VA Form 21-0960M-1 Neck (Cervical Spine) Disability Benefits Questionnaire

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

NECK (CERVICAL SPINE) 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 CERVICAL SPINE (neck) CONDITION?
YES

NO

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

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

1C. PROVIDE DIAGNOSES THAT PERTAIN TO CERVICAL SPINE (neck) 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 CERVICAL SPINE (neck) CONDITIONS, LIST USING ABOVE FORMAT

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

2B. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE CERVICAL SPINE (neck)?
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
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 45 degrees)
0

5

10

15

20

25

30

35

40

45 or greater

35

40

45 or greater

B. CHECK BOX AT WHICH EXTENSION ENDS (normal endpoint is 45 degrees)
0

5

10

15

20

25

30

C. CHECK BOX AT WHICH RIGHT LATERAL FLEXION ENDS (normal endpoint is 45 degrees)
0

5

10

15

20

25

30

35

40

45 or greater

D. CHECK BOX AT WHICH LEFT LATERAL FLEXION ENDS (normal endpoint is 45 degrees)
0

5

10

15

20

25

30

35

40

45 or greater

E. CHECK BOX AT WHICH RIGHT LATERAL ROTATION ENDS (normal endpoint is 80 degrees)
0

5

50

10
55

15
60

20
65

25
70

30
75

35

40

45

80 or greater

F. CHECK BOX AT WHICH LEFT LATERAL ROTATION ENDS (normal endpoint is 80 degrees)
0

5

10

15

20

25

30

35

40

45

50
55
60
65
70
75
80 or greater
G. If ROM does not conform to the normal range of motion identified above but is normal for this veteran (for reasons other than a cervical spine (neck)
condition, such as age, body habitus, neurologic disease), explain:

VA FORM
DEC 2010

21-0960M-13

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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

20

15

25

30

35

40

45 or greater

C. CHECK BOX AT WHICH POST-TEST EXTENSION ENDS (normal endpoint is 45 degrees)
0

5

10

15

20

25

30

35

40

45 or greater

35

40

45 or greater

35

40

45 or greater

35

40

45

40

45

D. CHECK BOX AT WHICH POST-TEST RIGHT LATERAL FLEXION ENDS
0

5

10

15

20

25

30

E. CHECK BOX AT WHICH POST-TEST LEFT LATERAL FLEXION ENDS
0

5

10

15

20

25

30

F. CHECK BOX AT WHICH POST- TESTRIGHT LATERAL ROTATION ENDS
0

5

50

10
55

15
60

20
65

25
70

30
75

80 or greater

G. CHECK BOX AT WHICH POST-TEST LEFT LATERAL ROTATION ENDS
5

0
50

10
55

20

15
60

65

25
70

30
75

35
80 or greater

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 CERVICAL SPINE (neck) FOLLOWING REPETITIVE-USE TESTING?
YES

NO

5B. DOES THE VETERAN HAVE ANY FUNCTIONAL LOSS AND/OR FUNCTIONAL IMPAIRMENT OF THE CERVICAL SPINE (neck)?
YES

NO

5C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT AND/OR ADDITIONAL LIMITATION OF ROM OF THE CERVICAL SPINE (neck) AFTER
REPETITIVE USE, INDICATE THE CONTRIBUTING FACTORS OF DISABILITY BELOW.

No
1
2
3
4
5
6
7
8
9
10
11
12

ITEM

YES

NO

Less movement than normal
More movement than normal
Weakened movement
Excess fatigability
Incoordination, impaired ability to execute skilled movements smoothly
Pain on movement
Swelling
Deformity
Atrophy of disuse
Instability of station
Disturbance of locomotion
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 CERVICAL SPINE (neck)?
YES

NO

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

NO

6C. DOES THE VETERAN HAVE GUARDING OR MUSCLE SPASM OF THE CERVICAL SPINE (neck)?
YES

NO

(If "Yes," is it severe enough to result in): (Check all that apply)

Abnormal gait
Abnormal spinal contour
Guarding or muscle spasm do not result in abnormal gait or spinal contour

SECTION VII - INTERVERTEBRAL DISC SYNDROME (IVDS)
7A. DOES THE VETERAN HAVE IVDS OF THE CERVICAL SPINE?
YES
YES

(If "Yes," has 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):
NO

Less than 1 week
At least 1 week but 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
VA FORM 21-0960M-13, DEC 2010

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SECTION VIII - RADICULOPATHY HISTORY AND NEUROLOGIC EXAM
8A. DOES THE VETERAN NOW HAVE OR HAS THE VETERAN HAD RADICULOPATHY?
YES

NO

(If "No," skip to Section IX) (If "Yes," complete Item 8B)

8B. 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 upper extremity:

None

Mild

Moderate

Severe

Left upper extremity:

None

Mild

Moderate

Severe

INTERMITTENT PAIN (usually dull)
Right upper extremity:

None

Mild

Moderate

Severe

Left upper extremity:

None

Mild

Moderate

Severe

PARESTHESIAS AND/OR DYSESTHESIAS
Right upper extremity:

None

Mild

Moderate

Severe

Left upper extremity:

None

Mild

Moderate

Severe

Right upper extremity:

None

Mild

Moderate

Severe

Left upper extremity:

None

Mild

Moderate

Severe

NUMBNESS

8C. ARE THERE ANY OTHER SIGNS OR SYMPTOMS OF RADICULOPATHY?
YES

NO

(If "Yes," describe):

8D. STRENGTH EXAM - RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE:

0/5
1/5
2/5
3/5
4/5
5/5

No muscle movement
Visible muscle movement
No movement against gravity
No movement against resistance
Less than normal strength
Normal strength

ELBOW FLEXION (C5):
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

ELBOW EXTENSION (C7):
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

WRIST EXTENSION (C6):
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

FINGER FLEXION (C8):
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

FINGER ABDUCTION (T1):
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

8E. 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
BICEPS:
Right

0

1+

2+

3+

4+

Left

0

1+

2+

3+

4+

Right

0

1+

2+

3+

4+

Left

0

1+

2+

3+

4+

TRICEPS:

BRACHIORADIALIS:
Right

0

1+

2+

3+

4+

Left

0

1+

2+

3+

4+

VA FORM 21-0960M-13, DEC 2010

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SECTION VIII - RADICULOPATHY HISTORY AND NEUROLOGIC EXAM (Continued)
8F. SENSORY EXAM - PROVIDE RESULTS FOR SENSATION TO LIGHT TOUCH (dermatomes) TESTING
C5 (Shoulder/lat arm)
C7 (Dorsum hand)
C6 (Thumb)
C8 (Ulnar side hand)
T1 (Medial arm/forearm)

Right

Normal

Decreased

Absent

Left

Normal

Decreased

Absent

Right

Normal

Decreased

Absent

Left

Normal

Decreased

Absent

Right

Normal

Decreased

Absent

Left

Normal

Decreased

Absent

Right

Normal

Decreased

Absent

Left

Normal

Decreased

Absent

Right

Normal

Decreased

Absent

Left

Normal

Decreased

Absent

8G. DOES THE VETERAN HAVE MUSCLE ATROPHY?
YES

NO

(If muscle atrophy is present, indicate location:
and provide difference measured in cm between normal and atrophied side, measured at maximum muscle bulk:

cm).

8H. IF THE VETERAN HAS RADICULOPATHY, INDICATE NERVE ROOTS INVOLVED: (Check all that apply)
INVOLVEMENT OF C5/C6 NERVE ROOTS (upper radicular group)
INVOLVEMENT OF C7 NERVE ROOTS (middle radicular group)
INVOLVEMENT OF C8/T1 NERVE ROOTS (lower radicular group)
8I. 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)
Right

Not affected

Mild

Moderate

Severe

Left

Not affected

Mild

Moderate

Severe

SECTION IX - OTHER NEUROLOGIC ABNORMALITIES
9. DOES THE VETERAN HAVE ANY OTHER NEUROLOGIC ABNORMALITIES RELATED TO A CERVICAL SPINE (neck) CONDITION (such as bowel or bladder

problems due to cervical myelopathy)?
YES

NO

(If "Yes," describe
Also complete the appropriate questionnaire, if indicated)

).

SECTION X - INCAPACITATING EPISODES
10. AS A RESULT OF THE CERVICAL SPINE CONDITION HAS THE VETERAN EXPERIENCED INCAPACITATING EPISODES DURING THE PAST 12 MONTHS?
YES

NO

(If "Yes," indicate the total duration for the 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 (or other healthcare provider))

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 XI - ASSISTIVE DEVICES AND REMAINING FUNCTION OF THE EXTREMITIES
11A. 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:
11B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION

11C. DUE TO A CERVICAL SPINE (neck) 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 upper

Left upper

VA FORM 21-0960M-13, DEC 2010

Bilateral upper

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

NO

(If "Yes," describe):

SECTION XIII - 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.
13A. HAVE THE IMAGING STUDIES OF THE CERVICAL SPINE BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

(If "Yes," is arthritis (degenerative joint disease) documented?)
YES

NO

13B. DOES THE VETERAN HAVE A VERTEBRAL FRACTURE?
YES

NO

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

NO

(If "Yes," describe impact of the veteran's cervical spine (neck) condition(s), providing one or more examples)

15. REMARKS (If any)

SECTION IX - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
16A. PHYSICIAN'S SIGNATURE

16D. PHYSICIAN'S PHONE NUMBER

16B. PHYSICIAN'S PRINTED NAME

16E. PHYSICIAN'S MEDICAL LICENSE NUMBER

16C. DATE SIGNED

16F. 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.
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, 58VA21/22/28, 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 low 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 45 minutes to review the instructions, find the information, and complete a 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
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VA FORM 21-0960M-13, DEC 2010

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