VA Form 21-0960C-4 Diabetic Sensory-Motor Peripheral Neuropathy Disability

OMB Control No. 2900-0776
Respondent Burden: 30 minutes
Expiration Date: XX/XX/XXXX

DIABETIC SENSORY-MOTOR PERIPHERAL NEUROPATHY
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
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 NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH DIABETIC PERIPHERAL NEUROPATHY?
YES

NO

(If "Yes," complete Item 1B)

1B. PROVIDE DIAGNOSES THAT PERTAIN TO DIABETIC PERIPHERAL NEUROPATHY:
DIAGNOSIS # 1 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 2 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 3 -

ICD CODE -

DATE OF DIAGNOSIS -

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO DIABETIC PERIPHERAL NEUROPATHY, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY
2A. DOES THE VETERAN HAVE DIABETES MELLITUS TYPE I OR TYPE II?
YES

NO

2B. DESCRIBE THE HISTORY (including cause, onset and course) OF THE VETERAN'S DIABETIC PERIPHERAL NEUROPATHY

2C. DOMINANT HAND
RIGHT

LEFT

AMBIDEXTROUS

SECTION III - SYMPTOMS
3. DOES THE VETERAN HAVE ANY SYMPTOMS ATTRIBUTABLE TO DIABETIC PERIPHERAL NEUROPATHY?
YES

NO (If "Yes," indicate symptoms' location and severity) (Check all that apply):

CONSTANT PAIN (may be excruciating at times)
RIGHT UPPER EXTREMITY:

None

Mild

Moderate

Severe

LEFT UPPER EXTREMITY:

None

Mild

Moderate

Severe

RIGHT LOWER EXTREMITY:

None

Mild

Moderate

Severe

LEFT LOWER EXTREMITY:

None

Mild

Moderate

Severe

INTERMITTENT PAIN (usually dull)
RIGHT UPPER EXTREMITY:

None

Mild

Moderate

Severe

LEFT UPPER EXTREMITY:

None

Mild

Moderate

Severe

RIGHT LOWER EXTREMITY:

None

Mild

Moderate

Severe

LEFT LOWER EXTREMITY:

None

Mild

Moderate

Severe

VA FORM
MAR 2014

21-0960C-4

SUPERSEDES VA FORM 21-0960C-4, OCT 2012,
WHICH WILL NOT BE USED.

Page 1

SECTION III - SYMPTOMS (Continued)
3. DOES THE VETERAN HAVE ANY SYMPTOMS ATTRIBUTABLE TO DIABETIC PERIPHERAL NEUROPATHY? (Continued)
PARESTHESIAS AND/OR DYSESTHESIAS
RIGHT UPPER EXTREMITY:

None

Mild

Moderate

Severe

LEFT UPPER EXTREMITY:

None

Mild

Moderate

Severe

RIGHT LOWER EXTREMITY:

None

Mild

Moderate

Severe

LEFT LOWER EXTREMITY:

None

Mild

Moderate

Severe

RIGHT UPPER EXTREMITY:

None

Mild

Moderate

Severe

LEFT UPPER EXTREMITY:

None

Mild

Moderate

Severe

RIGHT LOWER EXTREMITY:

None

Mild

Moderate

Severe

LEFT LOWER EXTREMITY:

None

Mild

Moderate

Severe

NUMBNESS

OTHER SYMPTOMS (Describe symptoms, location and severity):

SECTION IV - NEUROLOGIC EXAM
4A. STRENGTH - RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE:
0/5 No muscle movement

2/5 No movement against gravity

4/5 Less than normal strength

1/5 Visible muscle movement, but no joint movement

3/5 No movement against resistance

5/5 Normal strength

All normal
Elbow Flexion
Elbow Extension
Wrist Flexion
Wrist Extension
Grip
Pinch

(thumb to index finger)
Knee Extension
Knee Flexion
Ankle Plantar Flexion
Ankle Dorsiflexion

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

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

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

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

4B. DEEP TENDON REFLEXES (DTRs) - RATE REFLEXES ACCORDING TO THE FOLLOWING SCALE:
0 - Absent

2+ Normal

1+ Decreased

3+ Increased without clonus

4+ Increased with clonus

All normal
Biceps
Triceps
Brachioradialis
Knee
Ankle

RIGHT:

0

1+

2+

3+

LEFT:

0

1+

2+

3+

4+
4+

RIGHT:

0

1+

2+

3+

4+

LEFT:

0

1+

2+

3+

4+

RIGHT:

0

1+

2+

3+

4+

LEFT:

0

1+

2+

3+

4+

RIGHT:

0

1+

2+

3+

4+

LEFT:

0

1+

2+

3+

4+

RIGHT:

0

1+

2+

3+

4+

LEFT:

0

1+

2+

3+

4+

VA FORM 21-0960C-4, MAR 2014

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SECTION IV - NEUROLOGIC EXAM (Continued)
4C. LIGHT TOUCH/MONOFILAMENT TESTING RESULTS
All Normal
Shoulder area
Inner/outer forearm
Hand/fingers
Knee/thigh
Ankle/lower leg
Foot/toes

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

4D. POSITION SENSE (grasp index finger/great toe on sides and ask patient to identify up and down movement)
Not tested
RIGHT UPPER EXTREMITY

Normal

Decreased

Absent

LEFT UPPER EXTREMITY

Normal

Decreased

Absent

RIGHT LOWER EXTREMITY

Normal

Decreased

Absent

LEFT LOWER EXTREMITY

Normal

Decreased

Absent

4E. VIBRATION SENSATION (place low-pitched tuning fork over DIP joint of index finger/IP joint of great toe)
Not tested
RIGHT UPPER EXTREMITY

Normal

Decreased

LEFT UPPER EXTREMITY

Normal

Decreased

Absent
Absent

RIGHT LOWER EXTREMITY

Normal

Decreased

Absent

LEFT LOWER EXTREMITY

Normal

Decreased

Absent

4F. COLD SENSATION (test distal extremities for cold sensation with side of tuning fork)
Not tested
RIGHT UPPER EXTREMITY

Normal

Decreased

LEFT UPPER EXTREMITY

Normal

Decreased

Absent
Absent

RIGHT LOWER EXTREMITY

Normal

Decreased

Absent

LEFT LOWER EXTREMITY

Normal

Decreased

Absent

4G. DOES THE VETERAN HAVE MUSCLE ATROPHY?
YES

NO

(If muscle atrophy is present, indicate location):

(For each instance of muscle atrophy, provide measurements in cm between normal and atrophied side, measured at maximum muscle bulk:

cm.)

4H. DOES THE VETERAN HAVE TROPHIC CHANGES (characterized by loss of extremity hair, smooth, shiny skin, etc.) ATTRIBUTABLE TO DIABETIC PERIPHERAL
NEUROPATHY?
YES

NO (If "Yes," describe):

SECTION V - SEVERITY
NOTE: Based on symptoms and findings from Sections III and IV, complete Items 5a and 5b below to provide an evaluation of the severity of the veteran's diabetic peripheral neuropathy.
NOTE: For VA purposes, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the description of complete paralysis that is given with each
nerve. If the nerve is completely paralyzed, check the box for "complete paralysis". If the nerve is not completely paralyzed, check the box for "incomplete paralysis" and indicate severity.
For VA purposes, when nerve impairment is wholly sensory, the evaluation should be mild, or at most, moderate.
5A. DOES THE VETERAN HAVE AN UPPER EXTREMITY DIABETIC PERIPHERAL NEUROPATHY?
YES

NO (If "Yes," indicate nerve affected, severity and side affected)

RADIAL NERVE (musculospiral nerve)

(NOTE: Complete paralysis (hand and fingers drop, wrist and fingers flexed; cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb or
make lateral movement of wrist; supination of hand, elbow extension and flexion weak, hand grip impaired.)
RIGHT:

Normal

Incomplete paralysis

Complete paralysis

(If incomplete paralysis is checked, indicate severity):
Mild
VA FORM 21-0960C-4, MAR 2014

Moderate

Severe

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SECTION V - SEVERITY (Continued)
5A. DOES THE VETERAN HAVE AN UPPER EXTREMITY DIABETIC PERIPHERAL NEUROPATHY? (Continued)
LEFT:

Normal

Incomplete paralysis

Complete paralysis

(If incomplete paralysis is checked, indicate severity):
Mild

Moderate

Severe

MEDIAN NERVE

(NOTE: Complete paralysis (hand inclined to the ulnar side, index and middle fingers extended, atrophy of thenar eminence, cannot make fist, defective
opposition of thumb, cannot flex distal phalanx of thumb; wrist flexion weak.)
RIGHT:

Normal

Incomplete paralysis

Complete paralysis

(If incomplete paralysis is checked, indicate severity):
Mild
LEFT:

Moderate

Normal

Severe

Incomplete paralysis

Complete paralysis

(If incomplete paralysis is checked, indicate severity):
Mild

Moderate

Severe

ULNAR NERVE

(NOTE: Complete paralysis ("griffin claw" deformity, atrophy in dorsal interspaces, thenar and hypothenar eminences; cannot extend ring and little finger,
cannot spread fingers, cannot adduct the thumb; wrist flexion weakened.)
RIGHT:

Normal

Incomplete paralysis

Complete paralysis

(If incomplete paralysis is checked, indicate severity):
Mild
LEFT:

Moderate

Normal

Severe

Incomplete paralysis

Complete paralysis

(If incomplete paralysis is checked, indicate severity):
Mild

Moderate

Severe

5B. DOES THE VETERAN HAVE A LOWER EXTREMITY DIABETIC PERIPHERAL NEUROPATHY?
YES

NO (If "Yes," indicate nerve affected, severity and side affected)

SCIATIC NERVE

(NOTE: Complete paralysis (foot dangles and drops, no active movement of muscles below the knee, flexion of knee weakened or lost.)
RIGHT:

Normal

Incomplete paralysis

Complete paralysis

(If incomplete paralysis is checked, indicate severity):

LEFT:

Mild

Moderate

Normal

Incomplete paralysis

Moderately Severe

Severe, with marked muscular atrophy

Complete paralysis

(If incomplete paralysis is checked, indicate severity):
Mild

Moderate

Moderately Severe

Severe, with marked muscular atrophy

FEMORAL NERVE (anterior crural)

(NOTE: Complete paralysis (paralysis of quadriceps extensor muscles.)
RIGHT:

Normal

Incomplete paralysis

Complete paralysis

(If incomplete paralysis is checked, indicate severity):

LEFT:

Mild

Moderate

Moderately Severe

Normal

Incomplete paralysis

Complete paralysis

(If incomplete paralysis is checked, indicate severity):
Mild

Moderate

Moderately Severe

SECTION VI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS

6A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED
IN SECTION I, DIAGNOSIS?
YES

NO (If "Yes," are any of the scars painful and/or unstable, or is the total area of all related scars greater than or equal to 39 square cm (6 square inches?))

YES

NO (If "Yes," ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)

6B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO
ANY CONDITIONS LISTED IN SECTION I, DIAGNOSIS?
YES

NO (If "Yes," describe) (Brief summary):

VA FORM 21-0960C-4, MAR 2014

Page 4

SECTION VII - DIAGNOSTIC TESTING
NOTE: For purposes of this examination, electromyography (EMG) studies are rarely required to diagnose diabetic peripheral neuropathy. The diagnosis of diabetic
peripheral neuropathy can be made in the appropriate clinical setting by a history of characteristic pain and/or sensory changes in a stocking/glove distribution and
objective clinical findings, which may include symmetrical lost/decreased reflexes, decreased strength, lost/decreased sensation for cold, vibration and/or position sense,
and/or lost/decreased sensation to monofilament testing.
7A. HAVE EMG STUDIES BEEN PERFORMED?
YES

NO

(Extremities tested):
RIGHT UPPER EXTREMITY

Results:

Normal

Abnormal

Date:

LEFT UPPER EXTREMITY

Results:

Normal

Abnormal

Date:

RIGHT LOWER EXTREMITY

Results:

Normal

Abnormal

Date:

LEFT LOWER EXTREMITY

Results:

Normal

Abnormal

Date:

(If abnormal, describe):
7B. IF THERE ARE OTHER SIGNIFICANT FINDINGS OR DIAGNOSTIC TEST RESULTS, PROVIDE DATES AND DESCRIBE

SECTION VIII - FUNCTIONAL IMPACT
8. DOES THE VETERAN'S DIABETIC PERIPHERAL NEUROPATHY IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

If "Yes," describe impact of the veteran's diabetic peripheral neuropathy, providing one or more examples:

SECTION IX - REMARKS
9. REMARKS, if any:

SECTION X - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
10A. PHYSICIAN'S SIGNATURE

10B. PHYSICIAN'S PRINTED NAME

10D. PHYSICIAN'S PHONE AND FAX NUMBER 10E. PHYSICIAN'S MEDICAL LICENSE NUMBER

10C. DATE SIGNED

10F. 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.benefits.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, 58VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the
Federal Register. Your obligation to respond is voluntary. 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 a form. VA cannot conduct or sponsor a collection of information unless a valid OMB
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VA FORM 21-0960C-4, MAR 2014

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