VA Form 21-0960M-1 Amputations Disability Benefits Questionnaire

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

AMPUTATIONS
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.
NOTE: If the following are noted, complete the appropriate disability questionnaire.
1. For limited motion or instability in the joint above the amputation site, also complete the Disability Benefits Questionnaire for the specific joint.
2. For scars, or skin breakdown also complete the VA Form 21-0960F-1, Scars Disability Benefits Questionnaire.
3. For muscular injuries, also complete VA Form 21-0960M-10, Muscle Injury Disability Benefits Questionnaire.
4. For Osteomyelitis, also complete the VA Form 21-0960M-11, Osteomyelitis Disability Benefits Questionnaire.
5. For circulation conditions related to amputation, also complete VA Form 21-0960A-2, Arteries and Veins Disability Benefits Questionnaire.
6. For painful neuroma, also complete VA Form 21-0960C-10, Peripheral Nerve Disability Benefits Questionnaire.
SECTION I - DIAGNOSIS
1A. HAS AN AMPUTATION(S) BEEN PERFORMED?
YES

NO

(If "Yes," complete Item 1B)

1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO AMPUTATION(S)
AMPUTATION # 1 -

ICD CODE -

DATE OF AMPUTATION -

AMPUTATION # 2 -

ICD CODE -

DATE OF AMPUTATION -

AMPUTATION # 3 -

ICD CODE -

DATE OF AMPUTATION -

1C. IF ADDITIONAL AMPUTATION(S) EXIST, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY
2. DESCRIBE THE ETIOLOGY OF EACH AMPUTATION LISTED IN SECTION I:

SECTION III - DOMINANT HAND
3. DOMINANT HAND
RIGHT

LEFT

AMBIDEXTROUS

SECTION IV - AMPUTATION(S) SITE(S)
4. AMPUTATION(S) SITE(S) (Check all that apply):
UPPER EXTREMITIES (not including the fingers)
FINGERS
LOWER EXTREMITIES (including the forefoot)
TOES

(If checked, complete the appropriate section below)
NOTE - Imaging studies are not required to document amputation(s)
SECTION V - AMPUTATION(S) OF THE UPPER EXTREMITY(IES) (NOT INCLUDING FINGERS)
5A. IS THERE AN AMPUTATION OF EITHER ARM?
YES

NO

(If "Yes," check all that apply)

LEFT

RIGHT
Amputation is below insertion of deltoid

Amputation is below insertion of deltoid

Amputation is above insertion of deltoid

Amputation is above insertion of deltoid

Disarticulation
Does the amputation site allow the use of a suitable
prosthetic appliance?
YES

VA FORM
MAR 2014

NO

21-0960M-1

Disarticulation
Does the amputation site allow the use of a suitable
prosthetic appliance?
YES

NO

SUPERSEDES VA FORM 21-0960M-1, OCT 2012,
WHICH WILL NOT BE USED.

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SECTION V - AMPUTATION(S) OF THE UPPER EXTREMITY(IES) (NOT INCLUDING FINGERS) (Continued)
5B. IS THERE AN AMPUTATION OF EITHER FOREARM?
YES

NO

(If "Yes," check all that apply)

LEFT

RIGHT
Amputation resulting in loss of use of the hand

Amputation resulting in loss of use of hand

Amputation below insertion of pronator teres

Amputation below insertion of pronator teres

Amputation above insertion of pronator teres

YES

Amputation above insertion of pronator teres
Does the amputation site allow the use of a suitable
prosthetic appliance?

Does the amputation site allow the use of a suitable
prosthetic appliance?
NO

YES

NO

SECTION VI - AMPUTATION(S) OF FINGER(S)
6A. IS THERE AN AMPUTATION OF EITHER THUMB?
YES

NO

(If "Yes," check all that apply)

LEFT

RIGHT
Amputation at the distal joint or through the distal phalanx

Amputation at the distal joint or through the distal phalanx

Amputation at the metacarpophalangeal joint or through
the proximal phalanx

Amputation at the metacarpophalangeal joint or through
the proximal phalanx

Amputation with metacarpal resection

Amputation with metacarpal resection

6B. IS THERE AN AMPUTATION OF EITHER INDEX FINGER?
YES

NO

(If "Yes," check all that apply)

LEFT

RIGHT
Amputation through the long phalanx or at the distal joint

Amputation through the long phalanx or at the distal joint

Amputation without metacarpal resection, at the proximal
interphalangeal joint or proximal thereto
Amputation with metacarpal resection (more than one-half
the bone lost)

Amputation without metacarpal resection, at the proximal
interphalangeal joint or proximal thereto
Amputation with metacarpal resection (more than one-half
the bone lost)

6C. IS THERE AN AMPUTATION OF EITHER LONG FINGER?
YES

NO

(If "Yes," check all that apply)

LEFT

RIGHT
Amputation without metacarpal resection, at the proximal
interphalangeal joint or proximal thereto
Amputation with metacarpal resection (more than one-half
the bone lost)

Amputation without metacarpal resection, at the proximal
interphalangeal joint or proximal thereto
Amputation with metacarpal resection (more than one-half
the bone lost)

6D. IS THERE AN AMPUTATION OF EITHER RING FINGER?
YES

NO

(If "Yes," check all that apply)

LEFT

RIGHT
Amputation without metacarpal resection, at the proximal
interphalangeal joint or proximal thereto
Amputation with metacarpal resection (more than one-half
the bone lost)

Amputation without metacarpal resection, at the proximal
interphalangeal joint or proximal thereto
Amputation with metacarpal resection (more than one-half
the bone lost)

6E. IS THERE AN AMPUTATION OF EITHER LITTLE FINGER?
YES

NO

(If "Yes," check all that apply)

LEFT

RIGHT
Amputation without metacarpal resection, at the proximal
interphalangeal joint or proximal thereto
Amputation with metacarpal resection (more than one-half
the bone lost)

Amputation without metacarpal resection, at the proximal
interphalangeal joint or proximal thereto
Amputation with metacarpal resection (more than one-half
the bone lost)

SECTION VII - AMPUTATION(S) OF THE LOWER EXTREMITY(IES) (NOT INCLUDING THE TOES)
7A. IS THERE AN AMPUTATION ABOVE EITHER KNEE?
YES

NO

(If "Yes," check all that apply)

LEFT

RIGHT
Amputation of the middle or lower third

Amputation of the middle or lower third

Amputation of the upper third, one-third of the distance from
the perineum to the knee joint, measured from the perineum

Amputation of the upper third, one-third of the distance from
the perineum to the knee joint, measured from the perineum

Disarticulation with loss of extrinsic pelvic girdle muscles

Disarticulation with loss of extrinsic pelvic girdle muscles

Does the amputation site allow the use of a suitable prosthetic appliance?
YES

NO

VA FORM 21-0960M-1, MAR 2014

Does the amputation site allow the use of a suitable prosthetic appliance?
YES

NO

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SECTION VII - AMPUTATION(S) OF THE LOWER EXTREMITY(IES) (NOT INCLUDING THE TOES) (Continued)
7B. IS THERE AN AMPUTATION BELOW EITHER KNEE (TO INCLUDE FOREFOOT)?
YES

NO

(If "Yes," check all that apply)

LEFT

RIGHT
Amputation of the forefoot, which is proximal to the metatarsal
bones (more than one-half of metatarsal loss)
Amputation at a lower level (between the forefoot and knee),
permitting prosthesis
Amputation not improvable by prosthesis controlled by natural
knee action
Amputation with defective stump and amputation of the thigh
recommended

Amputation of the forefoot, which is proximal to the metatarsal
bones (more than one-half of metatarsal loss)
Amputation at a lower level (between the forefoot and knee),
permitting prosthesis
Amputation not improvable by prosthesis controlled by natural
knee action
Amputation with defective stump and amputation of the thigh
recommended

Does the amputation site allow the use of a suitable prosthetic appliance?

Does the amputation site allow the use of a suitable prosthetic appliance?

YES

NO

YES

NO

SECTION VIII - AMPUTATION(S) OF THE TOE(S)
8. IS THERE AN AMPUTATION OF A TOE(S) OF EITHER FOOT?
YES

NO

(If "Yes," check all that apply)

LEFT

RIGHT

Is there amputation of all toes without metatarsal loss?
YES

NO

Is there amputation of the great toe?
YES

NO

(If "Yes," indicate which of the following apply):

Is there amputation of all toes without metatarsal loss?
YES

NO

Is there amputation of the great toe?
YES

NO

(If "Yes," indicate which of the following apply):

Amputation without metatarsal involvement

Amputation without metatarsal involvement

Amputation with removal of the metatarsal head

Amputation with removal of the metatarsal head

Is there amputation of any lesser toe with removal of
the metatarsal head?
YES

NO

(If "Yes," indicate which of the following apply):

Is there amputation of any lesser toe with removal of
the metatarsal head?
YES

NO

(If "Yes," indicate which of the following apply):

Amputation of toes one or two

Amputation of toes one or two

Amputation without metatarsal involvement

Amputation without metatarsal involvement

Is there amputation of toes three or four without
metatarsal involvement?
YES

NO

(If "Yes," indicate which of the following apply):

Is there amputation of toes three or four without
metatarsal involvement?
YES

NO

(If "Yes," indicate which of the following apply):

Amputation not including great toe

Amputation not including great toe

Amputation including great toe

Amputation including great toe

SECTION IX - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
9A. 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)

9B. 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 21-0960M-1, MAR 2014

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SECTION X - ASSISTIVE DEVICES
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 devices 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

Other:

Frequency of use:

Occasional

Regular

Constant

10B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:

SECTION XI - DIAGNOSTIC TESTING
NOTE - Imaging studies are not required to document amputation(s)
11. ARE THERE ANY 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
12. DOES THE VETERAN'S AMPUTATION IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

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

SECTION XIII - REMARKS
13. REMARKS (If any):

SECTION XIV - 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 obtain additional medical information, including an examination, 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, 58/VA21/22/28, 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 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-1, MAR 2014

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