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

OMB Approved No. 2900-XXXX
Respondent Burden: 45 minutes

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 BEFORE COMPLETING THIS FORM.
NAME OF PATIENT/VETERAN

PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

NOTE TO PHYSICIAN - The veteran has applied to the Department of Veterans Affairs (VA) for disability benefits. Please complete this questionnaire,
which VA needs for review of the veteran's application.
SECTION I - DIAGNOSIS

1A. DOES THE VETERAN HAVE A THORACOLUMBAR SPINE (back) CONDITION?
YES

(If "No," complete Item 1B)

NO

(If "Yes," complete Item 1C)

1B. PROVIDE RATIONALE (e.g., veteran does not currently have any known thoracolumbar spine (back) condition(s))

1C. PROVIDE DIAGNOSES THAT PERTAIN TO THORACOLUMBAR SPINE (back) CONDITION(S)
DIAGNOSIS # 1 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 2 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 3 -

ICD CODE -

DATE OF DIAGNOSIS -

1D. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO THORACOLUMBAR SPINE (back) CONDITIONS, LIST USING ABOVE FORMAT

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

(If "Yes," document the veteran's description of the impact of flare-ups in his or her own words)

NO

SECTION III - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS
3. MEASURE ROM WITH A GONIOMETER, ROUNDING EACH MEASUREMENT TO THE NEAREST 5 DEGREES. REPORT INITIAL MEASUREMENTS BELOW.
NOTE: Following the initial assessment of ROM, perform repetitive use testing. For VA purposes, repetitive use testing must be included in all exams. The VA has
determined that 3 repetitions of ROM 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 Section IV.
A. CHECK BOX AT WHICH FORWARD FLEXION ENDS (normal endpoint is 90)
0

5

10

15

20

25

30

35

40

50

55

60

65

70

75

80

85

90 or greater

45

B. CHECK BOX AT WHICH EXTENSION ENDS (normal endpoint is 30)
0

5

10

15

20

25

30 or greater

C. CHECK BOX AT WHICH RIGHT LATERAL FLEXION ENDS (normal endpoint is 30)
0

5

10

15

20

25

30 or greater

D. CHECK BOX AT WHICH LEFT LATERAL FLEXION ENDS (normal endpoint is 30)
0

5

10

15

20

25

30 or greater

E. CHECK BOX AT WHICH RIGHT LATERAL ROTATION ENDS (normal endpoint is 30)
0

5

10

15

20

25

30 or greater

F. CHECK BOX AT WHICH LEFT LATERAL ROTATION ENDS (normal endpoint is 30)
0

5

10

15

20

25

30 or greater

G. If ROM for this veteran 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:

VA FORM
DEC 2010

21-0960M-14

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SECTION IV - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING
4A. IS VETERAN ABLE TO PERFORM REPETITIVE-USE TESTING WITH 3 REPETITIONS?
YES

NO

(If unable, provide reason):

(If veteran is unable to perform repetitive-use testing, skip to Section V)
(If veteran is able to perform repetitive-use testing, measure and report ROM after a minimum of 3 repetitions)
B. CHECK BOX AT WHICH POST-TEST FORWARD FLEXION ENDS
0

5

10

15

20

25

30

35

40

50

55

60

65

70

75

80

85

90 or greater

C. CHECK BOX AT WHICH POST-TEST EXTENSION ENDS
15
5
10
25
0
20

30 or greater

D. CHECK BOX AT WHICH POST-TEST RIGHT LATERAL FLEXION ENDS
15
5
10
25
30 or greater
0
20
E. CHECK BOX AT WHICH POST-TEST LEFT LATERAL FLEXION ENDS:
5
10
15
25
30 or greater
0
20
F. CHECK BOX AT WHICH POST- TEST RIGHT LATERAL ROTATION ENDS:
15
5
10
25
30 or greater
0
20
G. CHECK BOX AT WHICH POST-TEST LEFT LATERAL ROTATION ENDS:
5
10
15
25
30 or greater
0
20

SECTION V - FUNCTIONAL LOSS

NOTE: The following section addresses reasons for functional loss, if present, and additional loss of ROM after repetitive-use testing, if present. 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.
5A. DOES THE VETERAN HAVE ADDITIONAL LIMITATION IN ROM OF THE THORACOLUMBAR SPINE (back) FOLLOWING REPETITIVE-USE TESTING?
YES
NO
5B. DOES THE VETERAN HAVE ANY FUNCTIONAL LOSS AND/OR FUNCTIONAL IMPAIRMENT OF THE THORACOLUMBAR SPINE (back)?
YES
NO
5C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT AND/OR ADDITIONAL LIMITATION OF ROM OF THE THORACOLUMBAR SPINE (back)
AFTER REPETITIVE USE, INDICATE THE CONTRIBUTING FACTORS OF DISABILITY BELOW (Check all that apply)

No.

ITEM

1

Less movement than normal

2

More movement than normal

3

Weakened movement

4

Excess fatigability

5

Incoordination, impaired ability to execute skilled movements smoothly

6

Pain on movement

7

Swelling

8

Deformity

9

Atrophy of disuse

YES

NO

10 Instability of station
11 Disturbance of locomotion
12 Interference with sitting, standing and/or weight-bearing
SECTION VI - PAIN (PAINFUL MOTION, PAIN ON PALPATION, MUSCLE SPASM, GAIT)

6A. IS THERE OBJECTIVE EVIDENCE OF PAINFUL MOTION FOR THE THORACOLUMBAR SPINE (back)?
YES

NO

6B. DOES THE VETERAN HAVE LOCALIZED TENDERNESS OR PAIN TO PALPATION FOR JOINTS/SOFT TISSUE OF THE THORACOLUMBAR SPINE (back)?
YES

NO

6C. DOES THE VETERAN HAVE GUARDING OR MUSCLE SPASM OF THE THORACOLUMBAR SPINE (back)?
YES
NO (If "Yes," is it severe enough to result in): (Check all that apply)
Abnormal gait
Abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis
Guarding or muscle spasm do not result in abnormal gait or spinal contour
VA FORM DEC 2010, 21-0960M-14

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SECTION VII - RADICULOPATHY HISTORY AND NEUROLOGIC EXAM
7A. DOES THE VETERAN NOW HAVE OR HAS THE VETERAN HAD RADICULOPATHY?
YES

NO

(If "No," skip to Section VIII)

7B. DOES THE VETERAN CURRENTLY HAVE RADICULAR PAIN OR ANY OTHER SIGNS AND/OR SYMPTOMS DUE TO RADICULOPATHY?
YES

NO

(If "Yes," indicate symptoms, location, and degree of severity): (Check all that apply)

CONSTANT PAIN (may be excruciating at times)
Right lower extremity:

None

Mild

Moderate

Severe

Left lower extremity:

None

Mild

Moderate

Severe

Intermittent PAIN (usually dull)
Right lower extremity:

None

Mild

Moderate

Severe

Left lower extremity:

None

Mild

Moderate

Severe

PARESTHESIAS AND/OR DYSESTHESIAS
Right lower extremity:

None

Mild

Moderate

Severe

Left lower extremity:

None

Mild

Moderate

Severe

Right lower extremity:

None

Mild

Moderate

Severe

Left lower extremity:

None

Mild

Moderate

Severe

NUMBNESS

7C. ARE THERE ANY OTHER SIGNS OR SYMPTOMS OF RADICULOPATHY?
NO (If "Yes," describe):
YES

7D. STRENGTH EXAM - RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE:

0/5 No muscle movement
1/5 Visible muscle movement, but no joint movement
2/5 No movement against gravity
3/5 No movement against resistance
4/5 Less than normal strength
5/5 Normal strength
HIP FLEXION (L2)
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

KNEE EXTENSION (L3):
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

ANKLE PLANTAR FLEXION (S1):
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

ANKLE DORSIFLEXION (L4):
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

GREAT TOE EXTENSION (L5):
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

7E. REFLEX EXAM - RATE DEEP TENDON REFLEXES (DTRs) ACCORDING TO THE FOLLOWING SCALE:

0 Absent
1+ Decreased
2+ Normal
3+ Increased without sustained clonus
4+ Increased with clonus
KNEE:
Right

0

1+

2+

3+

4+

Left

0

1+

2+

3+

4+

ANKLE:
Right

0

1+

2+

3+

4+

Left

0

1+

2+

3+

4+

VA FORM DEC 2010, 21-0960M-14

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SECTION VII - RADICULOPATHY HISTORY AND NEUROLOGIC EXAM (Continued)
7F. SENSORY EXAM - PROVIDE RESULTS FOR SENSATION TO LIGHT TOUCH (dermatomes) TESTING
Right
Left

Normal

Decreased

Absent

L3 (Lower anterior thigh)

Right

Normal

Decreased

Absent

Left

Normal

Decreased

Absent

Right

Normal

Decreased

Absent

Left

Normal

Decreased

Absent

L5 (Lateral leg and calf,
dorsum medial foot)

Right

Normal

Decreased

Absent

Left

Normal

Decreased

Absent

S1 (Posterior leg and calf,
dorsum lateral foot)

Right

Normal

Decreased

Absent

Left

Normal

Decreased

Absent

L4 (Anterior leg, medial calf)

Normal

Decreased

Other sensory findings, if any:

Absent

L2 (Upper anterior thigh)

7G. STRAIGHT LEG RAISING TESTING - 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 in the back or hamstrings. Pain is often increased on dorsiflexion of the foot, and relieved by
knee flexion. A positive test suggests radiculopathy, often due to disc herniation.
Right

Negative

Positive

Unable to perform

Left

Negative

Positive

Unable to perform

7H. DOES THE VETERAN HAVE MUSCLE ATROPHY?
(If muscle atrophy is present, indicate location:
YES
NO
and provide difference measured in cm between normal and atrophied side, measured at maximum muscle bulk:

cm

7I. IF THE VETERAN HAS RADICULOPATHY, INDICATE NERVE ROOTS INVOLVED: (Check all that apply)
INVOLVEMENT OF L2/L3/L4 NERVE ROOTS (femoral nerve, if checked, indicate:
INVOLVEMENT OF L4/L5/S1/S2/S3 NERVE ROOTS (sciatic nerve, if checked, indicate:

Right

Left

Right

Both)
Left

Both)

OTHER NERVES (specify nerve and side(s) affected:
7J. IF THE VETERAN HAS RADICULOPATHY, INDICATE SEVERITY AND SIDE AFFECTED:
(NOTE: For VA purposes, when the involvement is wholly sensory, the evaluation should be for the mild, or at most, the moderate degree)
Mild
Moderate
Severe
Not affected
Right
Not affected

Left

Moderate

Mild

Severe

SECTION VIII - OTHER NEUROLOGIC ABNORMALITIES

8. DOES THE VETERAN HAVE ANY OTHER NEUROLOGIC ABNORMALITIES OR FINDINGS RELATED TO A THORACOLUMBAR SPINE (back) CONDITION (such as
bowel or bladder problems/pathologic reflexes)?
(If "Yes," describe condition and how it is related:
YES
NO Also if there are neurological abnormalities other than radiculopathy, also complete the appropriate questionnaire for each condition identified)

SECTION IX - INTERVERTEBRAL DISC SYNDROME (IVDS) AND INCAPACITATING EPISODES
9. DOES THE VETERAN HAVE IVDS OF THE THORACOLUMBAR SPINE?
YES

NO

(If "Yes," has the IVDS caused any incapacitating episodes over the past 12 months?)

Note: For VA purposes, an incapacitating episode is a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician
NO (If "Yes," provide the total duration over the past 12 months)
YES
LESS THAN 1 WEEK
AT LEAST 1 WEEK BUT LESS THAN 2 WEEKS
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

SECTION X - ASSISTIVE DEVICES AND REMAINING FUNCTION OF THE EXTREMITIES
10A. DOES THE VETERAN USE ANY ASSISTIVE DEVICE(S) AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS
MAY BE POSSIBLE?
(If "Yes," identify assistive device(s) used (check all that apply and indicate frequency))
YES
NO
Wheelchair

Frequency of use:

Occasional

Regular

Constant

Brace(s)

Frequency of use:

Occasional

Regular

Constant

Crutch(es)

Frequency of use:

Occasional

Regular

Constant

Cane(s)

Frequency of use:

Occasional

Regular

Constant

Walker

Frequency of use:

Occasional

Regular

Constant

Other:
Frequency of use:
Constant
Occasional
Regular
10B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:
10C. DUE TO A 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.; functions of the lower extremity include balance and propulsion, etc.)

YES, FUNCTIONING IS SO DIMINISHED THAT AMPUTATION WITH PROSTHESIS WOULD EQUALLY SERVE THE VETERAN
NO

(If "Yes," indicate extremity(ies) (check all extremities for which this applies)
Right lower

VA FORM DEC 2010, 21-0960M-14

Left lower

Bilateral lower

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SECTION XI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
11. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS?
YES

(If "Yes," describe (brief summary))

NO

SECTION XII - DIAGNOSTIC TESTING
NOTE: The diagnosis of arthritis must be confirmed by imaging studies. Once arthritis has been documented, no further imaging studies are indicated,
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 diagnosis of IVDS and/or radiculopathy can be made by a history of characteristic radiating pain and/or sensory
changes in the arms, and objective clinical findings, which may include the asymmetrical loss or decrease of reflexes, decreased strength and/or
abnormal sensation.
12A. HAVE THE IMAGING STUDIES OF THE THORACOLUMBAR SPINE BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
NO

YES

(If "Yes," is arthritis documented?)
NO

YES

12B. DOES THE VETERAN HAVE A VERTEBRAL FRACTURE?
YES

NO

(If "Yes," provide percent of loss of vertebral body):
12C. 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)):
SECTION XIII - FUNCTIONAL IMPACT AND REMARKS
13. DOES THE VETERAN'S THORACOLUMBAR SPINE (back) CONDITION IMPACT HIS OR HER ABILITY TO WORK?
YES

NO (If "Yes," describe impact of the veteran's thoracolumbar spine (back) condition(s), providing one or more examples)

14. REMARKS (If any)

SECTION XIV - 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 NUMBER

15B. PHYSICIAN'S PRINTED NAME

15E. PHYSICIAN'S MEDICAL LICENSE NUMBER

15C. DATE SIGNED

15F. PHYSICIAN'S ADDRESS

NOTE - VA may obtain additional medical information, including an examination, 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.
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VA FORM DEC 2010, 21-0960M-14

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