Form 21-0960M-9 Knee and Lower Leg Conditions Disability Benefits Questi

OMB Approved No. 2900-0813
Respondent Burden: 30 minutes
Expiration Date: 04-30-2017

KNEE AND LOWER LEG 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.)
Knee strain

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Knee tendonitis/tendonosis

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Knee meniscal tear
Knee anterior cruciate
ligament tear
Knee posterior cruciate
ligament tear
Patellar or quadriceps tendon
rupture

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:

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Knee joint osteoarthritis

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Knee joint ankylosis

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Knee fracture (including

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

patellar fracture)

Stress fracture of tibia

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Tibia and/or Fibula fracture

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Recurrent patellar dislocation

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Recurrent subluxation

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Knee instability

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Patellar dislocation
Knee cartilage restoration
surgery
Shin splints (including tibia

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:

Patellofemoral pain syndrome

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

and/or fibula stress fracture
and/or exertional
compartment syndrome)

VA FORM
XXX XXXX

21-0960M-9

SUPERSEDES VA FORM 21-0960M-9, 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:
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 KNEE AND/OR LOWER LEG CONDITION (brief summary):

2B. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE KNEE AND/OR LOWER LEG?
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
Knee

RIGHT
KNEE
All Normal

LEFT
KNEE
All Normal

Joint Movement

ROM Measurement

Flexion
(normal endpoint
= 140 degrees)

Not indicated

Extension

Not indicated

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
Flexion
(normal endpoint
= 140 degrees)

Not indicated

Extension

Not indicated

VA FORM 21-0960M-9, XXX XXXX

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 limitation 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 knee
condition, such as age, body habitus, neurologic disease), EXPLAIN:

SECTION IV - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING
4A. POST-TEST ROM MEASUREMENTS
Knee

Is there additional limitation in ROM
after repetitive-use testing?

Is the veteran able to perform repetitive-use testing?
Yes

If yes, perform repetitive-use testing

Yes

No

If no, provide reason below, then proceed to
Section 6

No, there is no change in ROM
after repetitive testing

RIGHT
KNEE

If yes, report ROM after a minimum
of 3 repetitions.
If no, documentation of ROM after
repetitive-use testing is not required.
Yes

If yes, perform repetitive-use testing

Yes

No

If no, provide reason below, then proceed to
Section 6

No, there is no change in ROM
after repetitive testing

LEFT
KNEE

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

Extension

Flexion

Extension

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:

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

Knee

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?

RIGHT
KNEE

Yes

Yes (you will be asked to further describe
these limitations in Section 6 below)

No

No

LEFT
KNEE

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:

5B. PAIN WHEN USED IN WEIGHT-BEARING OR IN NON WEIGHT-BEARING

Knee

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)

RIGHT
KNEE

Yes

Yes (you will be asked to further describe
these limitations in Section 6 below)

No

No

LEFT
KNEE

Yes

Yes (you will be asked to further describe
these limitations in Section 6 below)

No

No

VA FORM 21-0960M-9, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION V - PAIN (Continued)
5C. LOCALIZED TENDERNESS OR PAIN ON PALPATION
Knee

Does the Veteran have localized tenderness
or pain to palpation of joints or soft tissue?

RIGHT
KNEE

Yes

No

LEFT
KNEE

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 lower extremity attributable to claimed condition
No functional loss for right lower extremity attributable to claimed condition
Less movement than normal (due to ankylosis, limitation or blocking, adhesions,

Right

Left

Both

More movement than normal (from flail joints, resections, nonunion of fractures,

Right

Left

Both

Weakened movement (due to muscle injury, disease or injury of peripheral

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.)
relaxation of ligaments, etc.)

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.
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)

VA FORM 21-0960M-9, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION VI - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION OF ROM (Continued)
6C. CONTRIBUTING FACTORS OF DISABILITY ASSOCIATED WITH LIMITATION OF MOTION

Knee

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?

RIGHT
KNEE

Yes

LEFT
KNEE

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

Extension

Est. ROM is
not feasible

Flexion

Est. ROM is
not feasible

Extension

Est. ROM is
not feasible

No

Yes

No

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?
RIGHT KNEE

YES

NO

IF YES, DESCRIBE:

LEFT KNEE

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
Knee

Flexion/
Extension

Rate
Strength

RIGHT KNEE

Flexion

/5

All Normal

Extension

/5

LEFT KNEE

Flexion

/5

All Normal

Extension

/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:

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

7C. COMMENTS, IF ANY:

VA FORM 21-0960M-9, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

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 THE KNEE AND/OR LOWER LEG.
8A. INDICATE SEVERITY OF ANKYLOSIS AND SIDE AFFECTED (check all that apply):
LEFT SIDE:

RIGHT SIDE:
Favorable angle in full extension or in slight flexion
between 0 and 10 degrees

Favorable angle in full extension or in slight flexion
between 0 and 10 degrees

In flexion between 10 and 20 degrees

In flexion between 10 and 20 degrees

In flexion between 20 and 45 degrees

In flexion between 20 and 45 degrees

Extremely unfavorable, in flexion at an angle of 45
degrees or more

Extremely unfavorable, in flexion at an angle of 45
degrees or more

No ankylosis

No ankylosis

8B. INDICATE ANGLE OF ANKYLOSIS IN DEGREES:
RIGHT SIDE:

LEFT SIDE:

N/A, no ankylosis of knee joint

N/A, no ankylosis of knee joint

degrees

degrees

8C. COMMENTS, IF ANY:

SECTION IX - JOINT STABILITY TESTS
NOTE: Subluxation and lateral instability refers only to the knee joint itself (tibio-femoral) and not to the patello-femoral portion of the joint.
9A. IS THERE A HISTORY OF RECURRENT SUBLUXATION?
Right:

None

Slight

Moderate

Severe

Left:

None

Slight

Moderate

Severe

9B. IS THERE A HISTORY OF LATERAL INSTABILITY?
Right:

None

Slight

Moderate

Severe

Left:

None

Slight

Moderate

Severe

9C. IS THERE A HISTORY OF RECURRENT EFFUSION?
YES

NO

IF YES, DESCRIBE:

9D. PERFORMANCE OF JOINT STABILITY TESTING
Knee

Was joint stability testing performed?
Yes
No
Not Indicated

If joint stability testing
was performed is there
joint instability?
Yes
No

Anterior instability

(Lachman test)

Posterior instability

Indicated, but not able to perform
RIGHT
KNEE

If yes (joint stability testing was performed), complete the section below:

(Posterior drawer
test)

If joint stability is indicated, but unable
to test, provide reason:

Medial instability

(Apply valgus pressure to
knee in extension and with
30 degrees of flexion):
Lateral instability

Yes

Yes

No

No

Normal

2+(5-10 millimeters)

1+(0-5 millimeters)

3+(10-15 millimeters)

Normal

2+(5-10 millimeters)

1+(0-5 millimeters)

3+(10-15 millimeters)

Normal

2+(5-10 millimeters)

1+(0-5 millimeters)

3+(10-15 millimeters)

(Apply valgus pressure to
knee in extension and with
30 degrees of flexion):

Normal

2+(5-10 millimeters)

1+(0-5 millimeters)

3+(10-15 millimeters)

Anterior instability

Normal

2+(5-10 millimeters)

1+(0-5 millimeters)

3+(10-15 millimeters)

Normal

2+(5-10 millimeters)

1+(0-5 millimeters)

3+(10-15 millimeters)

Normal

2+(5-10 millimeters)

1+(0-5 millimeters)

3+(10-15 millimeters)

Normal

2+(5-10 millimeters)

1+(0-5 millimeters)

3+(10-15 millimeters)

(Lachman test)

Not Indicated
Indicated, but not able to perform
LEFT
KNEE

If joint stability is indicated, but unable
to test, provide reason:

Posterior instability

(Posterior drawer
test)
Medial instability

(Apply valgus pressure to
knee in extension and with
30 degrees of flexion):
Lateral instability

(Apply valgus pressure to
knee in extension and with
30 degrees of flexion):
VA FORM 21-0960M-9, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION IX - JOINT STABILITY TESTS (Continued)
9E. COMMENTS, IF ANY:

SECTION X - ADDITIONAL COMMENTS
10A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER HAD RECURRENT PATELLAR DISLOCATION, "SHIN SPLINTS" (medial tibial stress syndrome),
STRESS FRACTURES, CHRONIC EXERTIONAL COMPARTMENT SYNDROME OR ANY OTHER TIBIAL OR FIBULAR IMPAIRMENT?
YES

NO

IF YES, INDICATE CONDITION AND COMPLETE THE APPROPRIATE SECTIONS BELOW:
RECURRENT PATELLAR DISLOCATION
IF CHECKED, INDICATE SEVERITY AND SIDE AFFECTED:
Right:

None

Slight

Moderate

Severe

Left:

None

Slight

Moderate

Severe

"SHIN SPLINTS" (medial tibial stress syndrome)
Left

Both

Does this condition affect ROM of knee?

Yes

No

Does this condition affect ROM of ankle?

Yes

No

Left

Both

Yes

No

INDICATE SIDE AFFECTED:

Right

(If yes, complete ROM section of knee on this DBQ.)
(If yes, complete VA form 21-0960M-2 ANKLE CONDITIONS to document ROM of ankle.)

Describe current symptoms:
STRESS FRACTURE OF THE LOWER LEG
INDICATE SIDE AFFECTED:

Right

Does this condition affect ROM of ankle?

(If yes, complete VA form 21-0960M-2 ANKLE CONDITIONS to document ROM of ankle.)

Describe current symptoms:
CHRONIC EXERTIONAL COMPARTMENT SYNDROME (an exercise-induced neuromuscular condition that can cause pain and swelling, especially after repetitive

movements such as marching)
INDICATE SIDE AFFECTED:

Right

Does this condition affect ROM of ankle?

Left

Both

Yes

No

(If yes, complete VA form 21-0960M-2 ANKLE CONDITIONS to document ROM of ankle.)

Describe current symptoms:
ACQUIRED AND/OR TRAUMATIC GENU RECURVATUM WITH OBJECTIVELY DEMONSTRATED WEAKNESS AND INSECURITY IN WEIGHT-BEARING.
INDICATE SIDE AFFECTED:

Right

Left

Both

LEG LENGTH DISCREPANCY (shortening of any bones of the lower extremity)

(If checked, provide length of each lower extremity in inches (to the nearest 1/4 inch) or centimeters measuring from the anterior superior iliac spine
to the internal malleolus of the tibia.)
Measurements: Right leg:

cm

inches

Left leg:

cm

inches

For any leg length discrepancy, please describe the relationship to the conditions listed in the Diagnosis section above:

10B. COMMENTS, IF ANY:

SECTION XI - MENISCAL CONDITIONS
11A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER HAD A MENISCUS (semilunar cartilage) CONDITION?
YES

NO

(If "Yes," indicate severity and frequency of symptoms, and side affected):
RIGHT SIDE:

LEFT SIDE:

No current symptoms

No current symptoms

Meniscal dislocation

Meniscal dislocation

Meniscal tear

Meniscal tear

Frequent episodes of joint "locking"

Frequent episodes of joint "locking"

Frequent episodes of joint pain

Frequent episodes of joint pain

Frequent episodes of joint effusion

Frequent episodes of joint effusion

Other

Other

11B. FOR ALL CHECKED BOXES ABOVE, DESCRIBE:

VA FORM 21-0960M-9, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION XII - SURGICAL PROCEDURES
12. INDICATE ANY SURGICAL PROCEDURES THAT THE VETERAN HAS HAD PERFORMED AND PROVIDE THE ADDITIONAL INFORMATION AS REQUESTED
(check all that apply):
RIGHT SIDE:
LEFT SIDE:
TOTAL KNEE JOINT REPLACEMENT

TOTAL KNEE 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:

MENISCECTOMY, ARTHROSCOPIC OR OTHER KNEE SURGERY NOT
DESCRIBED ABOVE:

MENISCECTOMY, ARTHROSCOPIC OR OTHER KNEE SURGERY NOT
DESCRIBED ABOVE:

TYPE OF SURGERY:

TYPE OF SURGERY:

DATE OF SURGERY:

DATE OF SURGERY:

RESIDUAL SIGNS OF SYMPTOMS DUE TO MENISCECTOMY,
ARTHROSCOPIC OR OTHER KNEE SURGERY NOT DESCRIBED ABOVE:

RESIDUAL SIGNS OF SYMPTOMS DUE TO MENISCECTOMY,
ARTHROSCOPIC OR OTHER KNEE SURGERY NOT DESCRIBED ABOVE:

DESCRIBE RESIDUALS:

DESCRIBE RESIDUALS:

SECTION XIII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS AND SCARS
13A. 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 13B-13D.

13B. 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

NO

IF YES, DESCRIBE (brief summary):

13C. 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.
13D. COMMENTS, IF ANY:

SECTION XIV - ASSISTIVE DEVICES
14A. 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

14B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:

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SECTION XV - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
15. DUE TO THE VETERAN'S KNEE OR LOWER LEG CONDITION(S), 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 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.
SECTION XVI - 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.
16A. HAVE IMAGING STUDIES OF THE KNEE BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

IF YES, IS DEGENERATIVE OR TRAUMATIC ARTHRITIS DOCUMENTED?
YES

NO

IF YES, INDICATE KNEE:

RIGHT

LEFT

BOTH

16B. 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):

16C. IS THERE OBJECTIVE EVIDENCE OF CREPITUS?
YES

NO

IF YES, INDICATE KNEE:

RIGHT

LEFT

BOTH

16D. IF ANY TEST RESULTS ARE OTHER THAN NORMAL, INDICATE RELATIONSHIP OF ABNORMAL FINDINGS TO DIAGNOSED CONDITIONS:

SECTION XVII - 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.
17. 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 XVIII - REMARKS
18. REMARKS, IF ANY:

SECTION XIX - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
19A. PHYSICIAN'S SIGNATURE
19D. PHYSICIAN'S PHONE/FAX NUMBER

19B. PHYSICIAN'S PRINTED NAME
19E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER

19C. DATE SIGNED
19F. 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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