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Respondent Burden: 30 minutes
KNEE AND LOWER LEG 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 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 NOW HAVE OR HAS HE/SHE EVER HAD A KNEE AND/OR LOWER LEG CONDITION?
YES
NO
(If "Yes," complete Item 1B)
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO KNEE AND/OR LOWER LEG CONDITIONS:
DIAGNOSIS # 1 -
ICD CODE -
DATE OF DIAGNOSIS -
SIDE AFFECTED
DIAGNOSIS # 2 -
ICD CODE -
DATE OF DIAGNOSIS -
SIDE AFFECTED
DIAGNOSIS # 3 -
ICD CODE -
DATE OF DIAGNOSIS -
SIDE AFFECTED
RIGHT
RIGHT
RIGHT
LEFT
BOTH
LEFT
BOTH
LEFT
BOTH
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO KNEE AND/OR LOWER LEG CONDITIONS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
2. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S KNEE AND/OR LOWER LEG CONDITION(S) (Brief summary)
SECTION III - FLARE-UPS
3. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE KNEE AND/OR LOWER LEG CONDITION(S)?
YES
NO
(If "Yes," document the veteran's description of the impact of flare-ups in his or her own words):
SECTION IV - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS
MEASURE ROM WITH A GONIOMETER, ROUNDING EACH MEASUREMENT TO THE NEAREST 5 DEGREES. DURING THE MEASUREMENTS, DOCUMENT THE
POINT AT WHICH PAINFUL MOTION BEGINS, EVIDENCED BY VISABLE BEHAVIOR SUCH AS FACIAL EXPRESSION, WINCING, ETC. REPORT POST-TEST
MEASUREMENTS IN SECTION 5.
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 SECTION 5.
4A. RIGHT KNEE FLEXION
SELECT WHERE FLEXION ENDS (normal endpoint is 140 degrees):
0
5
10
15
20
25
75
80
85
90
95
100
30
35
105
40
110
45
115
50
120
55
60
125
65
130
70
135
140 or greater
SELECT WHERE OBJECTIVE EVIDENCE OF PAINFUL MOTION BEGINS:
No objective evidence of painful motion
0
5
10
15
20
25
75
80
85
90
95
100
30
105
35
40
110
45
115
50
120
55
125
60
65
130
70
135
140 or greater
4B. RIGHT KNEE EXTENSION
Select where extension ends:
0 or any degree of hyperextension (check this box if there is no limitation of extension)
Unable to fully extend; extension ends at:
5
VA FORM
JAN 2011
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15
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21-0960M-9
25
30
35
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45 or greater
Page 1
SECTION IV - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS (Continued)
4B. RIGHT KNEE EXTENSION (Continued)
Select where objective evidence of painful motion begins:
No objective evidence of painful motion
0 or any degree of hyperextension (check this box if there is no limitation of extension)
Unable to fully extend; extension ends at:
5
10
15
20
25
30
35
40
45 or greater
4C. LEFT KNEE FLEXION
SELECT WHERE FLEXION ENDS (normal endpoint is 140 degrees):
0
5
10
15
20
25
75
80
85
90
95
100
30
35
105
40
45
110
50
115
55
120
60
125
65
70
130
135
140 or greater
SELECT WHERE OBJECTIVE EVIDENCE OF PAINFUL MOTION BEGINS:
No objective evidence of painful motion
0
5
10
15
20
25
75
80
85
90
95
100
30
35
105
40
45
110
50
115
55
120
60
125
65
70
130
135
140 or greater
4D. LEFT KNEE EXTENSION
Select where extension ends:
0 or any degree of hyperextension (check this box if there is no limitation of extension)
Unable to fully extend; extension ends at:
5
10
15
20
25
30
35
40
45 or greater
Select where objective evidence of painful motion begins:
No objective evidence of painful motion
0 or any degree of hyperextension (check this box if there is no limitation of extension)
Unable to fully extend; extension ends at:
5
10
15
20
25
30
35
40
45 or greater
4E. If ROM does not conform to the normal range of motion identified above but is normal for this Veteran (for reasons other than a knee and/or leg condition, such as
age, body habitus, neurologic disease), explain:
SECTION V - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING
5A. 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 6)
(If Veteran is able to perform repetitive-use testing, measure and report ROM after a minimum of 3 repetitions):
5B. RIGHT KNEE POST-TEST ROM
Select where post-test flexion ends:
0
5
10
15
20
75
80
85
90
95
25
30
100
35
105
40
110
45
115
50
55
120
60
125
65
130
70
135
140 or greater
Select where post-test extension ends:
0 or any degree of hyperextension (check this box if there is no limitation of extension)
Unable to fully extend; extension ends at:
5
10
15
20
25
30
35
25
30
40
45 or greater
5C. LEFT KNEE POST-TEST ROM
Select where post-test flexion ends:
0
5
10
15
20
75
80
85
90
95
100
35
105
40
110
45
115
50
120
55
60
125
65
130
70
135
140 or greater
Select where post-test extension ends:
0 or any degree of hyperextension (check this box if there is no limitation of extension)
Unable to fully extend; extension ends at:
5
10
15
20
VA FORM 21-0960M-9, JAN 2011
25
30
35
40
45 or greater
Page 2
SECTION VI - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION IN ROM
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.
6A. DOES THE VETERAN HAVE ADDITIONAL LIMITATION IN ROM OF THE KNEE AND LOWER LEG FOLLOWING REPETITIVE-USE TESTING?
YES
NO
6B. DOES THE VETERAN HAVE ANY FUNCTIONAL LOSS AND/OR FUNCTIONAL IMPAIRMENT OF THE KNEE AND LOWER LEG?
YES
NO
6C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT OR ADDITIONAL LIMITATION OF ROM OF THE KNEE AND LOWER LEG AFTER
REPETITIVE USE, INDICATE THE CONTRIBUTING FACTORS OF DISABILITYBELOW (check all that apply and indicate side affected):
NO FUNCTIONAL LOSS FOR RIGHT LOWER EXTREMITY
NO FUNCTIONAL LOSS FOR LEFT LOWER EXTREMITY
LESS MOVEMENT THAN NORMAL
Right
Left
Both
MORE MOVEMENT THAN NORMAL
Right
Left
Both
WEAKENED MOVEMENT
Right
Left
Both
EXCESS FATIGABILITY
Right
Left
Both
INCOORDINATION, IMPAIRED ABILITY
TO EXECUTE SKILLED MOVEMENTS
SMOOTHLY
Right
Left
Both
PAIN ON MOVEMENT
Right
Left
Both
SWELLING
Right
Left
Both
DEFORMITY
Right
Left
Both
ATROPHY OF DISUSE
Right
Left
Both
INSTABILITY OF STATION
Right
Left
Both
DISTURBANCE OF LOCOMOTION
Right
Left
Both
INTERFERENCE WITH SITTING,
STANDING AND OR WEIGHT-BEARING
OTHER, DESCRIBE:
Right
Left
Both
SECTION VII - PAIN (PAIN ON PALPATION)
7. DOES THE VETERAN HAVE TENDERNESS OR PAIN TO PALPATION FOR JOINT LINE OR SOFT TISSUES OF EITHER KNEE?
YES
NO
(If "Yes," indicate side affected):
Right
Left
Both
SECTION VIII - PAINFUL MOTION, TENDERNESS AND STRENGTH TESTING
8. STRENGTH TESTING - 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
Knee flexion:
Knee extension:
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
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
SECTION IX - JOINT STABILITY TESTS
9A. ANTERIOR INSTABILITY (Lachman test):
Unable to test:
Right
Left
Both
Right:
Normal
1+(0-5 millimeters)
2+(5-10 millimeters)
3+(10-15 millimeters)
Left:
Normal
1+(0-5 millimeters)
2+(5-10 millimeters)
3+(10-15 millimeters)
9B. POSTERIOR INSTABILITY (Posterior drawer test):
Unable to test:
Right
Left
Both
Right:
Normal
1+(0-5 millimeters)
2+(5-10 millimeters)
3+(10-15 millimeters)
Left:
Normal
1+(0-5 millimeters)
2+(5-10 millimeters)
3+(10-15 millimeters)
9C. MEDIAL-LATERAL INSTABILITY (Apply valgus/varus pressure to knee in extension and 30 degrees of flexion):
Unable to test:
Right
Left
Both
Right:
Normal
1+(0-5 millimeters)
2+(5-10 millimeters)
3+(10-15 millimeters)
Left:
Normal
1+(0-5 millimeters)
2+(5-10 millimeters)
3+(10-15 millimeters)
VA FORM 21-0960M-9, JAN 2011
Page 3
SECTION X - PATELLAR SUBLUXATION/DISLOCATION
10. IS THERE EVIDENCE OR HISTORY OF RECURRENT PATELLAR SUBLUXATION/DISLOCATION?
YES
NO
(If "Yes," indicate severity and side affected):
Right:
None
Slight
Moderate
Severe
Left:
None
Slight
Moderate
Severe
SECTION XI - ADDITIONAL CONDITIONS
11. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER HAD "SHIN SPLINTS" (medial tibial stress syndrome), STRESS FRACTURES, CHRONIC
EXERTIONAL COMPARTMENT SYNDROME OR ANY OTHER TIBIAL AND/OR FIBULAR IMPAIRMENT?
YES
NO
(If "Yes," indicate condition and complete the appropriate sections below):
A. "SHIN SPLINTS" (medial tibial stress syndrome)
(If checked, indicate side affected):
Right
Left
Both
Left
Both
Describe current symptoms:
B. STRESS FRACTURE OF THE LOWER EXTREMITY
(If checked, indicate side affected):
Right
Describe current symptoms:
C. CHRINIC EXERTIONAL COMPARTMENT SYNDROME
(If checked, indicate side affected):
Right
Left
Both
Describe current symptoms:
D. EVIDENCE OF ACQUIRED, TRAUMATIC GENU RECURVATUM WITH WEAKNESS AND INSECURITY IN WEIGHT-BEARING
(If checked, indicate side affected):
Right
Left
Both
E. LEG LENGTH DISCREPANCY (shortening of any bones of the lower extremity)
(If checked, provide length of each lower extremity in inches (to the nearest 1/4 inch) or centimeters measuring from the anterior superior iliac spine
to the internal malleolus of the tibia.
Measurements: Right leg:
cm
inches
Left leg:
cm
inches
SECTION XII - MENISCAL CONDITIONS AND MENISCAL SURGERY
12. HAS THE VETERAN HAD ANY MENISCAL CONDITIONS OR SURGICAL PROCEDURES FOR A MENISCAL CONDITION?
YES
NO
(If "Yes," complete the following section):
A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER HAD A MENISCUS (semilunar cartilage) CONDITION?
YES
NO
(If "Yes," indicate severity and frequency of symptoms, and side affected):
No symptoms
Right
Left
Both
Meniscal dislocation
Right
Left
Both
Meniscal tear
Right
Left
Both
Frequent episodes of joint "locking"
Right
Left
Both
Frequent episodes of joint pain
Right
Left
Both
Frequent episodes of joint effusion
Right
Left
Both
B. HAS THE VETERAN HAD A MENISCECTOMY?
YES
NO
(If "Yes," indicate side affected):
Right
Left
Both
Date of surgery:
C. DOES THE VETERAN HAVE ANY RESIDUAL SIGNS AND/OR SYMPTOMS DUE TO A MENISCECTOMY?
YES
NO (If "Yes," indicate side affected):
(If "Yes," describe residuals):
Right
Left
Both
SECTION XIII - JOINT REPLACEMENT AND OTHER SURGICAL PROCEDURES
13A. HAS THE VETERAN HAD A TOTAL KNEE JOINT REPLACEMENT?
YES
NO
(If "Yes," indicate side and severity of residuals)
Right knee
Date of surgery:
Residuals:
None
Intermediate degrees of residual weakness, pain and/or limitation of motion
Chronic residuals consisting of severe painful motion and/or weakness
Other, describe:
VA FORM 21-0960M-9, JAN 2011
Page 4
SECTION XIII - JOINT REPLACEMENT AND OTHER SURGICAL PROCEDURES (Continued)
13A. HAS THE VETERAN HAD A TOTAL KNEE JOINT REPLACEMENT? (Continued)
Left knee
Date of surgery:
Residuals:
None
Intermediate degrees of residual weakness, pain and/or limitation of motion
Chronic residuals consisting of severe painful motion and/or weakness
Other, describe:
13B. HAS THE VETERAN HAD ARTHROSCOPIC OR OTHER KNEE SURGERY NOT DESCRIBED ABOVE?
YES
NO
(If "Yes," indicate side affected)
Right
Left
Both
Date and type of surgery:
13C. DOES THE VETERAN HAVE ANY RESIDUAL SIGNS AND/OR SYMPTOMS DUE TO ARTHROSCOPIC OR OTHER KNEE SURGERY NOT DESCRIBED ABOVE?
YES
NO
(If "Yes," indicate side affected):
Right
Left
Both
(If "Yes," describe symptoms):
SECTION XIV - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
14A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
SECTION I, DIAGNOSIS?
YES
NO
If "Yes," are any of the scars painful and/or unstable, or is the total area of all related scars greater than 9 square cm (6 square inches)?
YES
NO
(If "Yes," also complete VA Form 21-0960F-1, Scars/Disfigurement Questionnaire)
14B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN SECTION I, DIAGNOSIS?
YES
NO
If "Yes," describe (brief summary):
SECTION XV - ASSISTIVE DEVICES
15A. 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
Other:
Frequency of use:
Occasional
Regular
Constant
15B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:
VA FORM 21-0960M-9, JAN 2011
Page 5
SECTION XVI - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
16. DUE TO THE VETERANS KNEE AND/OR LOWER LEG 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 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 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 XVII - DIAGNOSTIC TESTING
NOTE: THE DIAGNOSIS OF DEGENERATIVE ARTHRITIS (osteoarthritis) OR TRAMATIC ARTHRITIS MUST BE CONFIRMED BY IMAGING STUDIES. ONCE SUCH
ARTHRITIS HAS BEEN DOCUMENTED, NO FURTHER IMAGING STUDIES ARE REQUIRED BY VA, EVEN IF ARTHRITIS HAS WORSENED.
17A. HAVE IMAGING STUDIES OF THE KNEE BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES
NO
(If "Yes," is degenerative or traumatic arthritis documented?)
YES
NO
(If "Yes," indicate knee)
Right
Left
Both
17B. DOES THE VETERAN HAVE X-RAY EVIDENCE OF PATELLAR SUBLUXATION?
YES
NO
(If "Yes," indicate affected side(s):
Right
Left
Both
17C. 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 XVIII - FUNCTIONAL IMPACT
18. DOES THE VETERAN'S KNEE AND/OR LOWER LEG CONDITION(S) IMPACT HIS OR HER ABILITY TO WORK?
YES
NO
(If "Yes," describe the impact of each of the veteran's knee and/or lower leg conditions providing one or more examples):
VA FORM 21-0960M-9, JAN 2011
Page 6
SECTION XIX - REMARKS
19. REMARKS (If any)
SECTION XX - PHYSICIAN'S CERTIFICATION AND SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
20A. PHYSICIAN'S SIGNATURE
20B. PHYSICIAN'S PRINTED NAME
20D. PHYSICIAN'S PHONE AND FAX NUMBER
20E. PHYSICIAN'S MEDICAL LICENSE NUMBER
20C. DATE SIGNED
20F. 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-9, JAN 2011
Page 7
| File Type | application/pdf |
| File Title | VA Form 21-0960M-9 |
| Subject | Knee and Lower Leg Conditions - Disability Benefits Questionnaire |
| Author | N. Kessinger |
| File Modified | 2011-12-29 |
| File Created | 2011-02-14 |