Form VA Form 21-0960M-1 VA Form 21-0960M-1 Back (Thoracolumbar Spine) Conditions Disability Benefit

OMB Approved No. 2900-0808
Respondent Burden: 45 minutes
Expiration Date: XXXXXXX

BACK (THORACOLUMBAR SPINE) 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?
NO

YES

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.)
Mechanical back pain
syndrome

ICD Code:

Date of diagnosis:

Lumbosacral sprain/strain

ICD Code:

Date of diagnosis:

Facet joint arthropathy

ICD Code:

Date of diagnosis:

Degenerative disc disease

ICD Code:

Date of diagnosis:

Degenerative scoliosis

ICD Code:

Date of diagnosis:

Foraminal/lateral recess/
central stenosis

ICD Code:

Date of diagnosis:

Degenerative spondylolisthesis
Spondylolysis/isthmic
spondylolisthesis

ICD Code:

Date of diagnosis:

ICD Code:

Date of diagnosis:

(degenerative joint disease
of lumbosacral spine)

Intervertebral disc syndrome

ICD Code:

Date of diagnosis:

Radiculopathy

ICD Code:

Date of diagnosis:

Ankylosis of thoracolumbar spine
Ankylosing spondylitis of the
thoracolumbar spine (back)

ICD Code:

Date of diagnosis:

ICD Code:

Date of diagnosis:

NOTE: If there are systemic or other constitutional manifestations of ankylosing spondylitis, ALSO complete the Non-degenerative Arthritis DBQ and the
appropriate DBQ for each affected system.
Vertebral fracture (vertebrae

of the back)

VA FORM
XXXX

21-0960M-14

ICD Code:

Date of diagnosis:

SUPERSEDES VA FORM 21-0960M-14, MAY 2013,
WHICH WILL NOT BE USED.

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION I - DIAGNOSIS (Continued)
1B. SELECT DIAGNOSES ASSOCIATED WITH THE CLAIMED CONDITION(S) (Check all that apply) (Continued):
Other (specify)
Other diagnosis #1:
ICD Code:

Date of diagnosis:

Other diagnosis #2:
ICD Code:

Date of diagnosis:

Other diagnosis #3:
Date of diagnosis:

ICD Code:
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 THORACOLUMBAR SPINE (back) CONDITION (brief summary):

2B. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE THORACOLUMBAR SPINE (back)?
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 THORACOLUMBAR SPINE (back) (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

BACK

All Normal

Joint Movement

ROM Measurement

Forward Flexion
(normal endpoint
= 90 degrees)

Not indicated

Extension
(normal endpoint
= 30 degrees)

Not indicated

Right Lateral
Flexion
(normal endpoint
= 30 degrees)

Not indicated

Left Lateral
Flexion
(normal endpoint
= 30 degrees)

Not indicated

Right Lateral
Rotation
(normal endpoint
= 30 degrees)

Not indicated

Left Lateral
Rotation
(normal endpoint
= 30 degrees)

Not indicated

VA FORM 21-0960M-14, 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 able to perform

Not able to perform

Not able to perform

Not able to perform
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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION III - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS (Continued)
3B. DO ANY ABNORMAL ROMs NOTED ABOVE CONTRIBUTE TO FUNCTIONAL LOSS?
YES (you will be asked to further describe these limitations in Section 7 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 back
condition, such as age, body habitus, neurologic disease), EXPLAIN:

SECTION IV - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING
4A. POST-TEST ROM MEASUREMENTS
Is there additional limitation in ROM
after repetitive-use testing?

Is the veteran able to perform repetitive-use testing?
Yes
No

If yes, perform repetitive-use testing

Yes

If no, provide reason below, then proceed to Section 5

No, there is no change in ROM
after repetitive testing
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

Forward Flexion
Extension
Left Lateral
Flexion
Right Lateral
Flexion
Left Lateral
Rotation
Right Lateral
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 7 below)
NO, EXPLAIN WHY THE POST-TEST ADDITIONAL LIMITATIONS OF ROMs DO NOT CONTRIBUTE:

SECTION V - PAIN
5A. ROM MOVEMENTS PAINFUL ON ACTIVE, PASSIVE AND/OR REPETITIVE USE TESTING
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)

If yes (there are painful movements), does the
pain contribute to functional loss or
additional limitation of ROM?

Yes

Yes (you will be asked to further describe
these limitations in Section 7 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:

5B. PAIN WHEN USED IN WEIGHT-BEARING OR IN NON WEIGHT-BEARING
Is there pain when the joint is
used in weight-bearing or non
weight-bearing?

If yes (there is pain when used in weight-bearing
or non weight-bearing), does the pain contribute
(If yes, identify whether weight- to functional loss or additional limitation of ROM?

If no (the pain does not contribute to functional loss or additional limitation of ROM),
explain why the pain does not contribute:

bearing or non weight-bearing
in question 5D)
Yes

Yes (you will be asked to further describe
these limitations in Section 7 below)

No

No

5C. LOCALIZED TENDERNESS OR PAIN ON PALPATION
Does the Veteran have localized tenderness
or pain to palpation of joints or soft tissue?
Yes

If yes, describe including location, severity and relationship to condition(s) listed in the Diagnosis section:

No

5D. COMMENTS, IF ANY:

VA FORM 21-0960M-14, XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION VI - GUARDING AND MUSCLE SPASM
6A. DOES THE VETERAN HAVE GUARDING OR MUSCLE SPASM OF THE THORACOLUMBAR SPINE (back)?
YES

NO

6B. GAIT:
NORMAL
ABNORMAL
Due to:
Muscle spasm
Guarding
Other, describe and provide etiology:

UNABLE TO EVALUATE, PROVIDE REASON:

6C. SPINAL CONTOUR:
NORMAL
ABNORMAL
Due to:
Muscle spasm
Guarding
Other, describe and provide etiology:

UNABLE TO EVALUATE, PROVIDE REASON:

SECTION VII - 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:
7A. CONTRIBUTING FACTORS OF DISABILITY (check all that apply and indicate side affected):
Less movement than normal (due to ankylosis, limitation or blocking, adhesions,

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.)

Excess fatigability
Incoordination, impaired ability to execute skilled movements smoothly
Pain on movement
Swelling
Deformity
Atrophy of disuse
Instability of station
Disturbance of locomotion
Interference with sitting
Interference with standing
Other, describe:

VA FORM 21-0960M-14, XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION VII - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION OF ROM (Continued)
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.
7B. ARE ANY OF THE ABOVE FACTORS ASSOCIATED WITH LIMITATION OF MOTION?
YES (If yes, complete question 7C and 7D)
NO (If no, proceed to question 7D)
7C. CONTRIBUTING FACTORS OF DISABILITY ASSOCIATED WITH LIMITATION OF MOTION
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

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:
Forward
Flexion

Est. ROM is
not feasible

Extension

Est. ROM is
not feasible

Right Lateral
Flexion

Est. ROM is
not feasible

Left Lateral
Flexion

Est. ROM is
not feasible

Right Lateral
Rotation

Est. ROM is
not feasible

Left Lateral
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:

7D. 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:

SECTION VIII - MUSCLE STRENGTH TESTING
8A. 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
Side

RIGHT
All Normal

Flexion/
Extension

Rate
Strength

Hip Flexion

/5

Knee Flexion

/5

Knee Extension

/5

Ankle Plantar
Flexion
Ankle
Dorsiflexion

If yes, is the reduction entirely due to the
claimed condition in the Diagnosis section?

If no (the reduction is not entirely due to the
claimed condition), provide rationale:

/5
/5

Foot Abduction

/5

Foot Adduction

/5

Great Toe
Extension

/5

VA FORM 21-0960M-14, XXXX

Is there a reduction in
muscle strength?

Yes

No

Yes

No

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION VIII - MUSCLE STRENGTH TESTING (Continued)
8A. MUSCLE STRENGTH - RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE (Continued):
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
Flexion/
Extension

Side

Rate
Strength

Hip Flexion

/5

Knee Flexion

/5

Knee
Extension
Ankle Plantar
Flexion
Ankle
Dorsiflexion

LEFT
All Normal

Is there a reduction in
muscle strength?

If yes, is the reduction entirely due to the
claimed condition in the Diagnosis section?

If no (the reduction is not entirely due to the
claimed condition), provide rationale:

/5
/5
/5

Foot Abduction

/5

Foot Adduction

/5

Great Toe
Extension

/5

Yes

No

Yes

No

8B. 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:

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 LOWER EXTREMITY (specify location of measurement such as "10cm above or below elbow"):
CIRCUMFERENCE OF MORE NORMAL SIDE:

CM

CIRCUMFERENCE OF ATROPHIED SIDE:

CM

LEFT LOWER EXTREMITY (specify location of measurement such as "10cm above or below elbow"):
CIRCUMFERENCE OF MORE NORMAL SIDE:

CM

CIRCUMFERENCE OF ATROPHIED SIDE:

CM

8C. COMMENTS, IF ANY:

SECTION IX - ANKYLOSIS
COMPLETE THIS SECTION IF VETERAN HAS ANKYLOSIS OF THE THORACOLUMBAR SPINE (back).

NOTE: For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is
fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the
mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or
dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position
(0 degrees) always represents favorable ankylosis.
9A. INDICATE SEVERITY OF ANKYLOSIS:
Favorable ankylosis of the entire thoracolumbar spine
Unfavorable ankylosis of the entire thoracolumbar spine
Unfavorable ankylosis of the entire spine (cervical and thoracolumbar)
No ankylosis
9B. COMMENTS, IF ANY:

SECTION X - REFLEX EXAM
10A. DEEP TENDON REFLEXES - RATE DEEP TENDON REFLEXES (DTRs) ACCORDING TO THE FOLLOWING SCALE:
0 Absent
RIGHT:
KNEE:
+
ANKLE:
+
All Normal
1+ Hypoactive
2+ Normal
3+ Hyperactive without clonus
LEFT:
KNEE:
+
ANKLE:
+
All Normal
4+ Hyperactive with clonus
VA FORM 21-0960M-14, XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION X - REFLEX EXAM (Continued)
10B. COMMENTS, IF ANY:

SECTION XI - SENSORY EXAM
11A. RESULTS FOR SENSATION TO LIGHT TOUCH (dermatome) TESTING:
Upper Anterior Thigh (L2)

Side
RIGHT

Normal

All Normal

Thigh/Knee (L3/4)

Decreased

Normal

Decreased

Absent

LEFT

Normal

All Normal

Normal

Decreased

Absent

Decreased

Normal

Decreased

Absent

Foot/Toes (L5)

Lower Leg/Ankle (L4/L5/S1)

Normal

Absent
Normal

Decreased

Absent

Decreased
Absent

Normal

Absent

Decreased
Absent

11B. WERE OTHER SENSORY TESTS INDICATED AND PERFORMED?
YES

NO

IF YES, INDICATE RESULTS:
Position Sense

(grasp great toe on sides and ask patient
to identify up and down movement)

Side

Vibration Sensation

(place low-pitched tuning fork over
IP joint of great toe)

Cold Sensation

(test distal extremities for cold sensation with
side of tuning fork or other cold object)

Not tested

Not tested

Not tested

RIGHT

Normal

Decreased

Absent

Normal

Decreased

Absent

Normal

Decreased

Absent

LEFT

Normal

Decreased

Absent

Normal

Decreased

Absent

Normal

Decreased

Absent

11C. OTHER SENSORY FINDINGS, IF ANY:

SECTION XII - STRAIGHT LEG RAISING TEST
NOTE: This test can be performed with the Veteran seated or supine. Raise each straightened leg until pain begins, typically at 30-70 degrees of elevation. The test is
positive if the pain radiates below the knee, not merely limited to the back or hamstring muscles. Pain is often increased on dorsiflexion of the foot, and relieved by
knee flexion. A positive test suggests radiculopathy, often due to disc herniation.
12. PROVIDE STRAIGHT LEG RAISING TEST RESULTS:
RIGHT:

NEGATIVE

POSITIVE

UNABLE TO PERFORM

LEFT:

NEGATIVE

POSITIVE

UNABLE TO PERFORM

SECTION XIII - RADICULOPATHY
NOTE: Radiculopathy is considered to be any condition due to disease of the nerve roots and nerves located in the back.
13A. DOES THE VETERAN HAVE RADICULAR PAIN OR ANY OTHER SUBJECTIVE SYMPTOMS DUE TO RADICULOPATHY?
YES

NO

IF YES, COMPLETE QUESTIONS 13B-13K, INCLUDING SYMPTOMS, SEVERITY OF RADICULOPATHY AND NERVE ROOTS INVOLVED (check all that apply)
IF THE VETERAN REPORTED RADICULAR-TYPE SYMPTOMS IN THE MEDICAL HISTORY SECTION ABOVE THAT YOU FIND ARE NOT DUE TO RADICULOPATHY,
PLEASE PROVIDE RATIONALE:

13B. CONSTANT PAIN, AT TIMES EXCRUCIATING (subjective symptom)
Present

Absent (does not occur)

Pain is present, but not due to radiculopathy (if checked, provide rationale in question 13K below)

If present, indicate location and severity:
Right lower extremity:

None

Mild

Moderate

Severe

Left lower extremity:

None

Mild

Moderate

Severe

13C. INTERMITTENT PAIN (subjective symptom)
Present

Absent (does not occur)

Pain is present, but not due to radiculopathy (if checked, provide rationale in question 13K below)

If present, indicate location and severity:
Right lower extremity:

None

Mild

Moderate

Severe

Left lower extremity:

None

Mild

Moderate

Severe

13D. DULL PAIN (subjective symptom)
Present

Absent (does not occur)

Pain is present, but not due to radiculopathy (if checked, provide rationale in question 13K below)

If present, indicate location and severity:
Right lower extremity:

None

Mild

Moderate

Severe

Left lower extremity:

None

Mild

Moderate

Severe

VA FORM 21-0960M-14, XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION XIII - RADICULOPATHY (Continued)
13E. PARESTHESIAS AND/OR DYSESTHESIAS (subjective symptom)
Paresthesias and/or dysesthesias are present, but not due to radiculopathy (if checked, provide rationale in
Present
Absent (does not occur)

question 13K below)

If present, indicate location and severity:
Right lower extremity:

None

Mild

Moderate

Severe

Left lower extremity:

None

Mild

Moderate

Severe

13F. NUMBNESS (subjective symptom)
Absent (does not occur)

Present

Numbness is present, but not due to radiculopathy (if checked, provide rationale in question 13K below)

If present, indicate location and severity:
Right lower extremity:

None

Mild

Moderate

Severe

Left lower extremity:

None

Mild

Moderate

Severe

13G. DOES THE VETERAN HAVE ANY OBJECTIVE FINDINGS DUE TO RADICULOPATHY NOT ADDRESSED IN THE PHYSICAL EXAM SECTION?
YES

NO

IF YES, DESCRIBE:

13H. INDICATE SEVERITY OF RADICULOPATHY (evaluate severity by incorporating the effects of subjective symptoms and objective findings, if any) AND SIDE
AFFECTED:
Right lower extremity:

Not affected

Mild

Moderate

Severe

Left lower extremity:

Not affected

Mild

Moderate

Severe

13I. SPECIFY NERVE ROOTS INVOLVED (check all that apply):
INVOLVEMENT OF L2/L3/L4 NERVE ROOTS (femoral nerve)
If checked, indicate side affected:

Right

Left

Both

INVOLVEMENT OF L4/L5/S1/S2/S3 NERVE ROOTS (sciatic nerve)
If checked, indicate side affected:

Right

Left

Both

Left

Both

OTHER NERVES (specify nerve root involved):
If checked, indicate side affected:

Right

13J. DOMINANT HAND
RIGHT

LEFT

AMBIDEXTROUS

13K. COMMENTS, IF ANY:

SECTION XIV - OTHER NEUROLOGIC ABNORMALITIES
14. DOES THE VETERAN HAVE ANY OTHER OBJECTIVE NEUROLOGIC ABNORMALITIES OR FINDINGS (including, but not limited to bowel or bladder problems)
ASSOCIATED WITH A THORACOLUMBAR SPINE (back) CONDITION?
YES

NO

IF YES, DESCRIBE CONDITION AND ITS RELATIONSHIP TO ANY CONDITION LISTED IN THE DIAGNOSIS SECTION:

NOTE: If there are neurological abnormalities other than those addressed in the Physical Exam or Radiculopathy sections above, ALSO complete appropriate
Disability Benefits Questionnaire for each condition identified.
SECTION XV - INTERVERTEBRAL DISC SYNDROME (IVDS) AND INCAPACITATING EPISODES
NOTE: For VA purposes, IVDS is a group of signs and symptoms due to nerve root irritation that commonly includes back pain and sciatica (pain along the course of
the sciatic nerve) in the case of lumbar disc disease, and neck and arm or hand pain in the case of cervical disc disease.
15A. DOES THE VETERAN HAVE IVDS OF THE THORACOLUMBAR SPINE?
YES

NO

15B. IF YES TO QUESTION 15A ABOVE, HAS THE VETERAN HAD ANY INCAPACITATING EPISODES (a period of acute signs and symptoms due to IVDS that requires
bed rest prescribed by a physician and treatment by a physician) OVER THE PAST 12 MONTHS?
YES

NO

15C. IF YES TO QUESTION 15B ABOVE, PROVIDE THE TOTAL DURATION OF ALL INCAPACITATING EPISODES OVER THE PAST 12 MONTHS:
Less than 1 week
At least 1 week but less than 2 weeks
At least 2 weeks but less than 4 weeks
At least 4 weeks but less than 6 weeks
At least 6 weeks
VA FORM 21-0960M-14, XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION XV - INTERVERTEBRAL DISC SYNDROME (IVDS) AND INCAPACITATING EPISODES (Continued)
15D. COMMENTS, IF ANY:

SECTION XVI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS AND SCARS
16A. 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 16B-16D.

16B. 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

16C. 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.
16D. COMMENTS, IF ANY:

SECTION XVII - ASSISTIVE DEVICES
17A. 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

Brace

Frequency of use:

Occasional

Regular

Constant
Constant

Crutches

Frequency of use:

Occasional

Regular

Constant

Cane

Frequency of use:

Occasional

Regular

Constant

Walker

Frequency of use:

Occasional

Regular

Constant

Other:

Frequency of use:

Occasional

Regular

Constant

17B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:

SECTION XVIII - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
18. DUE TO THE VETERAN'S THORACOLUMBAR SPINE (back) CONDITION, 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 PROTHESIS WOULD EQUALLY SERVE THE VETERAN.
NO
IF YES, INDICATE EXTREMITIES FOR WHICH THIS APPLIES:

RIGHT LOWER

LEFT LOWER

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.
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SECTION XIX - 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. Imaging
studies are not required to make the diagnosis of IVDS; Electromyography (EMG) studies are rarely required to diagnose radiculopathy in the appropriate clinical
setting. For purposes of this examination, the diagnoses of IVDS and radiculopathy can be made by a history of characteristic radiating pain and/or sensory changes in
the legs, and objective clinical findings, which may include the asymmetrical loss or decrease of reflexes, decreased strength and/or abnormal sensation.
19A. HAVE IMAGING STUDIES OF THE THORACOLUMBAR SPINE BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

IF YES, IS ARTHRITIS DOCUMENTED?
YES

NO

19B. DOES THE VETERAN HAVE A VERTEBRAL FRACTURE?
YES

NO

IF YES, PROVIDE PERCENT OF LOSS OF VERTEBRAL BODY HEIGHT:

%

19C. 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):

19D. IF ANY TEST RESULTS ARE OTHER THAN NORMAL, INDICATE RELATIONSHIP OF ABNORMAL FINDINGS TO DIAGNOSED CONDITIONS:

SECTION XX - 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.
20. 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:

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SECTION XXI - REMARKS
21. REMARKS, IF ANY:

SECTION XXII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
22A. PHYSICIAN'S SIGNATURE
22D. PHYSICIAN'S PHONE AND FAX NUMBER

22B. PHYSICIAN'S PRINTED NAME
22E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER

22C. DATE SIGNED
22F. 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.
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