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pdfOMB Approved No. 2900-0802
Respondent Burden: 30 minutes
Expiration Date: XX/XX/XXXX
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 - The veteran or service member 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 claim. VA reserves the right to confirm the authenticity of ALL DBQs
completed by private health care providers.
MEDICAL RECORD REVIEW
WAS THE VETERAN'S VA CLAIMS FILE REVIEWED?
YES
NO
IF YES, LIST ANY RECORDS THAT WERE REVIEWED BUT WERE NOT INCLUDED IN THE VETERAN'S VA CLAIMS FILE:
IF NO, CHECK ALL RECORDS REVIEWED:
Military service treatment records
Department of Defense Form 214 Separation Documents
Military service personnel records
Veterans Health Administration medical records (VA treatment records)
Military enlistment examination
Civilian medical records
Military separation examination
Interviews with collateral witnesses (family and others who have known the veteran before and after military service)
Military post-deployment questionnaire
Other:
No records were reviewed
SECTION I - DIAGNOSIS
NOTE: These are condition(s) for which an evaluation has been requested on an exam request form (Internal VA) or for which the Veteran has requested medical
evidence be provided for submission to VA.
1A. LIST THE CLAIMED CONDITION(S) THAT PERTAIN TO THIS DBQ:
NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed above. If there is no diagnosis, if the diagnosis is different
from a previous diagnosis for this condition, or if there is a diagnosis of a complication due to the claimed condition, explain your findings and reasons in comments
section.
Date of diagnosis can be the date of the evaluation if the clinician is making the initial diagnosis, or an approximate date determined through record review or reported
history.
1B. SELECT DIAGNOSES ASSOCIATED WITH THE CLAIMED CONDITION(S) (Check all that apply):
The Veteran does not have a current diagnosis associated with any claimed condition listed above. (Explain your findings and reasons in comments section.)
Shoulder strain
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Shoulder impingement syndrome Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Bicipital tendonitis
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Bicipital tendon tear
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Rotator cuff tendonitis
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Rotator cuff tear
Labral tear, including SLAP
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Subacromial/subdeltoid bursitis
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Glenohumeral joint osteoarthritis
Acromioclavicular joint
osteoarthritis
Ankylosis of glenohumeral
articulations (shoulder joint)
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
(Superior labral anteriorposterior lesion)
Glenohumeral joint instability
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Glenohumeral joint dislocation
Side affected:
Shoulder joint replacement (total
Right
Left
Both
ICD Code:
Date of diagnosis:
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Acromioclavicular joint separation Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
shoulder arthroplasty/
hemiarthroplasty)
VA FORM
XXX XXXX
21-0960M-12
SUPERSEDES VA FORM 21-0960M-12, MAY 2013,
WHICH WILL NOT BE USED.
Page 1
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION I - DIAGNOSIS (Continued)
Other (specify)
Other diagnosis #1:
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Right
Left
Both
ICD Code:
Date of diagnosis:
Right
Left
Both
ICD Code:
Date of diagnosis:
Other diagnosis #2:
Side affected:
Other diagnosis #3:
Side affected:
1C. COMMENTS (if any):
1D. WAS AN OPINION REQUESTED ABOUT THIS CONDITION (internal VA only)?
YES
NO
N/A
SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S SHOULDER OR ARM CONDITION (brief summary):
2B. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE SHOULDER OR ARM?
YES
NO
IF YES, DOCUMENT THE VETERAN'S DESCRIPTION OF THE IMPACT OF FLARE-UPS IN HIS OR HER OWN WORDS:
2C. DOES THE VETERAN REPORT HAVING ANY FUNCTIONAL LOSS OR FUNCTIONAL IMPAIRMENT OF THE JOINT OR EXTREMITY BEING EVALUATED ON THIS
DBQ (regardless of repetitive use)?
YES
NO
IF YES, DOCUMENT THE VETERAN'S DESCRIPTION OF FUNCTIONAL LOSS OR FUNCTIONAL IMPAIRMENT IN HIS OR HER OWN WORDS:
SECTION III - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS
Measure ROM with a goniometer. During the examination be cognizant of painful motion, which could be evidenced by visible behavior such as facial expression, wincing,
etc..., on pressure or manipulation. Document painful movement in Section 5.
Following the initial assessment of ROM, perform repetitive use testing. For VA purposes, repetitive use testing must be included in all joint exams. The VA has determined
that 3 repetitions of ROM (at a minimum) can serve as a representative test of the effect of repetitive use. After the initial measurement, reassess ROM after 3 repetitions.
Report post-test measurements in question 4A.
3A. INITIAL ROM MEASUREMENTS
Shoulder
RIGHT
SHOULDER
All Normal
Joint Movement
ROM Measurement
Flexion
(normal endpoint
= 180 degrees)
Not indicated
Abduction
(normal endpoint
= 180 degrees)
Not indicated
External Rotation
(normal endpoint
= 90 degrees)
Internal Rotation
(normal endpoint
= 90 degrees)
VA FORM 21-0960M-12, XXX XXXX
If ROM testing is not indicated for the veteran's condition or not able to be performed,
please explain why, and then proceed to Section 5:
Not able to perform
Not able to perform
Not indicated
Not able to perform
Not indicated
Not able to perform
Page 2
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION III - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS (Continued)
3A. INITIAL ROM MEASUREMENTS
Shoulder
LEFT
SHOULDER
All Normal
Joint Movement
ROM Measurement
Flexion
(normal endpoint
= 180 degrees)
Not indicated
Abduction
(normal endpoint
= 180 degrees)
Not indicated
External Rotation
(normal endpoint
= 90 degrees)
Internal Rotation
(normal endpoint
= 90 degrees)
If ROM testing is not indicated for the veteran's condition or not able to be performed,
please explain why, and then proceed to Section 5:
Not able to perform
Not able to perform
Not indicated
Not able to perform
Not indicated
Not able to perform
3B. DO ANY ABNORMAL ROMs NOTED ABOVE CONTRIBUTE TO FUNCTIONAL LOSS?
YES (you will be asked to further describe these limitations in Section 6 below)
NO, EXPLAIN WHY THE ABNORMAL ROMs DO NOT CONTRIBUTE:
3C. IF ROM DOES NOT CONFORM TO THE NORMAL RANGE OF MOTION IDENTIFIED ABOVE BUT IS NORMAL FOR THIS VETERAN (for reasons other than a
shoulder or arm condition, such as age, body habitus, neurologic disease), EXPLAIN:
SECTION IV - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING
4A. POST-TEST ROM MEASUREMENTS
Shoulder
RIGHT
SHOULDER
Is there additional limitation in ROM
after repetitive-use testing?
Is the veteran able to perform repetitive-use testing?
Yes
Yes
No
No, there is no change in ROM
after repetitive testing
If yes, perform repetitive-use testing
If no, provide reason below, then proceed to Section 5
If yes, report ROM after a minimum
of 3 repetitions.
If no, documentation of ROM after
repetitive-use testing is not required.
LEFT
SHOULDER
Yes
Yes
No
No, there is no change in ROM
after repetitive testing
If yes, perform repetitive-use testing
If no, provide reason below, then proceed to Section 5
If yes, report ROM after a minimum
of 3 repetitions.
If no, documentation of ROM after
repetitive-use testing is not required.
Joint Movement
Post-test ROM
Measurement
Flexion
Abduction
External Rotation
Internal Rotation
Flexion
Abduction
External Rotation
Internal Rotation
4B. DO ANY POST-TEST ADDITIONAL LIMITATIONS OF ROMs NOTED ABOVE CONTRIBUTE TO FUNCTIONAL LOSS?
YES (you will be asked to further describe these limitations in Section 6 below)
NO, EXPLAIN WHY THE POST-TEST ADDITIONAL LIMITATIONS OF ROMs DO NOT CONTRIBUTE:
VA FORM 21-0960M-12, XXX XXXX
Page 3
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION V - PAIN
5A. ROM MOVEMENTS PAINFUL ON ACTIVE, PASSIVE AND/OR REPETITIVE USE TESTING
Shoulder
Are any ROM movements painful on active,
passive and/or repetitive use testing?
(If yes, identify whether active, passive,
and/or repetitive use in question 5D)
LEFT
SHOULDER
If no (the pain does not contribute to functional loss
or additional limitation of ROM), explain why the pain
does not contribute:
Yes (you will be asked to further describe
these limitations in Section 6 below)
Yes
RIGHT
SHOULDER
If yes (there are painful movements), does the
pain contribute to functional loss or
additional limitation of ROM?
No
No
Yes
Yes (you will be asked to further describe
these limitations in Section 6 below)
No
No
5B. PAIN WHEN USED IN WEIGHT-BEARING OR IN NON WEIGHT-BEARING
Shoulder
Is there pain when the joint is used in
weight-bearing or non weight-bearing?
(If yes, identify whether weight-bearing or
non weight-bearing in question 5D)
If yes (there is pain when used in weight-bearing
or non weight-bearing), does the pain contribute
to functional loss or additional limitation of ROM?
RIGHT
SHOULDER
Yes
Yes (you will be asked to further describe
these limitations in Section 6 below)
No
No
LEFT
SHOULDER
Yes
Yes (you will be asked to further describe
these limitations in Section 6 below)
No
No
If no (the pain does not contribute to functional loss
or additional limitation of ROM), explain why the pain
does not contribute:
5C. LOCALIZED TENDERNESS OR PAIN ON PALPATION
Shoulder
Does the Veteran have localized tenderness
or pain to palpation of joints or soft tissue?
RIGHT
SHOULDER
Yes
No
LEFT
SHOULDER
Yes
No
If yes, describe including location, severity and relationship to condition(s) listed in the Diagnosis section:
5D. COMMENTS, IF ANY:
SECTION VI - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION OF ROM
NOTE: The VA defines functional loss as the inability, due to damage or infection in parts of the system, to perform normal working movements of the body with
normal excursion, strength, speed, coordination and/or endurance. As regards the joints, factors of disability reside in reductions of their normal excursion of
movements in different planes.
Using information from the history and physical exam, select the factors below that contribute to functional loss or impairment (regardless of repetitive use) or to
additional limitation of ROM after repetitive use for the joint or extremity being evaluated on this DBQ:
6A. CONTRIBUTING FACTORS OF DISABILITY (check all that apply and indicate side affected):
No functional loss for left upper extremity attributable to claimed condition
No functional loss for right upper extremity attributable to claimed condition
Less movement than normal (due to ankylosis, limitation or blocking, adhesions,
Right
Left
Both
Right
Left
Both
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
Right
Left
Both
Interference with standing
Right
Left
Both
tendon-tie-ups, contracted scars, etc.)
More movement than normal (from flail joints, resections, nonunion of fractures,
relaxation of ligaments, etc.)
Weakened movement (due to muscle injury, disease or injury of peripheral
nerves, divided or lengthened tendons, etc.)
Other, describe:
NOTE: If any of the above factors is/are associated with limitation of motion, the examiner must give an opinion on whether pain, weakness, fatigability, or incoordination
could significantly limit functional ability during flare-ups or when the joint is used repeatedly over a period of time and that opinion, if feasible, should be expressed in
terms of the degree of additional ROM loss due to pain on use or during flare-ups. The following section will assist you in providing this required opinion.
VA FORM 21-0960M-12, XXX XXXX
Page 4
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION VI - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION OF ROM (Continued)
6B. ARE ANY OF THE ABOVE FACTORS ASSOCIATED WITH LIMITATION OF MOTION?
YES (If yes, complete questions 6C and 6D)
NO (If no, proceed to question 6D)
6C. CONTRIBUTING FACTORS OF DISABILITY ASSOCIATED WITH LIMITATION OF MOTION
Shoulder
Can pain, weakness, fatigability, or
incoordination significantly limit functional
ability during flare-ups or when the joint is
used repeatedly over a period of time?
Yes
RIGHT
SHOULDER
Yes
LEFT
SHOULDER
No
No
If yes, please estimate ROM due to pain and/or
functional loss during flare-ups or when the
joint is used repeatedly over a period of time:
Flexion
Est. ROM is
not feasible
Abduction
Est. ROM is
not feasible
External
Rotation
Est. ROM is
not feasible
Internal
Rotation
Est. ROM is
not feasible
Flexion
Est. ROM is
not feasible
Abduction
Est. ROM is
not feasible
External
Rotation
Est. ROM is
not feasible
Internal
Rotation
Est. ROM is
not feasible
If there is a functional loss due to pain, during flare-ups and/or
when the joint is used repeatedly over a period of time but the
limitation of ROM cannot be estimated, please describe
the functional loss:
6D. CONTRIBUTING FACTORS OF DISABILITY NOT ASSOCIATED WITH LIMITATION OF MOTION
IS THERE ANY FUNCTIONAL LOSS (not associated with limitation of motion) DURING FLARE-UPS OR WHEN THE JOINT IS USED REPEATEDLY OVER A
PERIOD OF TIME OR OTHERWISE?
Yes
No If yes, describe:
RIGHT SHOULDER
LEFT SHOULDER
Yes
No
If yes, describe:
SECTION VII - MUSCLE STRENGTH TESTING
7A. MUSCLE STRENGTH - RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE:
0/5 No muscle movement
1/5 Palpable or visible muscle contraction, but no joint movement
2/5 Active movement with gravity eliminated
3/5 Active movement against gravity
4/5 Active movement against some resistance
5/5 Normal strength
Shoulder
Forward Flexion Rate
/Abduction
Strength
RIGHT
SHOULDER
Forward
Flexion
/5
All Normal
Abduction
/5
LEFT
SHOULDER
Forward
Flexion
/5
All Normal
Abduction
/5
Is there a reduction in
muscle strength?
If yes, is the reduction entirely due to the
claimed condition in the Diagnosis section?
Yes
No
Yes
No
Yes
No
Yes
No
If no (the reduction is not entirely due to the
claimed condition), provide rationale:
7B. DOES THE VETERAN HAVE MUSCLE ATROPHY?
YES
NO
IF YES, IS THE MUSCLE ATROPHY DUE TO THE CLAIMED CONDITION IN THE DIAGNOSIS SECTION?
YES
NO
IF NO, PROVIDE RATIONALE:
VA FORM 21-0960M-12, XXX XXXX
Page 5
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION VII - MUSCLE STRENGTH TESTING (Continued)
FOR ANY MUSCLE ATROPHY DUE TO A DIAGNOSES LISTED IN SECTION 1, INDICATE SIDE AND SPECIFIC LOCATION OF ATROPHY, PROVIDING
MEASUREMENTS IN CENTIMETERS OF NORMAL SIDE AND CORRESPONDING ATROPHIED SIDE, MEASURED AT MAXIMUM MUSCLE BULK.
LOCATION OF MUSCLE ATROPHY:
RIGHT UPPER EXTREMITY (specify location of measurement such as "10cm above or below elbow"):
CIRCUMFERENCE OF MORE NORMAL SIDE:
cm
CIRCUMFERENCE OF ATROPHIED SIDE:
cm
LEFT UPPER EXTREMITY (specify location of measurement such as "10cm above or below elbow"):
CIRCUMFERENCE OF MORE NORMAL SIDE:
cm
CIRCUMFERENCE OF ATROPHIED SIDE:
cm
7C. COMMENTS, IF ANY:
SECTION VIII - ANKYLOSIS
NOTE: Ankylosis is the immobilization and consolidation of a joint due to disease, injury or surgical procedure.
COMPLETE THIS SECTION IF THE VETERAN HAS ANKYLOSIS OF SCAPULOHUMERAL (glenohumeral) ARTICULATION (shoulder joint) (i.e., the scapula and
humerus move as one piece).
8A. INDICATE SEVERITY OF ANKYLOSIS AND SIDE AFFECTED (check all that apply):
RIGHT SIDE:
LEFT SIDE:
Ankylosis in abduction up to 60 degrees; can reach mouth and head
Ankylosis in abduction up to 60 degrees; can reach mouth and head
Ankylosis in abduction between favorable and unfavorable
Ankylosis in abduction between favorable and unfavorable
(Favorable ankylosis)
(Favorable ankylosis)
(Intermediate ankylosis)
(Intermediate ankylosis)
Ankylosis in abduction at 25 degrees or less from side (Unfavorable
Ankylosis in abduction at 25 degrees or less from side (Unfavorable
ankylosis)
ankylosis)
No ankylosis
No ankylosis
8B. COMMENTS, IF ANY:
SECTION IX - ROTATOR CUFF CONDITIONS
9. ROTATOR CUFF CONDITIONS
SHOULDER
IS ROTATOR CUFF
CONDITION
SUSPECTED?
Yes
RIGHT
SHOULDER
No
Yes
LEFT
SHOULDER
No
IF "YES" COMPLETE THE FOLLOWING
HAWKINS' IMPINGEMENT TEST
EMPTY-CAN TEST
EXTERNAL ROTATION/
INFRASPINATUS
(Forward flex the arm to 90
(Abduct arm to 90 degrees and
STRENGTH TEST
degrees with the elbow bent to 90
forward flex 30 degrees.
degrees. Internally rotate arm. Patient turns thumbs down and (Patient holds arms at side with
Pain on internal rotation
resists downward force applied elbow flexed 90 degrees. Patient
indicates a positive test; may
by the examiner. Weakness
externally rotates against
signify rotator cuff tendinopathy
indicates a positive test; may resistance. Weakness indicates a
or tear)
indicate rotator cuff pathology, positive test; may be associated
including supraspinatus
with infraspinatus tendinopathy
tendinopathy or tear)
or tear)
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
Positive
Positive
Positive
Negative
Negative
Negative
Negative
Unable to perform
Unable to perform
Unable to perform
Unable to perform
N/A
N/A
N/A
N/A
Positive
Positive
Positive
Positive
Negative
Negative
Negative
Negative
Unable to perform
Unable to perform
Unable to perform
Unable to perform
N/A
N/A
N/A
N/A
SECTION X - SHOULDER INSTABILITY, DISLOCATION OR LABRAL PATHOLOGY
10A. IS SHOULDER INSTABILITY, DISLOCATION OR LABRAL PATHOLOGY SUSPECTED?
YES
NO
IF YES, COMPLETE QUESTIONS 10B - 10D BELOW:
10B. IS THERE A HISTORY OF MECHANICAL SYMPTOMS (clicking, catching, etc.)?
YES
NO
INDICATE SIDE AFFECTED:
Right
Left
Both
10C. 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
Right
Left
Both
Guarding of all arm movement
Right
Left
Both
VA FORM 21-0960M-12, XXX XXXX
Page 6
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION X - SHOULDER INSTABILITY, DISLOCATION OR LABRAL PATHOLOGY (Continued)
10D. 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
IF POSITIVE, SIDE AFFECTED:
UNABLE TO PERFORM
Right
Left
N/A
Both
SECTION XI - CLAVICLE, SCAPULA, ACROMIOCLAVICULAR (AC) JOINT AND STERNOCLAVICULAR JOINT CONDITIONS
11A. IS A CLAVICLE, SCAPULA, ACROMIOCLAVICULAR (AC) JOINT OR STERNOCLAVICULAR JOINT CONDITION SUSPECTED?
YES
NO
IF YES, COMPLETE QUESTIONS 11B - 11D BELOW.
11B. 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 sternoclavicular
dislocation)
Right
Left
Both
Other (Describe)
Right
Left
Both
11C. IS THERE TENDERNESS ON PALPATION OF THE AC JOINT?
YES
NO
Right
IF YES, INDICATE SIDE:
Left
Both
11D. CROSS-BODY ADDUCTION TEST (Passively adduct arm across the patient's body toward the contralateral shoulder. Pain may indicate acromioclavicular joint
pathology)
POSITIVE
NEGATIVE
IF POSITIVE, SIDE AFFECTED:
UNABLE TO PERFORM
Right
Left
N/A
Both
SECTION XII - CONDITIONS OR IMPAIRMENTS OF THE HUMERUS
12A. DOES THE VETERAN HAVE LOSS OF HEAD (flail shoulder), NONUNION (false flail shoulder), OR FIBROUS UNION OF THE HUMERUS?
YES
NO
IF YES, CHECK ALL THAT APPLY:
Loss of head (flail shoulder)
Right
Left
Both
Nonunion (false flail shoulder)
Right
Left
Both
Fibrous union
Right
Left
Both
12B. DOES THE VETERAN HAVE MALUNION OF THE HUMERUS WITH MODERATE OR MARKED DEFORMITY?
YES
NO
IF YES, CHECK ALL THAT APPLY:
Moderate deformity
Right
Left
Both
Marked deformity
Right
Left
Both
12C. COMMENTS, IF ANY:
SECTION XIII - SURGICAL PROCEDURES
13. INDICATE ANY SURGICAL PROCEDURES THAT THE VETERAN HAS HAD PERFORMED AND PROVIDE THE ADDITIONAL INFORMATION AS REQUESTED
(check all that apply):
RIGHT SIDE:
TOTAL SHOULDER JOINT REPLACEMENT
LEFT SIDE:
TOTAL SHOULDER JOINT REPLACEMENT
DATE OF SURGERY:
DATE OF SURGERY:
RESIDUALS:
RESIDUALS:
None
None
Intermediate degrees of residual weakness, pain or limitation of motion
Intermediate degrees of residual weakness, pain or limitation of motion
Chronic residuals consisting of severe painful motion or weakness
Chronic residuals consisting of severe painful motion or weakness
Other, describe:
Other, describe:
ARTHROSCOPIC OR OTHER SHOULDER SURGERY
ARTHROSCOPIC OR OTHER SHOULDER SURGERY
TYPE OF SURGERY:
TYPE OF SURGERY:
DATE OF SURGERY:
DATE OF SURGERY:
RESIDUALS OF ARTHROSCOPIC OR OTHER SHOULDER SURGERY
RESIDUALS OF ARTHROSCOPIC OR OTHER SHOULDER SURGERY
DESCRIBE RESIDUALS:
DESCRIBE RESIDUALS:
VA FORM 21-0960M-12, XXX XXXX
Page 7
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION XIV - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS AND SCARS
14A. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS, OR ANY SCARS
(surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN THE DIAGNOSIS SECTION ABOVE?
YES
NO
IF YES, COMPLETE QUESTIONS 14B-14D.
14B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN THE DIAGNOSIS SECTION ABOVE?
YES
IF YES, DESCRIBE (brief summary):
NO
14C. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
THE DIAGNOSIS SECTION ABOVE?
YES
NO
IF YES, ARE ANY OF THESE SCARS PAINFUL OR UNSTABLE; HAVE A TOTAL AREA EQUAL TO OR GREATER THAN 39 SQUARE CM (6 square inches); OR ARE
LOCATED ON THE HEAD, FACE OR NECK?
YES
NO
IF YES, ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT.
IF NO, PROVIDE LOCATION AND MEASUREMENTS OF SCAR IN CENTIMETERS.
Location:
Measurements: length
cm X width
cm.
NOTE: An "unstable scar" is one where, for any reason, there is frequent loss of covering of the skin over the scar. If there are multiple scars, enter additional locations
and measurements in Comment section below. It is not necessary to also complete a Scars DBQ.
14D. COMMENTS, IF ANY:
SECTION XV - ASSISTIVE DEVICES
15A. DOES THE VETERAN USE ANY ASSISTIVE DEVICES?
YES
NO
IF YES, IDENTIFY ASSISTIVE DEVICES USED (check all that apply and indicate frequency):
Brace
Frequency of use:
Occasional
Regular
Constant
Other:
Frequency of use:
Occasional
Regular
Constant
15B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:
SECTION XVI - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
16A. DUE TO THE VETERAN'S SHOULDER OR ARM CONDITIONS, IS THERE FUNCTIONAL IMPAIRMENT OF AN EXTREMITY SUCH THAT NO EFFECTIVE
FUNCTIONS REMAIN 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 PROTHESIS WOULD EQUALLY SERVE THE VETERAN.
NO
IF YES, INDICATE EXTREMITIES FOR WHICH THIS APPLIES:
RIGHT UPPER
LEFT UPPER
FOR EACH CHECKED EXTREMITY, IDENTIFY THE CONDITION CAUSING LOSS OF FUNCTION, DESCRIBE LOSS OF EFFECTIVE FUNCTION AND PROVIDE
SPECIFIC EXAMPLES (brief summary):
NOTE: The intention of this section is to permit the examiner to quantify the level of remaining function; it is not intended to inquire whether the Veteran should
undergo an amputation with fitting of a prothesis. For example, if the functions of grasping (hand) or propulsion (foot) are as limited as if the Veteran had an
amputation and prosthesis, the examiner should check "yes" and describe the diminished functioning. The question simply asks whether the functional loss is to the
same degree as if there were an amputation of the affected limb.
SECTION XVII - DIAGNOSTIC TESTING
NOTE: Testing listed below is not indicated for every condition. The diagnosis of degenerative arthritis (osteoarthritis) or traumatic arthritis must be confirmed by
imaging studies. Once such arthritis has been documented, even if in the past, no further imaging studies are required by VA, even if arthritis has worsened.
17A. HAVE IMAGING STUDIES OF THE SHOULDER BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES
NO
IF YES, IS DEGENERATIVE OR TRAUMATIC ARTHRITIS DOCUMENTED?
YES
NO
IF YES, INDICATE SHOULDER:
VA FORM 21-0960M-12, XXX XXXX
RIGHT
LEFT
BOTH
Page 8
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION XVII - DIAGNOSTIC TESTING (Continued)
17B. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS OR RESULTS?
YES
NO
IF YES, PROVIDE TYPE OF TEST OR PROCEDURE, DATE AND RESULTS (brief summary):
17C. IS THERE OBJECTIVE EVIDENCE OF CREPITUS?
YES
NO
IF YES, INDICATE SHOULDER:
RIGHT
LEFT
BOTH
17D. IF ANY TEST RESULTS ARE OTHER THAN NORMAL, INDICATE RELATIONSHIP OF ABNORMAL FINDINGS TO DIAGNOSED CONDITIONS:
SECTION XVIII - FUNCTIONAL IMPACT
NOTE: Provide the impact of only the diagnosed condition(s), without consideration of the impact of other medical conditions or factors, such as age.
18. REGARDLESS OF THE VETERAN'S CURRENT EMPLOYMENT STATUS, DO THE CONDITION(S) LISTED IN THE DIAGNOSIS SECTION IMPACT HIS OR HER
ABILITY TO PERFORM ANY TYPE OF OCCUPATIONAL TASK (such as standing, walking, lifting, sitting, etc.)?
YES
NO
IF YES, DESCRIBE THE FUNCTIONAL IMPACT OF EACH CONDITION, PROVIDING ONE OR MORE EXAMPLES:
SECTION XIX - REMARKS
19. REMARKS, IF ANY:
SECTION XX - PHYSICIAN'S CERTIFICATION AND SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
20A. PHYSICIAN'S SIGNATURE
20D. PHYSICIAN'S PHONE AND FAX NUMBER
20B. PHYSICIAN'S PRINTED NAME
20E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER
20C. DATE SIGNED
20F. 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, XXX XXXX
Page 9
| File Type | application/pdf |
| File Title | 21-0960M-12 |
| Subject | Shoulder and Arm Conditions Disability Benefits Questionnaire |
| File Modified | 2017-03-14 |
| File Created | 2017-03-07 |