VA Form 21-0960M-5 Flatfoot (Pes Planus) Disability Benefits Questionnaire

OMB Approved No. 2900-0776
Respondent Burden: 30 minutes

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 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 FLATFOOT (PES PLANUS)?
YES

NO

IF YES, PROVIDE ONLY DIAGNOSES THAT PERTAIN TO FLATFOOT:

1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO FLATFOOT
DIAGNOSIS # 1 -

ICD CODE -

DATE OF DIAGNOSIS -

SIDE AFFECTED
RIGHT

DIAGNOSIS # 2 -

ICD CODE -

DATE OF DIAGNOSIS -

SIDE AFFECTED
RIGHT

DIAGNOSIS # 3 -

ICD CODE -

DATE OF DIAGNOSIS -

BOTH

LEFT

BOTH

LEFT

SIDE AFFECTED
RIGHT

BOTH

LEFT

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO FLATFOOT, LIST USING ABOVE FORMAT

NOTE - If the veteran has additional foot conditions other than flatfoot, (such as extreme tenderness on the plantar surfaces of the feet indicating plantar fasciitis),
complete a VAF 21-0960M-6 Foot (other than flatfoot) Disability Benefits Questionnaire.
SECTION II - MEDICAL HISTORY

2. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S CURRENT FLATFOOT CONDITION (i.e., when did flatfoot first become

symptomatic?) (brief summary):

SECTION III - SIGNS AND SYMPTOMS
3. INDICATE ALL SIGNS AND SYMPTOMS THAT APPLY TO THE VETERAN'S FLATFOOT CONDITION, REGARDLESS OF WHETHER SIMILAR SIGNS AND
SYMPTOMS APPEAR MORE THAN ONCE IN DIFFERENT SECTIONS
A. DOES THE VETERAN HAVE PAIN ON USE OF THE FEET?
YES

NO

If "Yes," indicate side affected:

Right

Left

Both

Right

Left

Both

If "Yes," is the pain accentuated on use?
YES

NO

If "Yes," indicate side affected:

B. DOES THE VETERAN HAVE PAIN ON MANIPULATION OF THE FEET?
YES

NO

If "Yes," indicate side affected:

Right

Left

Both

Left

Both

If "Yes," is the pain accentuated on manipulation?
YES

NO

If "Yes," indicate side affected:

VA FORM
JAN 2011

21-0960M-5

Right

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SECTION III - SIGNS AND SYMPTOMS (Continued)
C. IS THERE INDICATION OF SWELLING ON USE?
YES

NO

If "Yes," indicate side affected:

Right

Left

Both

D. DOES THE VETERAN HAVE CHARACTERISTIC CALLUSES (OR ANY CALLUSES CAUSED BY THE FLATFOOT CONDITION)?
YES

NO

If "Yes," indicate side affected:

Right

Left

Both

E. ARE THE VETERAN'S SYMPTOMS RELIEVED BY ARCH SUPPORTS (OR BUILT UP SHOES OR ORTHOTICS)?
YES

NO

If "No," indicate side that remains symptomatic despite arch supports or orthotics:
Right

Left

Both

F. DOES THE VETERAN HAVE EXTREME TENDERNESS OF PLANTAR SURFACES ON ONE OR BOTH FEET?
YES

NO

If "Yes," indicate side affected:

Right

Left

Both

Is the tenderness improved by orthopedic shoes or appliances?
YES

NO

SECTION IV - ALIGNMENT AND DEFORMITY
A. DOES THE VETERAN HAVE DECREASED LONGITUDINAL ARCH HEIGHT ON WEIGHT-BEARING?
YES

NO

If "Yes," indicate side affected:

Right

Left

Both

B. IS THERE OBJECTIVE EVIDENCE OF MARKED DEFORMITY OF THE FOOT (pronation, abduction etc.)?
YES
NO
If "Yes," indicate side affected:

Right

Left

Both

Left

Both

C. IS THERE MARKED PRONATION OF THE FOOT?
YES
NO
If "Yes," indicate side affected:

Right

if "Yes," is the condition improved by orthopedic shoes or appliances?
YES

NO

D. DOES THE WEIGHT-BEARING LINE FALL OVER OR MEDIAL TO THE GREAT TOE?
YES

NO

If "Yes," indicate side affected:

Right

Left

Both

E. IS THERE A LOWER EXTREMITY DEFORMITY OTHER THAN PES PLANUS, CAUSING ALTERATION OF THE WEIGHT-BEARING LINE?
YES

NO

If "Yes," indicate side affected:

Right

Left

Both

Describe lower extremity deformity other than pes planus causing alteration of the weight bearing line:
F. DOES THE VETERAN HAVE "INWARD" BOWING OF THE ACHILLES' TENDON (i.e., hind foot valgus, with lateral deviation of the heel)?
YES

NO

If "Yes," indicate side affected:

Right

Left

Both

G. DOES THE VETERAN HAVE MARKED INWARD DISPLACEMENT AND SEVERE SPASM OF THE ACHILLES' TENDON (rigid hindfoot) ON MANIPULATION?
YES

NO

If "Yes," indicate side affected:

Right

Left

Both

Is the marked inward displacement and severe spasm of the Achilles tendon improved by orthopedic shoes or appliances?
YES

NO

If "Yes," indicate side improved by orthopedic shoes or appliances:
Right

Left

Both

SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
5A. 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)?
YES

NO

IF YES, ALSO COMPLETE A VAF 21-0960F-1 Scars/Disfigurement Disability Benefits Questionnaire.

VA FORM 21-0960M-5, JAN 2011

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SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS (Continued)
5B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN DIAGNOSIS SECTION 1?
YES

NO

IF YES, DESCRIBE (brief summary):

SECTION VI - ASSISTIVE DEVICES
6A. DOES THE VETERAN USE ANY ASSISTIVE DEVICES (other than corrective shoes or orthotic inserts) 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:

6B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:

SECTION VII - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
7. DUE TO THE VETERAN'S FLATFOOT 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

IDENTIFY THE CONDITION CAUSING LOSS OF FUNCTION, DESCRIBE LOSS OF EFFECTIVE FUNCTION AND PROVIDE SPECIFIC EXAMPLES (brief summary):

SECTION VIII - DIAGNOSTIC TESTING
NOTE - Plain or weight-bearing foot x-rays are not required to make the diagnosis of flatfoot. 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.
8A. HAVE IMAGING STUDIES OF THE FOOT BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

IF YES, IS DEGENERATIVE OR TRAUMATIC ARTHRITIS DOCUMENTED?
YES

NO

IF YES, INDICATE FOOT:

Right

Left

Both

8B. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDING AND/OR RESULTS?
YES

NO

IF YES, PROVIDE TYPE OF TEST OR PROCEDURE, DATE AND RESULTS (brief summary):

VA FORM 21-0960M-5, JAN 2011

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SECTION IX - FUNCTIONAL IMPACT
9. DOES THE VETERAN'S FLATFOOT CONDITION IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

IF YES, DESCRIBE THE IMPACT OF EACH OF THE VETERAN'S FLATFOOT CONDITIONS PROVIDING ONE OR MORE EXAMPLES:

SECTION X - REMARKS
10. REMARKS (If any):

SECTION XI - PHYSICIAN'S CERTIFICATION AND SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
11A. PHYSICIAN'S SIGNATURE

11D. PHYSICIAN'S PHONE NUMBER

11B. PHYSICIAN'S PRINTED NAME

11E. PHYSICIAN'S MEDICAL LICENSE NUMBER

11C. DATE SIGNED

11F. 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-5, JAN 2011

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