VA Form 21-0960M-8 Hip and Thigh Conditions Disability Benefits Questionnai

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

HIP AND THIGH 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

SECTION I - DIAGNOSIS
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.
1A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD A HIP AND/OR THIGH CONDITION?
YES

NO

(If "Yes," complete Item 1B)

1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO HIP/THIGH CONDITIONS:

ICD code -

Diagnosis # 2 Diagnosis # 3 -

SIDE AFFECTED

Date of diagnosis -

ICD code -

Diagnosis # 1 -

RIGHT

Date of diagnosis -

BOTH

RIGHT

LEFT

BOTH

LEFT

BOTH

SIDE AFFECTED

Date of diagnosis -

ICD code -

LEFT

SIDE AFFECTED

1C. IF THERE ARE ADDITIONAL DIAGNOSES PERTAINING TO HIP/THIGH CONDITIONS, LIST USING ABOVE FORMAT:

RIGHT

SECTION II - MEDICAL HISTORY
2. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S CURRENT HIP/THIGH CONDITION(S) (Brief summary):

SECTION III - FLARE-UPS
3. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE HIP AND/OR THIGH?
YES

(If "Yes," document the veteran's description of the impact of flare-ups in his or her own words):

NO

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 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 REPTITIONS. REPORT POST-TEST MEASUREMENTS IN SECTION 5.
4A. Right hip flexion

Select where flexion ends (normal endpoint is 125 degrees):
0

5

10

15

20

25

75

80

85

90

95

100

30

35

105

40
110

45
115

50
120

55

60

65

70

125 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
110

45
115

50
120

55

60

65

70

125 or greater

4B. Right hip extension
Select where extension ends:
0

5

Greater than 5

Select where objective evidence of pain motion begins:
No objective evidence of painful motion
0

5

Greater than 5

Is abduction lost beyond 10 degrees?
YES

NO

Is adduction limited such that the Veteran cannot cross legs?
YES

NO

Is rotation limited such that the Veteran cannot toe-out more than 15 degrees?
YES
VA FORM
JAN 2011

NO

21-0960M-8

Page 1

4C. Left hip flexion
Select where flexion ends (normal endpoint is 125 degrees):
0

5

10

15

20

25

75

80

85

90

95

100

30

35

105

40

45

110

50

115

55

120

60

65

70

125 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

65

70

125 or greater

4D. Left hip extension
Select where extension ends:
0

5

Greater than 5

Select where objective evidence of painful motion begins:
No objective evidence of painful motion
0

5

Greater than 5

Is abduction lost beyond 10 degrees?
YES

NO

Is adduction limited such that the Veteran cannot cross legs?
YES

NO

Is rotation limited such that the Veteran cannot toe-out more than 15 degrees?
YES

NO

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 hip 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 VI)
(If veteran is able to perform repetitive-use testing, measure and report ROM after a minimum of 3 repetitions.)
5B. RIGHT HIP 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

65

70

125 or greater

Select where post-test flexion ends:
0

5 or greater

Is post-test adduction lost beyond 10 degrees?
YES

NO

Is post-test adduction limited such that the veteran cannot cross legs?
YES

NO

Is post-test rotation limited such that the veteran cannot toe-out more than 15 degrees?
YES

NO

5C. LEFT HIP POST-TEST ROM
Select where post-test flexion ends:
0

5

10

15

20

75

80

85

90

95

25
100

30

35
105

40
110

45
115

50
120

55

60

65

70

125 or greater

Select where post-test flexion ends:
0

5 or greater

Is post-test adduction lost beyond 10 degrees?
YES

NO

Is post-test adduction limited such that the veteran cannot cross legs?
YES

NO

Is post-test rotation limited such that the veteran cannot toe-out more than 15 degrees?
YES

NO

VA FORM 21-0960M-8, JAN 2011

Page 2

SECTION VI - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION IN 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 INABLILITY 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 HIP AND THIGH FOLLOWING REPETITIVE-USE TESTING?
YES

NO

6B. DOES THE VETERAN HAVE ANY FUNCTIONAL LOSS AND/OR FUNCTIONAL IMPAIRMENT OF THE HIP AND THIGH?
YES

NO

6C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT AND/OR ADDITIONAL LIMITATION OF ROM OF THE HIP AND THIGH AFTER REPETITIVE
USE, INDICATE THE CONTRIBUTING FACTORS OF DISABILITY BELOW (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

Right

Left

Both

SECTION VII - PAIN (PAIN ON PALPATION)
7. DOES THE VETERAN HAVE LOCALIZED TENDERNESS OR PAIN TO PALPATION FOR JOINTS/SOFT TISSUE OF EITHER HIP?
YES

NO

If "Yes," side affected:

Right

Left

Both

SECTION VIII - MUSCLE STRENGTH TESTING
8. RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE:
0/5 No muscle movement
1/5 Palpable or visible muscle contraction, but no joint movement
2/5 Active movement with gravity eliminated
3/5 Active movement against gravity
4/5 Active movement against some resistance
5/5 Normal strength
Hip flexion:
Hip abduction:
Hip 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

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 - ANKYLOSIS
9A. DOES THE VETERAN HAVE ANKYLOSIS OF EITHER HIP JOINT?
YES

NO If "Yes," complete Item 9B)

9B. INDICATE SEVERITY AND SIDE AFFECTED:
FAVORABLE, IN FLEXION AT AN ANGLE BETWEEN 20 AND 40 DEGREES, AND SLIGHT ADDUCTION OR ABDUCTION
Right

Left

Both

INTERMEDIATE, BETWEEN FAVORABLE AND UNFAVORABLE
Right

Left

Both

UNFAVORABLE, EXTREMELY UNFAVORABLE ANKYLOSIS, FOOT NOT REACHING GROUND, CRUTCHES NEEDED
Right

Left

VA FORM 21-0960M-8, JAN 2011

Both

Page 3

SECTION X - ADDITIONAL CONDITIONS
10A. DOES THE VETERAN HAVE MALUNION OR NONUNION OF FEMUR, FLAIL HIP JOINT OR LEG LENGTH DISCREPANCY?
YES

NO

(If "Yes," indicate condition and complete the appropriate sections below):

10B. MALUNION OR NONUNION OF THE FEMUR
If Checked, indicate condition and complete the appropriate sections below.
Malunion with slight hip disability

Right

Left

Both

Malunion with moderate hip disability

Right

Left

Both

Malunion with marked hip disability

Right

Left

Both

Fracture of surgical neck with false joint

Right

Left

Both

Fracture of shaft or neck (anatomical),
resulting in nonunion without loose motion;
weight-bearing preserved with
aid of a brace
Fracture of shaft or neck (anatomical), with
nonunion with loose motion; (spiral or

Right

Left

Both

Right

Left

Both

oblique fracture)

NOTE: If impairment of the femur causes knee disability, also complete VA Form 21-0960M-9, Knee and Lower Leg Conditions Disability Benefits Questionnaire.
10C. FLAIL HIP JOINT

If "Yes," indicate hip affected:

Right

Left

Both

10D. 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

cm

Left leg:

inches

SECTION XI - JOINT REPLACEMENT AND OTHER SURGICAL PROCEDURES
11A. HAS THE VETERAN HAD A TOTAL HIP JOINT REPLACEMENT?
YES

NO

If "Yes," indicate side and severity of residuals

Right hip
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:
Left hip
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:
11B. HAS THE VETERAN HAD ARTHROSCOPIC OR OTHER HIP SURGERY?
YES

NO

(If "Yes," indicate side affected):

Right

Left

Both

Date and type of surgery:
11C. DOES THE VETERAN HAVE ANY RESIDUAL SIGNS AND/OR SYMPTOMS DUE TO ARTHROSCOPIC OR OTHER HIP SURGERY?
YES

NO

(If "Yes," indicate side affected):

Right

Left

Both

(If "Yes," describe residuals):
SECTION XII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
12A. 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)
VA FORM 21-0960M-8, JAN 2011

Page 4

12B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED
TO ANY CONDITIONS LISTED IN SECTION I, DIANOSIS?
YES

NO

If "Yes," describe (brief summary):

SECTION XIII - ASSISTIVE DEVICES
13A. 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:

13B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:

SECTION XIV - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
14A. DUE TO THE VETERAN'S HIP AND/OR THIGH 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 PROTHESES? (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, identify the condition causing loss of function, describe loss of effective function and provide specific examples (brief summary):

SECTION XV - 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 INDICATED, EVEN IF ARTHRITIS HAS WORSENED.
15A. HAVE IMAGING STUDIES OF THE HIP BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

If "Yes," is degenerative or traumatic arthritis documented?
YES

NO

If "Yes," indicate hip:

Right

Left

Both

15B. 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-8, JAN 2011

Page 5

SECTION XVI - FUNCTIONAL IMPACT AND REMARKS
16. DOES THE VETERAN'S HIP AND/OR THIGH CONDITION IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

If "Yes," describe the impact of each of the Veteran's hip and/or thigh conditions providing one or more examples:

17. REMARKS (If any)

SECTION XVII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
18A. PHYSICIAN'S SIGNATURE

18B. PHYSICIAN'S PRINTED NAME

18D. PHYSICIAN'S PHONE AND FAX NUMBER

18E. PHYSICIAN'S MEDICAL LICENSE NUMBER

18C. DATE SIGNED

18F. 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-8, JAN 2011

Page 6