VA Form 21-0960M-1 Wrist Conditions DBQ

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

WRIST 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 WRIST 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 wrist conditions)
1C. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO WRIST 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 WRIST CONDITIONS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S CURRENT WRIST CONDITION(S) (brief summary)

2B. DOMINANT HAND
LEFT

RIGHT

AMBIDEXTROUS

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:
A. Right wrist ROM
Check box at which palmar flexion ends (endpoint of palmar flexion 80 degrees):
0

5

10

15

20

25

30

50

55

60

65

70

75

80 or greater

35

40

45

Check box at which dorsiflexion (extension) ends (endpoint of dorsiflexion (extension) 70 degrees):
0

5

10

15

20

25

30

40

45

50

55

60

65

70 or greater

35

B. Left wrist ROM
Check box at which palmar flexion ends (endpoint of palmar flexion 80 degrees):
0

5

10

15

20

25

30

50

55

60

65

70

75

80 or greater

35

40

45

Check box at which dorsiflexion (extension) ends (endpoint of dorsiflexion (extension) 70 degrees):
0

5

10

15

20

25

30

40

45

50

55

60

65

70 or greater

35

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 wrist condition, such as age,
body habitus, neurologic disease), explain:

VA FORM
JAN 2011

21-0960M-16

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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 6)
If veteran is able to perform repetitive-use testing, measure and report ROM after a minimum of 3 repetitions.
4B. RIGHT WRIST POST-TEST ROM
Check box at which palmar flexion ends:
0

5

10

15

20

25

55

60

65

70

75

80 or greater

30

35

40

45

50

Check box at which dorsiflexion (extension) ends:
0

5

10

15

55

60

65

70 or greater

20

25

30

35

40

45

50

30

35

40

45

50

35

40

45

50

4C. LEFT WRIST POST-TEST ROM
Check box at which palmar flexion ends:
0

5

10

15

20

25

55

60

65

70

75

80 or greater

Check box at which dorsiflexion (extension) ends:
0

5

10

15

55

60

65

70 or greater

20

25

30

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

NO

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

NO

5C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT AND/OR ADDITIONAL LIMITATION OF ROM OF THE WRIST 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
INCOORDINATION (IMPAIRED ABILITY TO
EXECUTE SKILLED MOVEMENTS
SMOOTHLY)
PAIN ON MOVEMENT

Right

Left

Both

Right

Left

Both

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 WRIST (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 WRIST?
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
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

5/5

4/5

3/5

2/5

1/5

0/5

5/5
Left:
VA FORM 21-0960m-16, JAN 2011

4/5

3/5

2/5

1/5

0/5

Wrist flexion:

Wrist extension: Right:

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SECTION VII - ANKYLOSIS
7. IS THERE ANKYLOSIS OF EITHER WRIST JOINT?
YES

NO

(If "Yes," indicate severity and side affected):
Favorable in 20 degree to 30 degree dorsiflexion

Right

Left

Both

Any other position, except favorable

Right

Left

Both

Unfavorable, in any degree of palmar flexion

Right

Left

Both

Unfavorable, with ulnar or radial deviation

Right

Left

Both

Extremely unfavorable

Right

Left

Both

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

NO

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

Right wrist

(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 wrist

(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 WRIST SURGERY?
YES

NO (If "Yes," side affected):
(Date and type of surgery):

Right

Left

Both

8C. DOES THE VETERAN HAVE ANY RESIDUAL SIGNS AND/OR SYMPTOMS DUE TO ARTHROSCOPIC OR OTHER WRIST SURGERY?
YES

NO (If "Yes," side affected):
(If "Yes," describe symptoms):

Right

Left

Both

SECTION IX - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
9. DOES THE VETERAN HAVE ANY OTHER WRIST-RELATED PERTINENT COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS NOT ALREADY ADDRESSED?
YES

NO

(If "Yes," describe):
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 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):

VA FORM 21-0960m-16, JAN 2011

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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 WRIST BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

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

NO

(If "Yes," indicate wrist)
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 WRIST CONDITION IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe the impact of each of the veteran's wrist conditions, providing one or more examples):

13. 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.
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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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
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VA FORM 21-0960m-16, JAN 2011

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