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Respondent Burden: 30 minutes
SHOULDER AND ARM 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 SHOULDER AND/OR ARM 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 shoulder conditions)
1C. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO SHOULDER AND/OR ARM CONDITIONS
DIAGNOSIS # 1 -
ICD CODE -
DATE OF DIAGNOSIS -
DIAGNOSIS # 2 -
ICD CODE -
DATE OF DIAGNOSIS -
DIAGNOSIS # 3 -
ICD CODE -
DATE OF DIAGNOSIS -
RIGHT
LEFT
BOTH
RIGHT
LEFT
BOTH
RIGHT
LEFT
BOTH
1D. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO SHOULDER AND/OR ARM CONDITIONS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S SHOULDER AND/OR ARM 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 shoulder ROM
Check box at which flexion ends (normal endpoint is 180 degrees):
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
Check box at which abduction ends (normal endpoint is 180 degrees):
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
B. Right shoulder ROM
Check box at which flexion ends (normal endpoint is 180 degrees):
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
Check box at which abduction ends (normal endpoint is 180 degrees):
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
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 back condition, such as age, body
habitus, neurologic disease), explain:
VA FORM
JAN 2011
21-0960M-12
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 6)
(If veteran is able to perform repetitive-use testing, measure and report ROM after a minimum of 3 repetitions.)
4B. RIGHT SHOULDER POST-TEST ROM
Check box at which flexion ends:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
Check box at which abduction ends:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
4C. LEFT SHOULDER POST-TEST ROM
Check box at which flexion ends:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
Check box at which abduction ends:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
SECTION V - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION IN ROM
5A.DOES THE VETERAN HAVE ANY FUNCTIONAL LOSS AND/OR FUNCTIONAL IMPAIRMENT OF THE SHOULDER AND ARM?
YES
NO
5B. DOES THE VETERAN HAVE ADDITIONAL LIMITATION IN ROM OF THE SHOULDER AND ARM FOLLOWING REPETITIVE-USE TESTING?
YES
NO
5C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT AND/OR ADDITIONAL LIMITATION OF ROM OF THE SHOULDER AND ARM 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
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
SECTION VI - PAINFUL MOTION, TENDERNESS AND STRENGTH TESTING
6A. IS THERE OBJECTIVE EVIDENCE OF PAINFUL MOTION FOR EITHER SHOULDER (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/BICEPS TENDON OF EITHER SHOULDER?
YES
NO
(If "Yes," indicate side affected):
Right
Left
Both
Left
Both
6C. DOES THE VETERAN HAVE GUARDING OF EITHER SHOULDER?
YES
NO
(If "Yes," indicate side affected):
VA FORM 21-0960M-12, JAN 2011
Right
Page 2
SECTION VII - STRENGTH TESTING
7. 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
Shoulder abduction:
Shoulder forward 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
SECTION VIII - SPECIFIC TESTS FOR ROTATOR CUFF CONDITIONS
8A. HAWKINS' IMPINGEMENT TEST (Forward flex the arm to 90 degrees with the elbow bent to 90 degrees. Internally rotate arm. Pain on internal rotation
indicates a positive test; may signify rotator cuff tendinopathy or tear)
POSITIVE
NEGATIVE
UNABLE TO PERFORM
N/A
(If "Positive," indicate side affected):
Left
Both
Right
8B. EMPTY-CAN TEST (Abduct arm to 90 degrees and forward flex 30 degrees. Patient turns thumbs down and resists downward force applied by the examiner.
Weakness indicates a positive test; may indicate rotator cuff pathology, including supraspinatus tendinopathy or tear)
POSITIVE
NEGATIVE
UNABLE TO PERFORM
N/A
(If "Positive," indicate side affected):
Left
Right
Both
8C. EXTERNAL ROTATION/INFRASPINATUS STRENGTH TEST (Patient holds arms at their sides with elbows flexed 90 degrees. Patient externally rotates against
resistance.. Weakness indicates a positive test; may be associated with infraspinatus tendinopathy or tear)
POSITIVE
NEGATIVE
UNABLE TO PERFORM
N/A
Left
Both
Right
(If "Positive," indicate side affected):
8D. LIFT-OFF SUBSCAPULARIS TEST (Patient internally rotates arm behind lower back, pushes against examiner's hand. Weakness indicates a positive test; may
indicate subscapularis tendinopathy or tear)
POSITIVE
NEGATIVE
UNABLE TO PERFORM
(If "Positive," indicate side affected):
N/A
Left
Right
Both
SECTION IX - HISTORY AND SPECIFIC TESTS FOR INSTABILITY/DISLOCATION/LABRAL PATHOLOGY
9A. IS THERE A HISTORY OF MECHANICAL SYMPTOMS (clicking, catching, etc.)?
YES
NO
(If "Yes," indicate side affected):
Left
Both
Right
9B. IS THERE A HISTORY OF RECURRENT DISLOCATION (subluxation) OF THE GLENOHUMERAL (scapulohumeral) JOINT?
YES
NO
(If "Yes," indicate frequency, severity and side affected) (check all that apply):
Infrequent episodes
Right
Left
Both
Frequent episodes
Right
Left
Both
Guarding of movement only at shoulder
level (moderate instability)
Right
Left
Both
Guarding of all arm movements
Right
Left
Both
(severe instability)
9C. CRANK APPREHENSION AND RELOCATION TEST (With patient supine, abduct patient's arm to 90 degrees and flex elbow 90 degrees. Pain and sense of
instability with further external rotation may indicate shoulder instability)
POSITIVE
NEGATIVE
UNABLE TO PERFORM
(If "Positive," indicate side affected):
N/A
Left
Right
Both
SECTION X - HISTORY AND SPECIFIC TESTS FOR ACROMIOCLAVICULAR (AC) JOINT CONDITIONS
10A. DOES THE VETERAN HAVE AN AC JOINT CONDITION OR ANY OTHER IMPAIRMENT OF THE CLAVICLE OR SCAPULA?
YES
NO
(If "Yes," indicate severity and side affected):
Malunion of clavicle or scapula
Right
Left
Both
Nonunion of clavicle or scapula without loose movement
Right
Left
Both
Nonunion of clavicle or scapula with loose movement
Right
Left
Both
Dislocation (acromioclavicular separation or
Right
Left
Both
Other, describe:
Right
Left
Both
Left
Both
sternoclavicular dislocation)
10B. IS THERE TENDERNESS TO PALPATION OVER THE AC JOINT?
YES
NO
(If "Yes," indicate side affected):
Right
10C. CROSS-BODY ADDUCTION TEST (Passively adduct arm across the patient's body toward the contralateral shoulder. Pain may indicate acromioclavicular joint
pathology)
POSITIVE
NEGATIVE
UNABLE TO PERFORM
(If "Positive," indicate side affected):
VA FORM 21-0960M-12, JAN 2011
Right
N/A
Left
Both
Page 3
SECTION XI - ANKYLOSIS
11. DOES THE VETERAN HAVE ANKYLOSIS OF THE GLENOHUMERAL (scapulohumeral) ARTICULATION?
NO
YES
(If "Yes," indicate severity and side affected):
Abduction to 60 degrees; can reach mouth and head
Right
Left
Both
Abduction limited to between 60 and 25 degrees
Right
Left
Both
Abduction limited to 25 degrees from the side
Right
Left
Both
SECTION XII - JOINT REPLACEMENT AND/OR OTHER SURGICAL PROCEDURES
12A. HAS THE VETERAN HAD A TOTAL SHOULDER JOINT REPLACEMENT?
NO
YES
(If "Yes," indicate side and severity of residuals):
Right shoulder
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 shoulder
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:
12B. HAS THE VETERAN HAD ARTHROSCOPIC OR OTHER SHOULDER SURGERY?
NO (If "Yes," indicate side affected):
YES
Right
Left
Both
Date and type of surgery:
12C. DOES THE VETERAN HAVE ANY RESIDUAL SIGNS AND/OR SYMPTOMS DUE TO ARTHROSCOPIC OR OTHER SHOULDER SURGERY?
NO (If "Yes," indicate side affected):
YES
Right
Left
Both
(If "Yes," describe):
SECTION XIII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
13. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS?
YES
NO (If "Yes," describe):
SECTION XIV - ASSISTIVE DEVICES AND REMAINING FUNCTION OF THE EXTREMITIES
14A. 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):
14B. 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
VA FORM 21-0960M-12, JAN 2011
Left upper
Right lower
Left lower
Page 4
SECTION XV - 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.
15A. HAVE IMAGING STUDIES OF THE SHOULDER BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES
NO
(If "Yes," is arthritis documented?)
YES
NO
(If "Yes," indicate shoulder)
Right
Left
Both
15B. 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 XVI - FUNCTIONAL IMPACT AND REMARKS
16. DOES THE VETERAN'S SHOULDER CONDITION IMPACT HIS OR HER ABILITY TO WORK?
YES
NO (If "Yes," describe the impact of each of the veteran's shoulder conditions, providing one or more examples):
17. REMARKS (If any)
SECTION XVII - PHYSICIAN'S CERTIFICATION AND SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
18A. PHYSICIAN'S SIGNATURE
18D. PHYSICIAN'S PHONE NUMBER
18B. PHYSICIAN'S PRINTED NAME
18E. PHYSICIAN'S MEDICAL LICENSE NUMBER
18C. DATE SIGNED
18F. 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-12, JAN 2011
Page 5
| File Type | application/pdf |
| File Title | VA Form 21-0960M-12 |
| Subject | Shoulder and Arm Conditions - Disability Benefits Questionnaire |
| Author | N. Kessinger |
| File Modified | 2011-02-23 |
| File Created | 2011-02-18 |