VA Form 21-0960M-7 Hand and Finger Conditions DBQ

OMB Approved No. 2900-XXXX
Respondent Burden: 30 minutes

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.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN HAVE A HAND CONDITION?
NO

YES

(If "Yes," complete Item 1C) (If "No," complete Item 1B)

1B. PROVIDE RATIONALE (e.g. veteran does not currently have any known hand condition)
1C. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO HAND CONDITIONS, UNDER RIGHT AND/OR LEFT HAND(S)
DIAGNOSIS #1 -

DATE OF DIAGNOSIS -

ICD CODE -

DIAGNOSIS #2 -

ICD CODE -

DIAGNOSIS #3 -

DATE OF DIAGNOSIS -

ICD CODE -

DATE OF DIAGNOSIS -

SIDE AFFECTED
Right

Left

Both

SIDE AFFECTED
Right

Left

Both

SIDE AFFECTED
Right

Left

Both

1D. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO HAND CONDITIONS, LIST USING ABOVE FORMAT:

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

2B. DOMINANT HAND
Left

Right

Ambidextrous

2C. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE AFFECTED JOINT?
YES
NO
If "Yes," document the veteran's description of the impact of flare-ups in his or her own words:

SECTION III - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS
3A. IS THERE LIMITATION OF MOTION FOR ANY FINGERS AND/OR THUMB?
YES
NO
If "No," skip to section 4
If "Yes," indicate digit(s) affected: (check all that apply)
Right:

None

Thumb

Index finger

Long finger

Ring finger

Little finger

Left:

None

Thumb

Index finger

Long finger

Ring finger

Little finger

3B. ABILITY TO OPPOSE THUMB: Is there a gap between the thumb pad and the fingers?
YES
NO
If "Yes," indicate distance of gap and side affected:
Less than 1 inch (2.5cm.)

Right

Left

1 to 2 inches (2.5 to 5.1 cm.)

Right

Left

Both
Both

More than 2 inches (5.1 cm.)

Right

Left

Both

3C. FINGER FLEXION: Is there a gap between any fingertips and the proximal transverse crease of the palm?
YES
NO
If "Yes," is the gap less than 1 inch (2.5 cm)?
YES
NO
If "Yes," indicate finger(s) affected (check all that apply):
Right:

Index finger

Long finger

Ring finger

Little finger

Left:

Index finger

Long finger

Ring finger

Little finger

If "Yes," is the gap less than 1 inch (2.5 cm) or more?
YES

NO

If "Yes," indicate finger(s) affected (check all that apply):

VA FORM
JAN 2011

Right:

Index finger

Long finger

Ring finger

Little finger

Left:

Index finger

Long finger

Ring finger

Little finger

21-0960M-7

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SECTION III - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS (Continued)
3D. FINGER EXTENSION: Is there limitation of extension for the index finger and/or long finger?
YES
NO
If "Yes," is extension limited by no more than 30 degrees (unable to extend finger fully, extension limited to between 0 and 30 degrees of flexion)?
YES

NO

If "Yes," indicate finger(s) affected (check all that apply):
Right:

Index finger

Long finger

Left:

Index finger

Long finger

If "Yes," is extension limited by more than 30 degrees (unable to extend finger fully, extension limited to 31 degrees or more of flexion)?
YES
NO
If "Yes," indicate finger(s) affected (check all that apply):
Right:

Index finger

Long finger

Left:

Index finger

Long finger

3E. 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
NOTE - For VA purposes, repetitive-use testing must also be performed. The VA has determined that 3 repetitions, at minimum, can serve as a representative test for the effect of repetitive
use. Following initial ROM assessment, the clinician must perform repetitive-use testing.
4A. IS VETERAN ABLE TO PERFORM REPETITIVE-USE TESTING WITH 3 REPETITIONS?
YES

NO

If "No," provide reason:
If "No," skip to section 5)
If veteran is able to perform repetitive-use testing, assess ROM after a minimum of 3 repetitions and report the the post-test results in 4B through 4E.
4B. IS THERE ADDITIONAL LIMITATION OF MOTION FOR ANY FINGERS POST-TEST?
YES
NO
If "Yes," indicate digit(s) affected (check all that apply):
Right:

Thumb

Index finger

Long finger

Ring finger

Little finger

Left:

Thumb

Index finger

Long finger

Ring finger

Little finger

4C. IS THERE A GAP BETWEEN THE THUMB PAD AND THE FINGERS (ability to oppose thumb) POST-TEST?
YES
NO
If "Yes," indicate distance of gap and side affected)
Less than 1 inch (2.5cm.)

Right

Left

Both

1 to 2 inches (2.5 to 5.1 cm.)

Right

Left

Both

More than 2 inches (5.1 cm.)

Right

Left

Both

4D. IS THERE A GAP BETWEEN ANY FINGERTIPS AND THE PROXIMAL TRANSVERSE CREASE OF THE PALM (assessment of limitation of finger flexion) POST-TEST?
YES
NO
If "Yes," is the gap less than 1 inch (2.5 cm)?
YES

NO

If "Yes," indicate finger(s) affected (check all that apply):
Right:

Index finger

Long finger

Ring finger

Little finger

Left:

Index finger

Long finger

Ring finger

Little finger

If "Yes," is the gap 1 inch (2.5 cm) or more?
YES

NO

If "Yes," indicate finger(s) affected (check all that apply):
Right:

Index finger

Long finger

Ring finger

Little finger

Left:

Index finger

Long finger

Ring finger

Little finger

4E. IS THERE ADDITIONAL LIMITATION OF EXTENSION FOR THE INDEX FINGER OR LONG FINGER POST-TEST?
YES
NO
If "Yes," is extension limited by no more than 30 degrees? (unable to extend finger fully; extension limited to between 5 and 30 degrees of flexion)
YES

NO

If "Yes," indicate finger(s) affected (check all that apply):
Right:

Index finger

Long finger

Left:

Index finger

Long finger

If "Yes," is extension limited by more than 30 degrees? (unable to extend finger fully; extension limited to 35 degrees or more of flexion)
YES

NO

If "Yes," indicate finger(s) affected (check all that apply):
Right:

Index finger

Long finger

Left:

Index finger

Long finger

VA FORM JAN 2011, 21-0960M-7

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SECTION V - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION OF ROM
5A. DOES THE VETERAN HAVE ANY FUNCTIONAL LOSS AND/OR FUNCTIONAL IMPAIRMENT OF ANY OF THE FINGERS AND/OR THUMB?
YES

NO

5B. DOES THE VETERAN HAVE ADDITIONAL LIMITATION IN ROM OF ANY OF THE FINGERS AND/OR THUMB FOLLOWING REPETITIVE-USE TESTING?
YES

NO

5C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT AND/OR ADDITIONAL LIMITATION OF ROM OF ANY OF THE FINGERS AND/OR
THUMB AFTER REPETITIVE USE, INDICATE THE CONTRIBUTING FACTORS OF DISABILITY BELOW
CHECK ALL THAT APPLY AND INDICATE DIGIT AND SIDE AFFECTED:
No functional loss for right hand, thumb or fingers
No functional loss for left hand, thumb or fingers
Less movement than normal
Right:
Thumb

Index finger

Long finger

Ring finger

Little finger

Left:

Index finger

Long finger

Ring finger

Little finger

Thumb

More movement than normal
Right:

Thumb

Index finger

Long finger

Ring finger

Little finger

Left:

Thumb

Index finger

Long finger

Ring finger

Little finger

Weakened movement
Right:

Thumb

Index finger

Long finger

Ring finger

Little finger

Left:

Thumb

Index finger

Long finger

Ring finger

Little finger

Excess fatigability
Right:

Thumb

Index finger

Long finger

Ring finger

Little finger

Left:

Thumb

Index finger

Long finger

Ring finger

Little finger

Incoordination, impaired ability to execute skilled movements smoothly
Right:

Thumb

Index finger

Long finger

Ring finger

Little finger

Left:

Thumb

Index finger

Long finger

Ring finger

Little finger

Pain on movement
Right:

Thumb

Index finger

Long finger

Ring finger

Little finger

Left:

Thumb

Index finger

Long finger

Ring finger

Little finger

Right:

Thumb

Index finger

Long finger

Ring finger

Little finger

Left:

Thumb

Index finger

Long finger

Ring finger

Little finger

Right:

Thumb

Index finger

Long finger

Ring finger

Little finger

Left:

Thumb

Index finger

Long finger

Ring finger

Little finger

Swelling

Deformity

Atrophy of disuse
Right:

Thumb

Index finger

Long finger

Ring finger

Little finger

Left:

Thumb

Index finger

Long finger

Ring finger

Little finger

SECTION VI - PAINFUL MOTION AND TENDERNESS

6A. IS THERE OBJECTIVE EVIDENCE OF PAINFUL MOTION FOR EITHER HAND, INCLUDING THUMB AND FINGER MOVEMENT (evidenced by visible behavior, such
as facial expression, wincing, etc.)?
NO
YES
Right
Left
Both
(If "Yes," hand affected):
6B.DOES THE VETERAN HAVE LOCALIZED TENDERNESS OR PAIN TO PALPATION FOR JOINTS/SOFT TISSUE OF EITHER HAND, INCLUDING THUMB AND
NO

FINGERS?
YES

(If "Yes," hand affected):

Right

Left

Both
SECTION VII - ANKYLOSIS

7A. DOES THE VETERAN HAVE ANKYLOSIS OF THE THUMB AND/OR FINGERS?
YES
NO
(If "Yes," check all that apply)
Right thumb
Carpometacarpal joint ankylosis:
Interphalangeal joint ankylosis:

In extension
In extension

In full flexion
In full flexion

In rotation or angulation
In rotation or angulation

Left thumb

Right:

Left:

Carpometacarpal joint ankylosis:

In extension

In full flexion

In rotation or angulation

Interphalangeal joint ankylosis:

In extension

In full flexion

In rotation or angulation

Index finger
Long finger
Metacarpophalangeal joint ankylosis:
Proximal interphalangeal joint ankylosis:

Ring finger

Little finger

In extension
In extension

In full flexion
In full flexion

Index finger
Long finger
Metacarpophalangeal joint ankylosis:
Proximal interphalangeal joint ankylosis:

Ring finger

Little finger

In extension
In extension

In full flexion
In full flexion

In rotation or angulation
In rotation or angulation
In rotation or angulation
In rotation or angulation

7B. IF THERE IS ANKYLOSIS OF MORE THAN ONE FINGER, PROVIDE DETAILS USING ABOVE DESCRIPTIONS:
7C. DOES THE ANKYLOSIS CONDITION RESULT IN LIMITATION OF MOTION OF OTHER DIGITS OR INTERFERENCE WITH OVERALL FUNCTION OF THE HAND?
YES

NO

VA FORM JAN 2011, 21-0960M-7

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

NO

(If "Yes," describe):

SECTION IX - ASSISTIVE DEVICES AND REMAINING FUNCTION OF THE EXTREMITIES
9A. DOES THE VETERAN USE ANY ASSISTIVE DEVICES?
YES
NO
(If "Yes," identify assistive device(s) used (check all that apply and indicate frequency):
Occasional
Regular
BRACE(S)
Frequency of use:
OTHER:

Frequency of use:

Occasional

Regular

Constant
Constant

(If "Yes," identify and describe each condition(s) causing the need for assistive device(s):

9B. DUE TO THE SERVICE-CONNECTED DISABLING CONDITION(S), 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 including grasping, manipulation, etc., while functions for 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
Right upper
Left upper

Left lower

SECTION X - 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.
10A. HAVE IMAGING STUDIES OF THE HAND(S) BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

(If "Yes," is arthritis documented in multiple joints of the same hand, including thumb and fingers?)
YES
NO
(If "Yes," indicate hand)
Right

Left

Both

10B. 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 XI - FUNCTIONAL IMPACT AND REMARKS
11. DOES THE VETERAN'S HAND, THUMB AND/OR FINGER CONDITION IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe the impact of each of the veteran's hand, thumb and/or finger conditions, providing one or more examples):

12. 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.
13A. PHYSICIAN'S SIGNATURE
13D. PHYSICIAN'S PHONE NUMBER

13B. PHYSICIAN'S PRINTED NAME
13E. PHYSICIAN'S MEDICAL LICENSE NUMBER

13C. DATE SIGNED
13F. 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.
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VA FORM JAN 2011, 21-0960M-7

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