Form 21-0960M-3 Non-Degenerative Arthritis (including inflammatory, auto

OMB Approved No. 2900-XXXX
Respondent Burden: 15 Minutes
Expiration Date: XX/XX/XXXX

NON-DEGENERATIVE ARTHRITIS (INCLUDING INFLAMMATORY,
AUTOIMMUNE, CRYSTALLINE AND INFECTIOUS ARTHRITIS) AND
DYSBARIC OSTEONECROSIS 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

NOTE: Complete this Questionnaire if the Veteran has an inflammatory, autoimmune, crystalline or infectious arthritis, or dysbaric osteonecrosis (Caisson disease of bone).
If the Veteran has degenerative arthritis (osteoarthritis) or traumatic arthritis, do not complete this Questionnaire, INSTEAD complete the joint Questionnaire for the
affected area (e.g., if the diagnosis is osteoarthritis of the knee, complete the Knee Questionnaire).
If the Veteran has arthritis due to systemic lupus erythematosus (SLE), instead complete the SLE Questionnaire.
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.)
Gout
ICD Code:
Date of diagnosis:
Rheumatoid arthritis (atrophic)

ICD Code:

Date of diagnosis:

Gonorrheal arthritis

ICD Code:

Date of diagnosis:

Pneumococcic arthritis

ICD Code:

Date of diagnosis:

Typhoid arthritis

ICD Code:

Date of diagnosis:

Syphilitic arthritis

ICD Code:

Date of diagnosis:

Streptococcic arthritis

ICD Code:

Date of diagnosis:

Dysbaric osteonecrosis

ICD Code:

Date of diagnosis:

(Caisson Disease of Bone)

Other (specify) (If checked, provide only diagnoses that pertain to inflammatory, autoimmune, crystalline or infectious arthritis.)
Other diagnosis #1:

ICD Code:

Date of diagnosis:

Other diagnosis #2:

ICD Code:

Date of diagnosis:

Other diagnosis #3:

ICD Code:

Date of diagnosis:

VA FORM
XXX XXXX

21-0960M-3

SUPERSEDES VA FORM 21-0960M-3, MAR 2014,
WHICH WILL NOT BE USED.

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION I - DIAGNOSIS (Continued)
1C. COMMENTS (if any):

1D. WAS AN OPINION REQUESTED ABOUT THIS CONDITION (internal VA only)?
YES

NO

IF YES, INCLUDE MEDICAL OPINION DBQ.

N/A

SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S INFLAMMATORY, AUTOIMMUNE, CRYSTALLINE OR INFECTIOUS ARTHRITIS OR
DYSBARIC OSTEONECROSIS (brief summary):

2B. DOES THE VETERAN REQUIRE CONTINUOUS USE OF MEDICATION FOR THE ARTHRITIS CONDITION?
YES

NO

IF YES, LIST ONLY THOSE MEDICATIONS USED FOR THIS ARTHRITIS:

2C. HAS THE VETERAN LOST WEIGHT DUE TO THE ARTHRITIS CONDITION?
YES

NO

IF YES, PROVIDE BASELINE WEIGHT (average weight for 2-year period preceding onset of disease):

, AND CURRENT WEIGHT

IF YES, DOES THE VETERAN'S WEIGHT LOSS ATTRIBUTABLE TO THE ARTHRITIS CONDITION CAUSE IMPAIRMENT OF HEALTH?
YES

NO

IF YES, DESCRIBE THE IMPAIRMENT:

2D. DOES THE VETERAN HAVE ANEMIA DUE TO THE ARTHRITIS CONDITION?
YES

NO

IF YES, DOES THE VETERAN'S ANEMIA ATTRIBUTABLE TO THE ARTHRITIS CONDITION CAUSE IMPAIRMENT OF HEALTH?
YES

NO

IF YES, DESCRIBE THE IMPAIRMENT (also provide CBC under diagnostic testing section #9):

SECTION III - JOINT INVOLVEMENT
3A. DOES THE VETERAN HAVE PAIN (with or without joint movement) ATTRIBUTABLE TO THIS ARTHRITIS CONDITION?
YES

NO

IF YES, INDICATE AFFECTED JOINTS (check all that apply):
CERVICAL SPINE

THORACOLUMBAR SPINE

SACROILIAC JOINTS

RIGHT:

SHOULDER

ELBOW

WRIST

HAND/FINGERS

HIP

KNEE

ANKLE

FOOT/TOES

LEFT:

SHOULDER

ELBOW

WRIST

HAND/FINGERS

HIP

KNEE

ANKLE

FOOT/TOES

FOR ALL CHECKED JOINTS, DESCRIBE INVOLVEMENT (brief summary):

3B. DOES THE VETERAN HAVE ANY LIMITATION OF JOINT MOVEMENT ATTRIBUTABLE TO THE ARTHRITIS CONDITION?
YES

NO

IF YES, INDICATE AFFECTED JOINTS (check all that apply):
CERVICAL SPINE

THORACOLUMBAR SPINE

SACROILIAC JOINTS

RIGHT:

SHOULDER

ELBOW

WRIST

HAND/FINGERS

HIP

KNEE

ANKLE

FOOT/TOES

LEFT:

SHOULDER

ELBOW

WRIST

HAND/FINGERS

HIP

KNEE

ANKLE

FOOT/TOES

FOR ALL CHECKED JOINTS, DESCRIBE LIMITATION OF MOVEMENT (brief summary):

VA FORM 21-0960M-3, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION III - JOINT INVOLVEMENT (Continued)
3C. DOES THE VETERAN HAVE ANY JOINT DEFORMITIES ATTRIBUTABLE TO THE ARTHRITIS CONDITION?
YES

NO

IF YES, INDICATE AFFECTED JOINTS (check all that apply):
THORACOLUMBAR SPINE

CERVICAL SPINE

SACROILIAC JOINTS

RIGHT:

SHOULDER

ELBOW

WRIST

HAND/FINGERS

HIP

KNEE

ANKLE

FOOT/TOES

LEFT:

SHOULDER

ELBOW

WRIST

HAND/FINGERS

HIP

KNEE

ANKLE

FOOT/TOES

FOR ALL CHECKED JOINTS, DESCRIBE DEFORMITIES (brief summary):

3D. COMMENTS (if any):

NOTE: For pain, limitation of joint movement and joint deformities, ALSO complete the appropriate DBQ for each affected joint, if indicated. ALSO complete the
appropriate DBQ for each affected system, if indicated.
SECTION IV - SYSTEMIC INVOLVEMENT OTHER THAN JOINTS
4A. DOES THE VETERAN HAVE ANY INVOLVEMENT OF ANY SYSTEMS, OTHER THAN JOINTS, ATTRIBUTABLE TO THIS ARTHRITIS CONDITION?
YES

NO

IF YES, INDICATE SYSTEMS INVOLVED (check all that apply):
SKIN AND MUCOUS MEMBRANES

OPHTHALMOLOGICAL
NEUROLOGIC

RENAL

GASTROINTESTINAL

HEMATOLOGIC

PULMONARY

CARDIAC

VASCULAR

FOR ALL CHECKED SYSTEMS, DESCRIBE INVOLVEMENT (brief summary) (Also complete the appropriate DBQ for each affected system, if indicated):

4B. COMMENTS (if any):

SECTION V - INCAPACITATING AND NON-INCAPACITATING EXACERBATIONS
5A. DUE TO THE ARTHRITIS CONDITION, DOES THE VETERAN HAVE EXACERBATIONS WHICH ARE NOT INCAPACITATING?
NO

YES

IF YES, INDICATE FREQUENCY OF NON-INCAPACITATING EXACERBATIONS PER YEAR:
0

1

2

3

4 OR MORE

Date of most recent non-incapacitating exacerbation:
Duration of most recent non-incapacitating exacerbation:
Describe non-incapacitating exacerbation:
5B. DUE TO THE ARTHRITIS CONDITION, DOES THE VETERAN HAVE EXACERBATIONS WHICH ARE INCAPACITATING?
YES

NO

IF YES, INDICATE FREQUENCY OF INCAPACITATING EXACERBATIONS PER YEAR (on average):
0

1

2

3

4 OR MORE

INDICATE THE TOTAL DURATION OF INCAPACITATION OVER THE PAST 12 MONTHS:
< 1 WEEK
1 WEEK TO < 2 WEEKS
2 WEEKS TO < 4 WEEKS
4 WEEKS TO < 6 WEEKS
6 WEEKS OR MORE
Date of most recent incapacitating exacerbation:
Duration of most recent incapacitating exacerbation:
Describe incapacitating exacerbation:
5C. IS THE VETERAN'S ARTHRITIS MANIFESTED BY CONSTITUTIONAL MANIFESTATIONS ASSOCIATED WITH ACTIVE JOINT INVOLVEMENT WHICH ARE
TOTALLY INCAPACITATING?
YES

NO

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION V - INCAPACITATING AND NON-INCAPACITATING EXACERBATIONS (Continued)
5D. IS THE VETERAN'S ARTHRITIS MANIFESTED BY WEIGHT LOSS AND ANEMIA PRODUCTIVE OF SEVERE IMPAIRMENT OF HEALTH?
YES

NO

5E. IS THE VETERAN'S ARTHRITIS MANIFESTED BY SEVERELY INCAPACITATING EXACERBATIONS OCCURRING 4 OR MORE TIMES A YEAR OR A LESSER
NUMBER OVER PROLONGED PERIODS?
YES

NO

5F. IS THE VETERAN'S ARTHRITIS MANIFESTED BY SYMPTOM COMBINATIONS PRODUCTIVE OF DEFINITE IMPAIRMENT OF HEALTH OBJECTIVELY
SUPPORTED BY EXAMINATION FINDINGS?
YES

NO

5G. COMMENTS (if any):

SECTION VI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS AND SCARS
6A. 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 6B-6D.

6B. 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

6C. 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.
6D. COMMENTS, IF ANY:

SECTION VII - ASSISTIVE DEVICES
7A. 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

7B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:

VA FORM 21-0960M-3, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION VIII - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
8. DUE TO THE VETERAN'S ARTHRITIS CONDITION, IS THERE FUNCTIONAL IMPAIRMENT OF AN EXTREMITY SUCH THAT NO EFFECTIVE FUNCTIONS 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 UPPER

LEFT UPPER

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 IX - DIAGNOSTIC TESTING
NOTE: Testing listed below is not indicated for every condition.
9A. HAVE IMAGING STUDIES BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

IF YES, INDICATE TYPE OF STUDY:
X-RAY

Area(s) imaged:

Date:

Results:

Area(s) imaged:

Date:

Results:

OTHER, SPECIFY:

9B. HAVE LABORATORY STUDIES BEEN PERFORMED?
YES

NO

IF YES, CHECK ALL THAT APPLY:
IF ANY TEST RESULTS IN THIS SECTION (Section B) ARE OTHER THAN NORMAL, INCLUDE NORMAL REFERENCE RANGES FOR YOUR FACILITY.
ERYTHROCYTE SEDIMENTATION RATE (ESR)

Date of test:

Results:

C-REACTIVE PROTEIN

Date of test:

Results:

RHEUMATOID FACTOR (RF)

Date of test:

Results:

ANTI-DNA ANTIBODIES

Date of test:

Results:

ANTINUCLEAR ANTIBODIES (ANA)

Date of test:

Results:

ANTI-CYCLIC CITRULLINATED PEPTIDE (ANTI-CCP) ANTIBODIES

Date of test:

Results:

CBC

Date of test:

Hemoglobin:

Hematocrit:

White blood cell count:

Platelets:

URIC ACID TEST

Date of test:

Results:

OTHER, SPECIFY:

Date of test:

Results:

9C. HAS THE VETERAN HAD A JOINT ASPIRATION OR SYNOVIAL FLUID ANALYSIS?
YES

NO

IF YES, INDICATE JOINT ASPIRATED, DATE AND RESULTS:

9D. HAS THE VETERAN HAD A BIOPSY (e.g., skin, nerve, fat, rectum, kidney)?
YES

NO

IF YES, INDICATE AREA BIOPSIED, DATE AND RESULTS:

9E. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES

NO

IF YES, PROVIDE TYPE OF TEST OR PROCEDURE, DATE AND RESULTS (brief summary):

9F. IF ANY TEST RESULTS ARE OTHER THAN NORMAL, INDICATE RELATIONSHIP OF ABNORMAL FINDINGS TO DIAGNOSED CONDITIONS:

VA FORM 21-0960M-3, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION X - 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.
10. 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 XI - REMARKS
11. REMARKS, IF ANY:

SECTION XII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
12A. PHYSICIAN'S SIGNATURE

12D. PHYSICIAN'S PHONE AND FAX NUMBER

12B. PHYSICIAN'S PRINTED NAME

12E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER

12C. DATE SIGNED
12F. 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 15 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-3, XXX XXXX

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