Form VA Form 21-0960M-6 VA Form 21-0960M-6 Foot Miscellaneous (Other than Flatfoot/Pes Planus) Disa

OMB Approved No. 2900-0776
Respondent Burden: 15 minutes

FOOT MISCELLANEOUS (OTHER THAN FLATFOOT/PES PLANUS)
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

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.

1. DIAGNOSIS
Does the Veteran now have or has he/she ever had a foot condition (other than flatfoot)?
YES
NO
If yes, indicate diagnosis/es: (check all that apply) and complete appropriate section(s).
PROVIDE ONLY DIAGNOSES THAT PERTAIN TO FOOT CONDITIONS OTHER THAN FLATFOOT:
MORTON'S NEUROMA

ICD CODE:

DATE OF DIAGNOSIS:

METATARSALGIA

ICD CODE:

DATE OF DIAGNOSIS:

HAMMER TOES

ICD CODE:

DATE OF DIAGNOSIS:

HALLUX VALGUS

ICD CODE:

DATE OF DIAGNOSIS:

HALLUX RIGIDUS

ICD CODE:

DATE OF DIAGNOSIS:

CLAW FOOT (PES CAVUS) ICD CODE:

DATE OF DIAGNOSIS:

MALUNION/NONUNION OF
TARSAL/METATARSAL
BONES

ICD CODE:

DATE OF DIAGNOSIS:

FOOT INJURIES (specify)

ICD CODE:

DATE OF DIAGNOSIS:

OTHER FOOT CONDITIONS ICD CODE:

DATE OF DIAGNOSIS:

(specify)

NOTE - If the veteran has flatfoot, also complete the Flatfoot Questionnaire.
2. MEDICAL HISTORY

DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S CURRENT FOOT CONDITION (brief summary):

3. MORTON'S NEUROMA (Morton's disease) AND METATARSALGIA
3A. DOES THE VETERAN HAVE MORTON'S NEUROMA?
YES

NO

If yes, indicate side affected:

Right

Left

Both

Left

Both

3B. DOES THE VETERAN HAVE METATARSALGIA?
YES
NO
If yes, indicate side affected:

Right

4. HAMMER TOE
DOES THE VETERAN HAVE HAMMER TOE(S)?
YES
NO
If yes, which toes are affected on each side?
Right:

None

Great toe

Second toe

Third toe

Fourth toe

Little toe

Left:

None

Great toe

Second toe

Third toe

Fourth toe

Little toe

5. HALLUX VALGUS
DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD HALLUX VALGUS?
YES

NO

If yes, complete the following:
5A. DOES THE VETERAN HAVE SYMPTOMS DUE TO A HALLUX VALGUS CONDITION?
YES

NO If yes, indicate severity (check all that apply):
Mild or moderate symptoms
Side affected:

Right

Left

Both

Severe symptoms, with function equivalent to amputation of great toe
Side affected:
VA FORM
JAN 2011

21-0960M-6

Right

Left

Both

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5. HALLUX VALGUS (Continued)
5B. HAS THE VETERAN HAD SURGERY FOR HALLUX VALGUS?
NO If yes, indicate type of surgery and side affected:

YES

Resection of metatarsal head
Date of surgery:
Side affected:

Left

Right

Both

Metatarsal osteotomy/metatarsal head osteotomy (equivalent to metatarsal head resection)
Date of surgery:
Side affected:

Left

Right

Both

Other surgery for hallux valgus, describe:
Date of surgery:
Side affected:

Left

Right

Both

6. HALLUX RIGIDUS
DOES THE VETERAN HAVE HALLUX RIGIDUS?

YES

NO

If yes, does the Veteran have symptoms due to hallux rigidus?

YES

NO

If yes, indicate severity (check all that apply):
Mild or moderate symptoms
Side affected:

Right

Left

Both

Severe symptoms, with function equivalent to amputation of great toe
Side affected:

Right

Left

Both

7. PES CAVUS (CLAW FOOT)
DOES THE VETERAN HAVE ACQUIRED CLAW FOOT (PES CAVUS)?
YES
NO
If yes, complete the following:
7A. Effect on toes due to pes cavus (check all that apply)
None
Right

Left

Both

Great toe dorsiflexed

Right

Left

Both

All toes tending to dorsiflexion

Right

Left

Both

All toes hammer toes

Right

Left

Both

Other, describe (if there is an effect on toes due to other etiology than pes cavus, indicate other etiology)
B. Pain and tenderness (check all that apply)
None

Right

Left

Definite tenderness under metatarsal heads

Right

Left

Both

Marked tenderness under metatarsal heads

Right

Left

Both

Very painful callosities

Right

Left

Both

Both

Other, describe (if the Veteran has pain and tenderness due to other etiology than pes cavus, indicate other etiology):
C. Effect on plantar fascia (check all that apply)
None
Shortened plantar fascia

Right

Left

Both

Left

Both
Marked contraction of plantar fascia with
Right
Left
Both
dropped forefoot
Other, describe (if there is an effect on plantar fascia due to other etiology than pes cavus, indicate other etiology):

D.Dorsiflexion and varus deformity (check all that apply)
None

Right

Right

Left

Both

Some limitation of dorsiflexion at ankle

Right

Left

Both

Limitation of dorsiflexion at ankle to right angle

Right

Left

Both

Marked varus deformity

Right

Left

Both

Other, describe (if the Veteran has dorsiflexion and varus deformity due to other etiology than pes cavus, indicate other etiology):

8. MALUNION OR NONUNION OF TARSAL OR METATARSAL BONES
DOES THE VETERAN HAVE MALUNION OR NONUNION OF TARSAL OR METATARSAL BONES?
YES

NO

Indicate severity and side affected:
Moderate

Left

Right

Moderately severe

Right

Severe

Left

Right

VA FORM 21-0960M-6, JAN 2011

Both
Left

Both

Both
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9. FOOT INJURIES
DOES THE VETERAN HAVE ANY OTHER FOOT INJURIES?
YES

NO If yes, describe:

If yes, indicate severity and side affected:
Moderate
Right
Left
Moderately severe
Severe

Right

Right

Left

Left

Both

Both
Both

10. BILATERAL WEAK FOOT
NOTE - For VA purposes, bilateral weak foot is a symptomatic condition secondary to many constitutional conditions characterized by atrophy of the musculature,
disturbed circulation, and weakness.
IS THERE EVIDENCE OF BILATERAL WEAK FOOT?
YES

NO

If yes, describe and report underlying condition:

11. OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
11A. 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, are any of the scars painful and/or unstable, or is the total area of all related scars greater than 39 square cm (6 square inches)?
NO If yes, also complete a Scars Questionnaire.

YES

11B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN THE DIAGNOSIS SECTION ABOVE?
YES
NO If yes, describe (brief summary):

12. ASSISTIVE DEVICES
12A. DOES THE VETERAN USE ANY ASSISTIVE DEVICES AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER
METHODS MAY BE POSSIBLE?
YES

NO

If yes, identify assistive devices 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

12B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE FOR EACH CONDITION:

13. REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
Due to the Veteran's foot 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., 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 extremities for which this applies:
Right lower

Left lower

For each checked extremity, describe loss of effective function, identify the condition causing loss of function, and provide specific examples (brief summary):

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14. DIAGNOSTIC TESTING
The diagnosis of degenerative arthritis (osteoarthritis) or traumatic 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.
14A. HAVE IMAGING STUDIES OF THE FOOT BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES
NO
If yes, are there abnormal findings?
YES

NO

If yes, indicate findings:
Degenerative or traumatic arthritis
Foot

Right

Both

Left

Is degenerative or traumatic arthritis documented in multiple joints of the same foot?
YES

NO

If yes, indicate foot:

Right

Both

Left

Other, describe:
Foot

Right

Left

Both

14B. 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):

15. FUNCTIONAL IMPACT
DOES THE VETERAN'S FOOT CONDITION IMPACT HIS OR HER ABILITY TO WORK?
YES
NO
If yes, describe the impact of each of the Veteran's foot conditions providing one or more examples:

16. 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.
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 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-6, JAN 2011

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