bones in the lower extremity (leg length discrepancy)?
YES
NO
Right
Left
Both
(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:
cm
inches
Left leg:
cm
inches
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):
VA FORM 21-0960M-9, JAN 2011
Page 4
SECTION XII - ASSISTIVE DEVICES AND REMAINING FUNCTION OF THE EXTREMITIES
12A. 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):
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 fro 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
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 KNEE(S) BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES
NO
(If "Yes," is arthritis documented?)
YES
NO
(If "Yes," indicate knee)
Right
Left
Both
13B. DOES THE VETERAN HAVE X-RAY EVIDENCE OF PATELLAR SUBLUXATION?
YES
NO
(If "Yes," indicate affected side(s):
Right
Left
Both
13C. 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-9, JAN 2011
Page 5
SECTION XIV - FUNCTIONAL IMPACT AND REMARKS
14. DOES THE VETERAN'S KNEE AND/OR LOWER LEG CONDITION(S) 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 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 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-9, JAN 2011
Page 6
| File Type | application/pdf |
| File Title | VA Form 21-0960M-9 |
| Subject | Knee and Lower Leg Conditions - Disability Benefits Questionnaire |
| Author | N. Kessinger |
| File Modified | 2011-02-15 |
| File Created | 2011-02-14 |