VA Form 21-0960M-7 Hand and Finger Conditions Disability Benefits Questionn

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

HAND AND FINGER 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 HAND OR FINGER CONDITION?
YES

NO

(If "Yes," provide only diagnoses that pertain to hand and finger conditions in Item B):

1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO HAND AND FINGER CONDITION(S):
DIAGNOSIS #1 -

DATE OF DIAGNOSIS -

ICD CODE -

DIAGNOSIS #2 -

ICD CODE -

DIAGNOSIS #3 -

DATE OF DIAGNOSIS -

ICD CODE -

DATE OF DIAGNOSIS -

SIDE AFFECTED
Right

Left

Both

SIDE AFFECTED
Right

Left

Both

SIDE AFFECTED
Right

Left

Both

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO HAND AND FINGER CONDITIONS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY

2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S HAND OR FINGER CONDITION(S) (Brief summary):

2B. DOMINANT HAND
Left

Right

Ambidextrous

2C. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE HAND?
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
NOTE: 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 visible behavior such as facial expression, wincing, etc. Report initial measurements below.
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 IV.
3A. IS THERE LIMITATION OF MOTION OR EVIDENCE OF PAINFUL MOTION FOR ANY FINGERS AND/OR THUMBS?
YES
NO
If "No," skip to Section IV
If "Yes," indicate digit(s) affected: (check all that apply)
Right:

Thumb

Index finger

Long finger

Ring finger

Little finger

Left:

Thumb

Index finger

Long finger

Ring finger

Little finger

3B. ABILITY TO OPPOSE THUMB: Is there a gap between the thumb pad and the fingers?
YES
NO
If "Yes," indicate distance of gap and side affected:
Less than 1 inch (2.5cm.)

Right

Left

Both

1 to 2 inches (2.5 to 5.1 cm.)

Right

Left

Both

More than 2 inches (5.1 cm.)

Right

Left

Both

Select where objective evidence of painful motion begins:
No objective evidence of painful motion

VA FORM
JAN 2011

Pain begins at gap of less than 1 inch (2.5 cm.)

Right

Left

Both

Pain begins at gap of 1 to 2 inches (2.5 to 5.1 cm.)

Right

Left

Both

Pain begins at gap of more than 2 inches (5.1 cm.)

Right

Left

Both

21-0960M-7

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SECTION III - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS (Continued)

3C. FINGER FLEXION: Is there a gap between any fingertips and the proximal transverse crease of the palm or evidence of painful motion in attempting to touch the palm with
the fingertips?
YES
NO
If "Yes," indicate the gap:
Gap less than 1 inch (2.5 cm) (Indicate fingers affected (check all that apply)):
Right:

Index finger

Long finger

Ring finger

Little finger

Left:

Index finger

Long finger

Ring finger

Little finger

Gap 1 inch (2.5 cm) or more (Indicate fingers affected (check all that apply)):
Right:

Index finger

Long finger

Ring finger

Little finger

Left:

Index finger

Long finger

Ring finger

Little finger

Select where objective evidence of painful motion begins:
No objective evidence of painful motion
Painful motion begins at a gap of less than 1 inch (2.5 cm.)
(Indicate fingers affected (check all that apply)):
Right:

Index finger

Long finger

Ring finger

Little finger

Left:

Index finger

Long finger

Ring finger

Little finger

Painful motion begins at a gap of 1 inch (2.5 cm.) or more
(Indicate fingers affected (check all that apply)):
Right:

Index finger

Long finger

Ring finger

Little finger

Left:

Index finger

Long finger

Ring finger

Little finger

3D. FINGER EXTENSION: Is there limitation of extension or evidence of painful motion for the index finger and/or long finger?
YES
NO
If "Yes," indicate limitation of extension:
Extension limited by no more than 30 degrees (unable to extend finger fully, extension limited to between 0 and 30 degrees of flexion)
Indicate fingers affected (check all that apply):
Right:

Index finger

Long finger

Left:

Index finger

Long finger

Extension limited by more than 30 degrees (unable to extend finger fully, extension limited to 31 degrees or more of flexion)
Indicate fingers affected (check all that apply):
Right:

Index finger

Long finger

Left:

Index finger

Long finger

Select where objective evidence of painful motion begins:
No objective evidence of painful motion
Painful motion begins at extension of no more than 30 degrees (unable to extend finger fully, painful extension begins between 0 and 30 degrees of flexion)
(Indicate fingers affected (check all that apply)):
Right:

Index finger

Long finger

Left:

Index finger

Long finger

Painful motion begins at extension of more than 30 degrees (unable to extend finger fully, painful extension begins at 31 degrees or more of flexion)
(Indicate fingers affected (check all that apply)):
Right:

Index finger

Long finger

Left:

Index finger

Long finger

3E. IF ROM DOES NOT CONFORM TO THE NORMAL RANGE OF MOTION IDENTIFIED ABOVE BUT IS NORMAL FOR THIS VETERAN (for reasons other than a hand
condition, such as age, body habitus, neurologic disease), EXPLAIN:

SECTION IV - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING
4A. IS THE VETERAN ABLE TO PERFORM REPETITIVE-USE TESTING WITH 3 REPETITIONS?
YES

NO

If unable, provide reason:
If veteran is unable to perform, skip to Section V.)
If veteran is able to perform repetitive-use testing, measure and report ROM after a minimum of 3 repetitions.
4B. IS THERE ADDITIONAL LIMITATION OF MOTION FOR ANY FINGERS POST-TEST?
YES
NO
If "Yes," indicate digit(s) affected (check all that apply):
Right:

Thumb

Index finger

Long finger

Ring finger

Little finger

Left:

Thumb

Index finger

Long finger

Ring finger

Little finger

VA FORM 21-0960M-7, JAN 2011

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SECTION IV - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING (Continued)
4C. ABILITY TO OPPOSE THUMB: Is there a gap between the thumb pad and the fingers post-test?
YES
NO
If "Yes," indicate distance of gap and side affected)
Less than 1 inch (2.5cm.)

Right

Left

Both

1 to 2 inches (2.5 to 5.1 cm.)

Right

Left

Both

More than 2 inches (5.1 cm.)

Right

Left

Both

4D. FINGER FLEXION: Is there a gap between any fingertips and the proximal transverse crease of the palm in attempting to touch the palm with the fingertips post-test?
YES
NO
If "Yes," indicate the gap:
Gap less than 1 inch (2.5 cm) (Indicate fingers affected (check all that apply)):
Right:

Index finger

Long finger

Ring finger

Little finger

Left:

Index finger

Long finger

Ring finger

Little finger

Gap 1 inch (2.5 cm) or more (Indicate fingers affected (check all that apply)):
Right:

Index finger

Long finger

Ring finger

Little finger

Left:

Index finger

Long finger

Ring finger

Little finger

4E. FINGER EXTENSION: Is there limitation of extension for the index finger or long finger post-test?
YES
NO
If "Yes," indicate limitation of extension:
Extension limited by no more than 30 degrees (unable to extend finger fully, extension limited to between 0 and 30 degrees of flexion)
Indicate fingers affected (check all that apply):
Right:

Index finger

Long finger

Left:

Index finger

Long finger

Extension limited by more than 30 degrees (unable to extend finger fully, extension limited to 31 degrees or more of flexion)
Indicate fingers affected (check all that apply):
Right:

Index finger

Long finger

Left:

Index finger

Long finger

SECTION V - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION OF ROM
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 ANY FUNCTIONAL LOSS OR FUNCTIONAL IMPAIRMENT OF ANY OF THE FINGERS OR THUMBS?
YES

NO

5B. DOES THE VETERAN HAVE ADDITIONAL LIMITATION IN ROM OF ANY OF THE FINGERS OR THUMBS FOLLOWING REPETITIVE-USE TESTING?
YES
NO
5C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT OR ADDITIONAL LIMITATION OF ROM OF ANY OF THE FINGERS OR THUMBS AFTER
REPETITIVE USE, INDICATE THE CONTRIBUTING FACTORS OF DISABILITY BELOW.
CHECK ALL THAT APPLY; INDICATE DIGIT AND SIDE AFFECTED:
No functional loss for right hand, thumb or fingers
No functional loss for left hand, thumb or fingers
Less movement than normal
Right:

All

Thumb

Index finger

Long finger

Ring finger

Little finger

Left:

All

Thumb

Index finger

Long finger

Ring finger

Little finger

More movement than normal
Right:

All

Thumb

Index finger

Long finger

Ring finger

Little finger

Left:

All

Thumb

Index finger

Long finger

Ring finger

Little finger

Weakened movement
Right:

All

Thumb

Index finger

Long finger

Ring finger

Little finger

Left:

All

Thumb

Index finger

Long finger

Ring finger

Little finger

Excess fatigability
Right:

All

Thumb

Index finger

Long finger

Ring finger

Little finger

Left:

All

Thumb

Index finger

Long finger

Ring finger

Little finger

Incoordination, impaired ability to execute skilled movements smoothly
Right:

All

Thumb

Index finger

Long finger

Ring finger

Little finger

All

Thumb

Index finger

Long finger

Ring finger

Little finger

All

Thumb

Index finger

Long finger

Ring finger

Little finger

All

Thumb

Index finger

Long finger

Ring finger

Little finger

Right:

All

Thumb

Index finger

Long finger

Ring finger

Little finger

Left:

All

Thumb

Index finger

Long finger

Ring finger

Little finger

Left:

Pain on movement
Right:
Left:
Swelling

VA FORM 21-0960M-7, JAN 2011

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SECTION V - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION OF ROM (Continued)

5C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT OR ADDITIONAL LIMITATION OF ROM OF ANY OF THE FINGERS OR THUMBS AFTER
REPETITIVE USE, INDICATE THE CONTRIBUTING FACTORS OF DISABILITY BELOW (Continued)
Deformity
Right:

All

Thumb

Index finger

Long finger

Ring finger

Little finger

Left:

All

Thumb

Index finger

Long finger

Ring finger

Little finger

Right:

All

Thumb

Index finger

Long finger

Ring finger

Little finger

Left:

All

Thumb

Index finger

Long finger

Ring finger

Little finger

Atrophy of disuse

Other, describe:

SECTION VI - PAIN (Pain on Palpation)
6. DOES THE VETERAN HAVE TENDERNESS OR PAIN TO PALPATION FOR JOINTS OR SOFT TISSUE OF EITHER HAND, INCLUDING THUMB AND FINGERS?
NO

YES

Right

(If "Yes," side affected):

Left

Both

SECTION VII - MUSCLE STRENGTH TESTING

7. RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE:
0/5 No muscle movement

2/5 Active movement with gravity eliminated 4/5 Active movement against some resistance

1/5 Palpable or visible muscle contraction, but no joint movement
Hand grip

3/5 Active movement against gravity

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

5/5 Normal strength

SECTION VIII - ANKYLOSIS
8A. DOES THE VETERAN HAVE ANKYLOSIS OF THE THUMB AND/OR FINGERS?
YES

NO

(If "Yes," check all that apply)

Right thumb:
Carpometacarpal joint ankylosis:
In extension

In full flexion

In rotation or angulation

Thumb is abducted and rotated so that the thumb pad faces the finger pads

Interphalangeal joint ankylosis:
In extension
In full flexion
Thumb is abducted and rotated so that the thumb pad faces the finger pads
In rotation or angulation
There is a gap of more than two inches (5.1 cm.) or less between the thumb pad and the fingers, with the thumb attempting to oppose the fingers.
There is a gap of two inches (5.1 cm.) or less between the thumb pad and the fingers, with the thumb attempting to oppose the fingers.
Left thumb:
Carpometacarpal joint ankylosis:
In extension

In full flexion

In rotation or angulation

Thumb is abducted and rotated so that the thumb pad faces the finger pads

Interphalangeal joint ankylosis:
In extension
In full flexion
Thumb is abducted and rotated so that the thumb pad faces the finger pads
In rotation or angulation
There is a gap of more than two inches (5.1 cm.) or less between the thumb pad and the fingers, with the thumb attempting to oppose the fingers.
There is a gap of two inches (5.1 cm.) or less between the thumb pad and the fingers, with the thumb attempting to oppose the fingers.
Right:

Index finger

Long finger

Metacarpophalangeal joint ankylosis:
Proximal interphalangeal joint ankylosis:

Ring finger

Little finger

In extension
In extension

In full flexion
In full flexion

In rotation or angulation
In rotation or angulation

Flexed to 30 degrees
Flexed to 30 degrees

There is a gap of more than two inches (5.1 cm.) between the fingertip(s) and the proximal transverse crease of the palm, with the finger(s) flexed to the extent possible.
There is a gap of two inches (5.1 cm.) or less between the fingertip(s) and the proximal transverse crease of the palm, with the finger(s) flexed to the extent possible.
Left:

Index finger

Long finger

Metacarpophalangeal joint ankylosis:
Proximal interphalangeal joint ankylosis:

Ring finger

Little finger

In extension
In extension

In full flexion
In full flexion

In rotation or angulation
In rotation or angulation

Flexed to 30 degrees
Flexed to 30 degrees

There is a gap of more than two inches (5.1 cm.) between the fingertip(s) and the proximal transverse crease of the palm, with the finger(s) flexed to the extent possible.
There is a gap of two inches (5.1 cm.) or less between the fingertip(s) and the proximal transverse crease of the palm, with the finger(s) flexed to the extent possible.
8B. IF THERE IS ANKYLOSIS OF MORE THAN ONE FINGER, PROVIDE DETAILS USING ABOVE DESCRIPTIONS:

8C. DOES THE ANKYLOSIS CONDITION RESULT IN LIMITATION OF MOTION OF OTHER DIGITS OR INTERFERENCE WITH OVERALL FUNCTION OF THE HAND?
YES

NO (If "Yes," describe):

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SECTION IX - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
9A. 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 39 square cm (6 square inches?)):
YES

NO

(If "Yes," ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)
9B. 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 X - ASSISTIVE DEVICES AND REMAINING FUNCTION OF THE EXTREMITIES
10A. DOES THE VETERAN USE ANY ASSISTIVE DEVICES?
YES
NO
(If "Yes," identify assistive device(s) used (check all that apply and indicate frequency):
BRACE(S)

Frequency of use:

Occasional

Regular

Constant

OTHER:

Frequency of use:

Occasional

Regular

Constant

10B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDTION:

SECTION XI - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES

11. DUE TO THE VETERAN'S HAND, FINGER OR THUMB CONDITIONS, 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.)
YES, functioning is so diminished that amputation with prosthesis would equally serve the veteran.
NO
(If "Yes," indicate extremities for which this applies):
Right upper

Left upper

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

SECTION XII - 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.

12A. HAVE IMAGING STUDIES OF THE HANDS 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

Left
Both
Right
Hand:
(Is degenerative or traumatic arthritis documented in multiple joints of the same hand, including thumb and fingers?)
YES
NO
(If "Yes," indicate hand):

Right

Left

Both

Other, describe:__________________________________________________________________________________________________________________
Hand:

Right

Left

Both

12B. 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)):

VA FORM 21-0960M-7, JAN 2011

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SECTION XIII - FUNCTIONAL IMPACT
13. DOES THE VETERAN'S HAND, THUMB OR FINGER CONDITIONS IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe the impact of each of the veteran's hand, thumb and/or finger conditions, providing one or more examples):

SECTION XIV - REMARKS
14. 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.
15A. PHYSICIAN'S SIGNATURE

15B. PHYSICIAN'S PRINTED NAME

15D. PHYSICIAN'S PHONE AND FAX NUMBER 15E. PHYSICIAN'S MEDICAL LICENSE NUMBER

15C. DATE SIGNED
15F. 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
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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
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VA FORM 21-0960M-7, JAN 2011

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