Form 21-0960M-7 Hand and Finger Conditions Disability Benefits Questionn

Hand and Finger Conditions Disability Benefits Questionnaire (VA Form 21-0960M-7)

VA Form 21-0960M-7 (508 Conformant 1-19-17)

Hand and Finger Conditions Disability Benefits Questionnaire (21-0960M-7)

OMB: 2900-0809

Document [pdf]

Download: pdf | pdf

OMB Approved No. 2900-0809
Respondent Burden: 30 minutes
Expiration Date: XXXXXX

HAND AND FINGER 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 - Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you
provide on this questionnaire as part of their evaluation in processing the veteran's claim. VA reserves the right to confirm the authenticity of ALL DBQ's completed by
private health care providers.
MEDICAL RECORD REVIEW
WAS THE VETERAN'S VA CLAIMS FILE REVIEWED?

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.)
Dupuytren's contracture

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Trigger finger

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Swan neck deformity

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Boutonniere deformity

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Mallet finger

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Gamekeeper's thumb

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Instability (collateral

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Volar plate injury

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Degenerative arthritis

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

MCP/PIP joint prosthetic
replacement

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Ankylosis of digit joint(s),
specify joint(s):

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

ligament sprain, chronic)

(MCP/PIP/DIP)

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:
VA FORM
XXXX

21-0960M-7

SUPERSEDES VA FORM 21-0960M-7,MAY 2013,
WHICH WILL NOT BE USED.

Page 1

PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S HAND, FINGER OR THUMB CONDITION (brief summary):

2B. DOMINANT HAND:
RIGHT

LEFT

AMBIDEXTROUS

2C. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE HAND, FINGER OR THUMB?
YES

IF YES, DOCUMENT THE VETERAN'S DESCRIPTION OF THE IMPACT OF FLARE-UPS IN HIS OR HER OWN HANDS:

2D. 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

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, rounding each measurement to the nearest 5 degrees, or measure the gap between thumb pad and fingers or between fingers and palm
according to the guidance below. During ROM evaluation, observe any evidence of painful motion, manifested by visible behavior such as facial expression, wincing, on
pressure or manipulation, etc. Document painful movement in question 5 below.
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 4.
For digits II through V, the metacarpophalangeal joint has a range of zero to 90 degrees of flexion, the proximal interphalangeal joint has a range of zero to 100 degrees of
flexion, and the distal (terminal) interphalangeal joint has a range of zero to 70 or 80 degrees of flexion. For the index, long, ring, and little fingers (digits II, III, IV, and V), zero
degrees of flexion represents the fingers fully extended, making a straight line with the rest of the hand.
3A. WERE ALL ROM MEASUREMENTS NORMAL?
YES

NO, COMPLETE QUESTIONS 3B THROUGH 3F

3B. FINGER FLEXION: DOCUMENT THE ROM IN DEGREES
Check “Not Tested” only if all joints within that described hand/digit were not tested. In the case of each named individual joint, “Not Tested” simply means that joint was not
tested. In either case, provide reason for not testing in the section provided below the tables.
Left Hand
Thumb

CMC
IP

Long finger

Not Tested

ROM:

Not tested

ROM:

Not tested

ROM:

Not tested

Ring finger

Little finger

Not tested
ROM:
Not tested

MP
PIP
DIP

Right Hand
Thumb

CMC
IP

Not Tested

Index finger

Ring finger

Little finger

Not Tested

Index finger

Long finger

Not Tested

ROM:

Not tested

ROM:

Not tested

ROM:

Not tested

Not tested
ROM:
Not tested

MP
PIP
DIP

IF ANY OF THE ABOVE JOINTS WERE NOT TESTED, PLEASE EXPLAIN WHY (e.g., not indicated or Veteran was physically not able to perform):

VA FORM 21-0960M-7, XXXX

Page 2

PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION III - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS (Continued)
3C. FINGER EXTENSION: DOCUMENT THE ROM IN DEGREES
Check “Not Tested” only if all joints within that described hand/digit were not tested. In the case of each named individual joint, “Not Tested” simply means that joint was not
tested. In either case, provide reason for not testing in the section provided below the tables.
Left Hand
Thumb

CMC

Long finger

Not Tested

ROM:

Not tested

ROM:

Not tested

ROM:

Not tested

Ring finger

Little finger

Not tested
ROM:

Not tested

MP
PIP
DIP

Right Hand
Thumb

CMC

Ring finger

Little finger

Not Tested

Index finger

Long finger

Not Tested

ROM:

Not tested

ROM:

Not tested

ROM:

Not tested

Not tested
ROM:

Not Tested

Index finger

Not tested

MP
PIP
DIP

IF ANY OF THE ABOVE JOINTS WERE NOT TESTED, PLEASE EXPLAIN WHY (e.g., not indicated or Veteran was physically not able to perform):

3D. IS THERE A GAP BETWEEN ANY OF THE BELOW LISTED FINGERTIPS AND THE PROXIMAL TRANSVERSE CREASE OF THE PALM, WITH THE FINGER FLEXED
TO THE EXTENT POSSIBLE?
Left Hand
Index
finger

No gap

Long
finger

No gap

Right Hand
No gap
cm. gap

cm. gap
No gap

cm. gap

3E. IS THERE A GAP BETWEEN THE THUMB PAD AND THE FINGERS, WITH THE THUMB ATTEMPTING TO OPPOSE THE FINGERS?
Left Hand
Index
finger

No gap

Long
finger

No gap

Ring
finger

No gap

Little
finger

No gap

Right Hand
No gap
cm. gap

cm. gap
No gap

cm. gap

cm. gap
No gap

cm. gap

cm. gap
No gap

cm. gap

3F. DO ANY ABNORMAL ROMs NOTED ABOVE CONTRIBUTE TO FUNCTIONAL LOSS?
YES

NO, EXPLAIN WHY THE ABNORMAL ROMs DO NOT CONTRIBUTE:

VA FORM 21-0960M-7, XXXX

Page 3

PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION III - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS (Continued)
3G. IF ROM DOES NOT CONFORM TO THE NORMAL RANGE OF MOTION IDENTIFIED ABOVE BUT IS NORMAL FOR THIS VETERAN (for reasons other than a hand
condition, such as age, body habitus, neurologic disease), EXPLAIN:

SECTION IV - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING
4A. IS THE VETERAN ABLE TO PERFORM REPETITIVE-USE TESTING WITH 3 REPETITIONS FOR ANY OF THE JOINTS OF THE DIGITS OR HANDS?
YES, THE VETERAN IS ABLE TO PERFORM REPETITIVE-USE TESTING FOR AT LEAST ONE OF THE JOINTS OF THE DIGITS OR HANDS
NO, THE VETERAN IS NOT ABLE TO PERFORM ANY REPETITIVE-USE TESTING FOR ANY OF THE JOINTS OF THE DIGITS OR HANDS
IF YES, CONTINUE TO QUESTION B.
IF NO, PROVIDE REASON, THEN SKIP TO QUESTION 5:

4B. IS THERE ANY ADDITIONAL LIMITATION IN ROM IN ANY OF THE JOINTS OF THE DIGITS OR HANDS AFTER REPETITIVE-USE TESTING?
YES, THERE IS A CHANGE IN ROM IN AT LEAST ONE OF THE JOINTS OF THE DIGITS OR HANDS AFTER REPETITIVE-USE TESTING
NO, THERE IS NO CHANGE IN ROM IN ANY OF THE JOINTS OF THE DIGITS OR HANDS AFTER REPETITIVE-USE TESTING
IF YES, COMPLETE QUESTIONS C THROUGH G (report ROM after a minimum of 3 repetitions).
IF NO, DOCUMENTATION OF ROM AFTER REPETITIVE-USE TESTING IS NOT REQUIRED. PLEASE SKIP TO QUESTION 5.
4C. POST-TEST FINGER FLEXION: DOCUMENT THE POST-TEST ROM IN DEGREES:
Check “No change in ROM” (or “No change”) only if all joints within that described hand/digit were tested and there was no additional limitation in ROM in any of the joints
within that described hand/digit.
Check “Not Tested” only if all joints within that described hand/digit were not tested. In the case of each named individual joint, “Not Tested” simply means that joint was not
tested. In either case, provide reason for not testing in the section provided below the tables.
Left Hand
Thumb

CMC
IP

Ring finger

Little finger

No change in
ROM

Not Tested

ROM:

Not tested

ROM:

Not tested

ROM:

Not tested

Ring finger

Little finger

ROM:
Not tested
ROM:
Not tested

MP
PIP

No change in ROM

Right Hand
Thumb

Not Tested

Long finger

No change in
ROM

DIP

CMC

No change in ROM

Index finger

Not Tested

Long finger

No change in
ROM

Not Tested

ROM:

Not tested

ROM:

Not tested

ROM:

Not tested

ROM:
Not tested
ROM:
Not tested

MP
PIP
DIP

IF ANY OF THE ABOVE JOINTS WERE NOT TESTED, PLEASE EXPLAIN WHY (e.g., not indicated or Veteran was physically not able to perform):

VA FORM 21-0960M-7, XXXX

Page 4

PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION IV - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING (Continued)
4D. POST-TEST FINGER EXTENSION: DOCUMENT THE POST-TEST ROM IN DEGREES
Check “No change in ROM” (or “No change”) only if all joints within that described hand/digit were tested and there was no additional limitation in ROM in any of the joints
within that described hand/digit.
Check “Not Tested” only if all joints within that described hand/digit were not tested. In the case of each named individual joint, “Not Tested” simply means that joint was not
tested. In either case, provide reason for not testing in the section provided below the tables.
Left Hand
Thumb

CMC
IP

Ring finger

Little finger

No change in
ROM

Not Tested

ROM:

Not tested

ROM:

Not tested

ROM:

Not tested

Ring finger

Little finger

Not tested
ROM:
Not tested

MP
PIP

No change in ROM

Right Hand
Thumb

Index finger

No change in
ROM

Not Tested

Long finger

No change in
ROM

DIP

CMC

No change in ROM

Index finger

Not Tested

Long finger

No change in
ROM

Not Tested

ROM:

Not tested

ROM:

Not tested

ROM:

Not tested

Not tested
ROM:
Not tested

MP
PIP
DIP

IF ANY OF THE ABOVE JOINTS WERE NOT TESTED, PLEASE EXPLAIN WHY (e.g., not indicated or Veteran was physically not able to perform):

4E. AFTER REPETITIVE-USE TESTING, IS THERE A GAP BETWEEN ANY OF THE BELOW LISTED FINGERTIPS AND THE PROXIMAL TRANSVERSE CREASE OF THE
PALM, WITH THE FINGER FLEXED TO THE EXTENT POSSIBLE?
Left Hand
Index
finger

No gap

Long
finger

No gap

Right Hand
No gap
cm. gap

cm. gap
No gap

cm. gap

4F. AFTER REPETITIVE-USE TESTING, IS THERE A GAP BETWEEN THE THUMB PAD AND THE FINGERS, WITH THE THUMB ATTEMPTING TO OPPOSE THE
FINGERS?
Left Hand
Index
finger

No gap

Long
finger

No gap

Ring
finger

No gap

Little
finger

No gap

Right Hand
No gap
cm. gap

cm. gap
No gap

cm. gap

cm. gap
No gap

cm. gap

VA FORM 21-0960M-7, XXXX

cm. gap
No gap

cm. gap

cm. gap
Page 5

PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION IV - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING (Continued)
4G. 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 questions 6 below)
NO, EXPLAIN WHY THE POST-TEST ADDITIONAL LIMITATIONS OF ROMs DO NOT CONTRIBUTE:

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

Index
finger

Long
finger

Ring finger

Little finger

If yes, does the pain contribute to functional loss or additional limitation of ROM?

Yes

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

No, explain why the pain does not contribute:

Yes

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

No, explain why the pain does not contribute:

Yes

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

No, explain why the pain does not contribute:

Yes

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

No, explain why the pain does not contribute:

Yes

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

No, explain why the pain does not contribute:

Right Hand
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)
Thumb

Index
finger

Long
finger

Ring finger

Little finger

If yes, does the pain contribute to functional loss or additional limitation of ROM?

Yes

Yes (you will be asked to further

No, explain why the pain does not contribute:

Yes

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

No, explain why the pain does not contribute:

Yes

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

No, explain why the pain does not contribute:

Yes

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

No, explain why the pain does not contribute:

Yes

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

No, explain why the pain does not contribute:

VA FORM 21-0960M-7, XXXX

describe these limitations in
question 6 below)

Page 6

PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION V - PAIN (Continued)
5B. PAIN WHEN JOINT IS USED IN WEIGHT-BEARING OR IN NON WEIGHT-BEARING
Left Hand
Is there pain when joint is used in weightbearing or in non weight-bearing?

(If yes, identify whether weight-bearing or
non weight-bearing in question 5D)

If yes, does the pain contribute to functional loss or additional limitation of ROM?

Yes

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

No, explain why the pain does not contribute:

Index
finger

Yes

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

No, explain why the pain does not contribute:

Long
finger

Yes

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

No, explain why the pain does not contribute:

Yes

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

No, explain why the pain does not contribute:

Yes

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

No, explain why the pain does not contribute:

Thumb

Ring finger

Little finger

Right Hand
Is there pain when joint is used in weightbearing or in non weight-bearing?

(If yes, identify whether weight-bearing or
non weight-bearing in question 5D)
Thumb

Index
finger

Long
finger

Ring finger

Little finger

If yes, does the pain contribute to functional loss or additional limitation of ROM?

Yes

Yes (you will be asked to further

No, explain why the pain does not contribute:

Yes

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

No, explain why the pain does not contribute:

Yes

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

No, explain why the pain does not contribute:

Yes

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

No, explain why the pain does not contribute:

Yes

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

No, explain why the pain does not contribute:

describe these limitations in
question 6 below)

5C. LOCALIZED TENDERNESS OR PAIN TO PALPATION
Left Hand
Does the Veteran have localized tenderness
or pain to palpation for joints or soft tissue?
Thumb

Yes

Index
finger

Yes

Long
finger

Yes

Ring finger

Yes

Little finger

Yes

VA FORM 21-0960M-7, XXXX

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

Page 7

PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION V - PAIN (Continued)
Right Hand
Does the Veteran have localized tenderness
or pain to palpation for joints or soft tissue?
Thumb

Yes

Index
finger

Yes

Long
finger

Yes

Ring finger

Yes

Little finger

Yes

If yes, describe the tenderness or pain (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 to perform normal working movements of the body with normal excursion, strength, speed, coordination and/or
endurance.
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 or increased gap distance after repetitive use for the joint or extremity being evaluated on this DBQ:
6A. CONTRIBUTING FACTORS OF DISABILITY (check all that apply and indicate digit affected):
No functional loss for left hand, thumb or fingers
No functional loss for right hand, thumb or fingers
Contributing factor

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

VA FORM 21-0960M-7, XXXX

Left Hand

Right Hand

None

All

Thumb

Index finger

Long finger

Ring finger

Little finger

None

All

Thumb

Index finger

Long finger

Ring finger

Little finger

None

All

Thumb

Index finger

Long finger

Ring finger

Little finger

None

All

Thumb

Index finger

Long finger

Ring finger

Little finger

Page 8

PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION VI - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION OF ROM (Continued)
6A. CONTRIBUTING FACTORS OF DISABILITY (check all that apply and indicate digit affected):
Contributing factor

Incoordination, impaired ability to execute skilled movements smoothly

Pain on movement

Swelling

Deformity

Atrophy of disuse

Left Hand

Right Hand

None

All

Thumb

Index finger

Long finger

Ring finger

Little finger

None

All

Thumb

Index finger

Long finger

Ring finger

Little finger

None

All

Thumb

Index finger

Long finger

Ring finger

Little finger

None

All

Thumb

Index finger

Long finger

Ring finger

Little finger

None

All

Thumb

Index finger

Long finger

Ring finger

Little finger

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 ROM loss or gap distances 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, COMPLETE QUESTIONS 6C THROUGH 6E, AND F BELOW.
NO, SKIP TO F.

VA FORM 21-0960M-7, XXXX

Page 9

PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION VI - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION OF ROM (Continued)
6C. DOES PAIN, WEAKNESS, FATIGABILITY, OR INCOORDINATION SIGNIFICANTLY LIMIT FUNCTIONAL ABILITY DURING FLARE-UPS OR WHEN THE FINGER IS
USED REPEATEDLY OVER A PERIOD OF TIME?
Estimated ROM due to pain and/or functional loss
during flare-ups or when the joint is used repeatedly
over a period of time
LEFT HAND
Flexion

Yes (complete

Thumb

CMC

Est. ROM:
Estimate is not
feasible

CMC

Est. ROM:
Estimate is not
feasible

PIP

Est. ROM:
Estimate is not
feasible

PIP

Est. ROM:
Estimate is not
feasible

DIP

Est. ROM:
Estimate is not
feasible

DIP

Est. ROM:
Estimate is not
feasible

PIP

Est. ROM:
Estimate is not
feasible

PIP

Est. ROM:
Estimate is not
feasible

DIP

Est. ROM:
Estimate is not
feasible

DIP

Est. ROM:
Estimate is not
feasible

PIP

Est. ROM:
Estimate is not
feasible

PIP

Est. ROM:
Estimate is not
feasible

DIP

Est. ROM:
Estimate is not
feasible

DIP

Est. ROM:
Estimate is not
feasible

PIP

Est. ROM:
Estimate is not
feasible

PIP

Est. ROM:
Estimate is not
feasible

DIP

Est. ROM:
Estimate is not
feasible

DIP

Est. ROM:
Estimate is not
feasible

estimated ROM)
No

Yes (complete
Index
finger

estimated ROM
and gap distances)

Yes (complete
Long
finger

estimated ROM
and gap distances)

Yes (complete
Ring
finger

estimated ROM
and gap distances)

Yes (complete
Little
finger

estimated ROM
and gap distances)

Extension

Estimated ROM due to pain and/or functional loss
during flare-ups or when the joint is used repeatedly
over a period of time
RIGHT HAND
Flexion

Yes (complete

Thumb

CMC

Est. ROM:
Estimate is not
feasible

estimated ROM)
No

VA FORM 21-0960M-7, XXXX

Extension

CMC

Est. ROM:
Estimate is not
feasible

Estimated Gap distance due to pain and/or functional loss
during flare-ups or when the joint is used repeatedly
over a period of time
Gap between the fingertip and
the proximal transverse crease
of the palm, with the finger
flexed to the extent possible

Gap between the thumb pad
and the finger, with the thumb
attempting to oppose
the fingers

N/A

No estimated gap

Est.
cm gap
Estimate is not
feasible

No estimated gap

Est.
cm gap
Estimate is not
feasible

No estimated gap

Est.
cm gap
Estimate is not
feasible

No estimated gap

Est.
cm gap
Estimate is not
feasible

Gap between the thumb pad
and the finger, with the thumb
attempting to oppose
the fingers

N/A

Page 10

PATIENT/VETERAN'S SOCIAL SECURITY NO.

estimated ROM
and gap distances)

Est. ROM:
Estimate is not
feasible

PIP

Est. ROM:
Estimate is not
feasible

PIP

Est. ROM:
Estimate is not
feasible

DIP

Est. ROM:
Estimate is not
feasible

DIP

Est. ROM:
Estimate is not
feasible

PIP

Est. ROM:
Estimate is not
feasible

PIP

Est. ROM:
Estimate is not
feasible

DIP

Est. ROM:
Estimate is not
feasible

DIP

Est. ROM:
Estimate is not
feasible

PIP

Est. ROM:
Estimate is not
feasible

PIP

Est. ROM:
Estimate is not
feasible

DIP

Est. ROM:
Estimate is not
feasible

DIP

Est. ROM:
Estimate is not
feasible

PIP

Est. ROM:
Estimate is not
feasible

PIP

Est. ROM:
Estimate is not
feasible

DIP

Est. ROM:
Estimate is not
feasible

DIP

Est. ROM:
Estimate is not
feasible

Yes (complete
Long
finger

estimated ROM
and gap distances)

Yes (complete
Ring
finger

estimated ROM
and gap distances)

Yes (complete
Little
finger

estimated ROM
and gap distances)

Gap between the fingertip and
the proximal transverse crease
of the palm, with the finger
flexed to the extent possible

Extension

MP
Yes (complete
Index
finger

Estimated Gap distance due to pain and/or functional loss
during flare-ups or when the joint is used repeatedly
over a period of time
Gap between the thumb pad
and the finger, with the thumb
attempting to oppose
the fingers

No estimated gap

Est.
cm gap
Estimate is not
feasible

No estimated gap

Est.
cm gap
Estimate is not
feasible

No estimated gap

Est.
cm gap
Estimate is not
feasible

No estimated gap

Est.
cm gap
Estimate is not
feasible

6D. FOR ANY JOINTS IN WHICH ESTIMATED LIMITATION OF ROM OR GAP DISTANCES DUE TO PAIN AND/OR FUNCTIONAL LOSS DURING FLARE-UPS OR WHEN
THE JOINT IS USED REPEATEDLY OVER A PERIOD OF TIME IS NOT FEASIBLE, PROVIDE RATIONALE:

6E. FOR ANY JOINTS IN WHICH 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 OR GAP DISTANCES CANNOT BE ESTIMATED, PLEASE DESCRIBE THE FUNCTIONAL LOSS:

6F. INDICATE ANY FINGERS IN WHICH THERE IS 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:
Left:

None

All

Thumb

Index finger

Long finger

Ring finger

Little finger

Right:

None

All

Thumb

Index finger

Long finger

Ring finger

Little finger

VA FORM 21-0960M-7, XXXX

Page 11

PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION VII - MUSCLE STRENGTH TESTING
7A. MUSCLE STRENGTH - RATE STRENTH 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
All normal (5/5)
Hand grip:

Right:

5/5

4/5

3/5

2/5

1/5

0/5

Left:

5/5

4/5

3/5

2/5

1/5

0/5

IF THE VETERAN HAS A REDUCTION IN MUSCLE STRENGTH, IS IT DUE TO A DIAGNOSIS LISTED IN SECTION 1?
YES

IF NO, PROVIDE RATIONALE:

7B. DOES THE VETERAN HAVE MUSCLE ATROPHY?
YES

IF YES, IS THE MUSCLE ATROPHY DUE TO A DIAGNOSIS LISTED IN SECTION 1?
YES

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 UPPER EXTREMITY (specify location of measurement):
CIRCUMFERENCE OF MORE NORMAL SIDE:
CIRCUMFERENCE OF ATROPHIED SIDE:

CM
CM

LEFT UPPER EXTREMITY (specify location of measurement):
CIRCUMFERENCE OF MORE NORMAL SIDE:
CIRCUMFERENCE OF ATROPHIED SIDE:

CM
CM

7C. COMMENTS, IF ANY:

SECTION VIII - ANKYLOSIS
Complete this section if Veteran has ankylosis of any thumb or finger joints.
NOTE: Ankylosis is the immobilization and consolidation of a joint due to disease, injury or surgical procedure.
8A. INDICATE LOCATION, SEVERITY AND SIDE AFFECTED (check all that apply):
Left Hand
No ankylosis
Name of
joint
CMC
Thumb
No ankylosis
IP

MCP
Index Finger
No ankylosis
PIP

VA FORM 21-0960M-7, XXXX

Is it ankylosed?

If ankylosed, what is the
position of ankylosis

Yes

In extension

Other,

Yes

In extension

Other,

Yes

In extension

Other,

Yes

In extension

Other,

In full flexion
degrees of flexion
In full flexion
degrees of flexion
In full flexion
degrees of flexion
In full flexion
degrees of flexion

If ankylosed, is there
rotation of a bone?

If ankylosed, is there
angulation of a bone?

Yes

No
Page 12

PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION VIII - ANKYLOSIS (Continued)
8A. INDICATE LOCATION, SEVERITY AND SIDE AFFECTED (check all that apply):

MCP
Long Finger
No ankylosis
PIP

MCP
Ring Finger
No ankylosis
PIP

MCP
Little Finger
No ankylosis
PIP

Yes

In extension

Other,

Yes

In extension

Other,

Yes

In extension

Other,

Yes

In extension

Other,

Yes

In extension

Other,

Yes

In extension

Other,

Yes

Right Hand
No ankylosis
Name of
joint
CMC
Thumb
No ankylosis
IP

MCP
Index Finger
No ankylosis
PIP

MCP
Long Finger
No ankylosis
PIP

MCP
Ring Finger
No ankylosis
PIP

MCP
Little Finger
No ankylosis
PIP

Is it ankylosed?
Yes

If ankylosed, what is the
position of ankylosis
In extension

Other,

Yes

In extension

Other,

Yes

In extension

Other,

Yes

In extension

Other,

Yes

In extension

Other,

Yes

In extension

Other,

Yes

In extension

Other,

Yes

In extension

Other,

Yes

In extension

Other,

Yes

In extension

Other,

In full flexion
degrees of flexion
In full flexion
degrees of flexion
In full flexion
degrees of flexion
In full flexion
degrees of flexion
In full flexion
degrees of flexion
In full flexion
degrees of flexion
In full flexion
degrees of flexion
In full flexion
degrees of flexion
In full flexion
degrees of flexion
In full flexion
degrees of flexion

If ankylosed, is there
rotation of a bone?

If ankylosed, is there
angulation of a bone?

Yes

8B. DOES THE ANKYLOSIS RESULT IN LIMITATION OF MOTION OF OTHER DIGITS OR INTERFERENCE WITH OVERALL FUNCTION OF THE HAND?
YES

IF YES, PLEASE DESCRIBE AND PROVIDE RATIONALE FOR YOUR RESPONSE:

VA FORM 21-0960M-7, XXXX

Page 13

PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION VIII - ANKYLOSIS (Continued)
8C. COMMENTS, IF ANY:

SECTION IX - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS AND SCARS
9A. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS, OR ANY SCARS (surgical
or otherwise) RELATED TO ANY CONDITION OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN THE DIAGNOSIS SECTION ABOVE?
YES

IF YES, COMPLETE THE FOLLOWING SECTION

9B. 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):

9C. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITION OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN THE
DIAGNOSIS SECTION ABOVE?
YES

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

IF YES, ALSO COMPLETE A SCARS DBQ.

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.
9D. COMMENTS, IF ANY:

SECTION X - ASSISTIVE DEVICES
10A. DOES THE VETERAN USE ANY ASSISTIVE DEVICES?
YES

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

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

SECTION XI - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
11A. DUE TO THE VETERAN'S HAND, FINGER OR THUMB CONDITIONS, 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

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.
VA FORM 21-0960M-7, XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION XII - 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.
12A. HAVE IMAGING STUDIES OF THE HANDS BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

IF YES, ARE THERE ABNORMAL FINDINGS?
YES

IF YES, INDICATE FINDINGS:
DEGENERATIVE OR TRAUMATIC ARTHRITIS

HAND:

RIGHT

LEFT

BOTH

IS DEGENERATIVE OR TRAUMATIC ARTHRITIS DOCUMENTED IN MULTIPLE JOINTS OF THE SAME HAND, INCLUDING THUMB AND FINGERS?
YES

IF YES, INDICATE HAND:

RIGHT

LEFT

BOTH

OTHER. DESCRIBE:

HAND:

RIGHT

LEFT

BOTH

12B. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS OR RESULTS?
YES

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

12C. IF ANY TEST RESULTS ARE OTHER THAN NORMAL, INDICATE RELATIONSHIP OF ABNORMAL FINDINGS TO DIAGNOSED CONDITIONS:

SECTION XIII - 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.
13. 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

IF YES, DESCRIBE THE FUNCTIONAL IMPACT OF EACH CONDITION, PROVIDING ONE OR MORE EXAMPLES:

SECTION XIV - REMARKS
14. REMARKS, IF ANY:

SECTION XV - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
15A. PHYSICIAN'S SIGNATURE
15D. PHYSICIAN'S PHONE AND FAX NUMBER

15B. PHYSICIAN'S PRINTED NAME
15E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER

15C. DATE SIGNED
15F. 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-7, XXXX

Page 15

File Type	application/pdf
File Title	21-0960M-7
Subject	Hand and Finger Conditions Disability Benefits Questionnaire
File Modified	2017-01-03
File Created	2017-01-03