VA Form 21-0960M-3 Arthritis Disability Benefits Questionnaire

OMB Approved No. 2900-XXXX
Respondent Burden: 15 minutes

ARTHRITIS 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.
NOTE: Complete this questionnaire if the veteran has an inflammatory, autoimmune, crystalline or infectious arthritis, or another inflammatory or autoimmune condition.
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 VA Form 21-0960M-9, Knee and Lower Leg Conditions Disability Benefits Questionnaire).
If the veteran has arthritis due to systemic lupus erythematosus (SLE), INSTEAD complete the VA Form 21-0960I-4, Systemic Lupus Erytematous (SLE) and Other
Immune System Disorders (except HIV) Disability Benefits Questionnaire.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN HAVE INFLAMMATORY, AUTOIMMUNE, CRYSTALLINE OR INFECTIOUS ARTHRITIS?
YES

NO

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

1B. PROVIDE RATIONALE (e.g. veteran does not currently have inflammatory, autoimmune, crystalline or infectious arthritis)

1C. INDICATE DIAGNOSIS:
GOUT

ICD CODE(S):

DATE OF DIAGNOSIS:

RHEUMATOID ARTHRITIS (atrophic)

ICD CODE(S):

DATE OF DIAGNOSIS:

GONORRHEAL ARTHRITIS

ICD CODE(S):

DATE OF DIAGNOSIS:

PNEUMOCOCCIC ARTHRITIS

ICD CODE(S):

DATE OF DIAGNOSIS:

TYPHOID ARTHRITIS

ICD CODE(S):

DATE OF DIAGNOSIS:

SYPHILITIC ARTHRITIS

ICD CODE(S):

DATE OF DIAGNOSIS:

STREPTOCOCCIC ARTHRITIS

ICD CODE(S):

DATE OF DIAGNOSIS:

DYSBARIC OSTEONECROSIS (Caisson Disease of Bone)

ICD CODE(S):

DATE OF DIAGNOSIS:

OTHER (If checked, complete Item 1D)
1D. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO INFLAMMATORY, AUTOIMMUNE, CRYSTALLINE OR INFECTIOUS ARTHRITIS.
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 INFLAMMATORY, AUTOIMMUNE, CRYSTALLINE OR INFECTIOUS ARTHRITIS, LIST USING ABOVE
FORMAT:

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

(brief summary):

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

NO

(If "Yes," list only those medications used for this arthritis):
2C. HAS THE VETERAN LOST WEIGHT DUE TO THIS ARTHRITIS CONDITION?
YES

NO

(If "Yes," does the Veteran's weight loss attributable to this arthritis condition cause severe impairment of health?)
YES

NO

(If "Yes," provide baseline weight (average weight for 2-year period preceding onset of disease):
VA FORM
FEB 2011

21-0960M-3

, and current weight:

.)
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SECTION II - MEDICAL HISTORY (Continued)
2D. DOES THE VETERAN HAVE ANEMIA DUE TO THIS ARTHRITIS CONDITION?
YES

NO

(If "Yes," does the Veteran's anemia attributable to this arthritis condition cause severe impairment of health?)
YES
NO (If "Yes," provide CBC under diagnostic Section 9).
SECTION III - JOINT INVOLVEMENT
3A. DOES THE VETERAN HAVE PAIN WITH JOINT MOVEMENT ATTRIBUTABLE TO THIS ARTHRITIS CONDITION?
YES

NO

(If "Yes," indicate affected joints (check all that apply)):
THORACOLUMBAR SPINE

CERVICAL SPINE
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). Also complete a Questionnaire for each affected joint, if indicated.)

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

NO

(If "Yes," indicate affected joints (check all that apply)):
THORACOLUMBAR SPINE

CERVICAL SPINE
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). Also complete a Questionnaire for each affected joint, if indicated.)

3C. DOES THE VETERAN HAVE ANY JOINT DEFORMITIES ATTRIBUTABLE TO THIS ARTHRITIS CONDITION?
YES

NO

(If "Yes," indicate affected joints (check all that apply)):
THORACOLUMBAR SPINE

CERVICAL SPINE
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). Also complete a Questionnaire for each affected joint, if indicated.)

SECTION IV - SYSTEMIC INVOLVEMENT OTHER THAN JOINTS
4. 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 Questionnaire if indicated.)

VA FORM 21-0960M-3, FEB 2011

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SECTION V - INCAPACITATING AND NON-INCAPACITATING EXACERBATION
5A. DUE TO THE ARTHRITIS CONDITION, DOES THE VETERAN HAVE EXACERBATIONS WHICH ARE NOT INCAPACITATING?
YES

NO

(If "Yes," indicate frequency of non-incapacitating exacerbations per year):
1

0

2

3

4 OR MORE

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

NO

(If "Yes," describe):
(Indicate frequency of incapacitating exacerbations per year):
0

1

2

3

4 OR MORE

Date of most recent incapacitating exacerbation:
Duration of most recent incapacitating exacerbation:
Describe incapacitation exacerbation:
5C. DUE TO THE ARTHRITIS CONDITION, DOES THE VETERAN HAVE CONSTITUTIONAL MANIFESTATIONS ASSOCIATED WITH ACTIVE JOINT INVOLVEMENT
WHICH ARE TOTALLY INCAPACITATING?
YES

NO

(If "Yes," has the Veteran been totally incapacitated due to this during the past 12 months?)
YES

NO

(If "Yes," indicate the total duration of incapacitation over the past 12 months):
LESS THAN 1 WEEK
1 WEEK TO LESS THAN 2 WEEKS
2 WEEKS TO LESS THAN 4 WEEKS
4 WEEKS TO LESS THAN 6 WEEKS
6 WEEKS OR MORE

(Describe constitutional manifestations and the manner in which those manifestations cause incapacitation):

SECTION VI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
6A. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS?
YES

NO

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

6B. 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," also complete a Scars Questionnaire.)
SECTION VII - ASSISTIVE DEVICES

7A. DOES THE VETERAN USE ANY ASSISTIVE DEVICE(S) AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS
MAY BE POSSIBLE?
YES

NO

(If "Yes," identify assistive device(s) used (check all that apply and indicate frequency)):
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

Frequency of use:

Occasional

Regular

Constant

Other:

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SECTION VII - ASSISTIVE DEVICES (Continued)
7B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION

SECTION VIII - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
8. DUE TO THE VETERAN'S INFLAMMATORY, AUTOIMMUNE, CRYSTALLINE OR INFECTIOUS ARTHRITIS, 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., 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) 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)):

SECTION IX - DIAGNOSTIC TESTING
NOTE - The diagnosis of arthritis must be confirmed by imaging studies. Once arthritis has been documented, no further imaging studies are required by VA, even if
arthritis has worsened.
9A. HAVE IMAGING STUDIES BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

(If "Yes," indicate type of study):
X-RAY

Area imaged:

Date:

Results:

Area imaged:

Date:

Results:

OTHER, SPECIFY:
9B. HAVE LABORATORY STUDIES BEEN PERFORMED? (Note: Once a diagnosis has been confirmed, laboratory studies are not indicated for a disability exam.)
YES

NO

(If "Yes," check all that apply):
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:

OTHER, SPECIFY:

Date of test:

Platelets:
Results:

9C. HAS THE VETERAN HAD A JOINT ASPIRATION/SYNOVIAL FLUID ANALYSIS? (Note: Once a diagnosis has been confirmed, testing is not indicated for a

disability exam.)
YES

NO

(If "Yes," indicate joint aspirated, date and results):
9D. HAS THE VETERAN HAD A BIOPSY (e.g., skin, nerve, fat, rectum, kidney)? (Note: Once a diagnosis has been confirmed, testing is not indicated for a disability exam.)
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)):

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SECTION X - FUNCTIONAL IMPACT
10. DOES THE VETERAN'S INFLAMMATORY, AUTOIMMUNE, CRYSTALLINE OR INFECTIOUS ARTHRITIS CONDITION IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe the impact of each of the veteran's arthritis conditions, 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 NUMBER

12B. PHYSICIAN'S PRINTED NAME

12E. PHYSICIAN'S MEDICAL LICENSE 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, FEB 2011

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