VA Form 21-0960M-9 Knee and Lower Leg Conditions Disability Benefits Questi

Disability Benefits Questionnaires (Group 2)

21-0960M-9

Disability Benefits Questionnaires (Group 2)

OMB: 2900-0776

Document [pdf]
Download: pdf | pdf
OMB Approved No. 2900-0776
Respondent Burden: 30 minutes

KNEE AND LOWER LEG 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 KNEE AND/OR LOWER LEG CONDITION?
YES

NO

(If "Yes," complete Item 1B)

1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO KNEE AND/OR LOWER LEG CONDITIONS:
DIAGNOSIS # 1 -

ICD CODE -

DATE OF DIAGNOSIS -

SIDE AFFECTED

DIAGNOSIS # 2 -

ICD CODE -

DATE OF DIAGNOSIS -

SIDE AFFECTED

DIAGNOSIS # 3 -

ICD CODE -

DATE OF DIAGNOSIS -

SIDE AFFECTED

RIGHT
RIGHT
RIGHT

LEFT

BOTH

LEFT

BOTH

LEFT

BOTH

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO KNEE AND/OR LOWER LEG CONDITIONS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY
2. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S KNEE AND/OR LOWER LEG CONDITION(S) (Brief summary)

SECTION III - FLARE-UPS
3. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE KNEE AND/OR LOWER LEG CONDITION(S)?
YES

NO

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

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 VISABLE BEHAVIOR SUCH AS FACIAL EXPRESSION, WINCING, ETC. REPORT POST-TEST
MEASUREMENTS IN SECTION 5.
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 5.
4A. RIGHT KNEE FLEXION
SELECT WHERE FLEXION ENDS (normal endpoint is 140 degrees):
0

5

10

15

20

25

75

80

85

90

95

100

30

35

105

40
110

45
115

50
120

55

60

125

65
130

70
135

140 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
105

35

40
110

45
115

50
120

55
125

60

65
130

70
135

140 or greater

4B. RIGHT KNEE EXTENSION
Select where extension ends:
0 or any degree of hyperextension (check this box if there is no limitation of extension)
Unable to fully extend; extension ends at:
5
VA FORM
JAN 2011

10

15

20

21-0960M-9

25

30

35

40

45 or greater

Page 1

SECTION IV - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS (Continued)
4B. RIGHT KNEE EXTENSION (Continued)
Select where objective evidence of painful motion begins:
No objective evidence of painful motion
0 or any degree of hyperextension (check this box if there is no limitation of extension)
Unable to fully extend; extension ends at:
5

10

15

20

25

30

35

40

45 or greater

4C. LEFT KNEE FLEXION
SELECT WHERE FLEXION ENDS (normal endpoint is 140 degrees):
0

5

10

15

20

25

75

80

85

90

95

100

30

35

105

40

45

110

50

115

55

120

60

125

65

70

130

135

140 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

125

65

70

130

135

140 or greater

4D. LEFT KNEE EXTENSION
Select where extension ends:
0 or any degree of hyperextension (check this box if there is no limitation of extension)
Unable to fully extend; extension ends at:
5

10

15

20

25

30

35

40

45 or greater

Select where objective evidence of painful motion begins:
No objective evidence of painful motion
0 or any degree of hyperextension (check this box if there is no limitation of extension)
Unable to fully extend; extension ends at:
5

10

15

20

25

30

35

40

45 or greater

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 knee and/or leg 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 6)
(If Veteran is able to perform repetitive-use testing, measure and report ROM after a minimum of 3 repetitions):
5B. RIGHT KNEE 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
125

65
130

70
135

140 or greater

Select where post-test extension ends:
0 or any degree of hyperextension (check this box if there is no limitation of extension)
Unable to fully extend; extension ends at:
5

10

15

20

25

30

35

25

30

40

45 or greater

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

5

10

15

20

75

80

85

90

95

100

35
105

40
110

45
115

50
120

55

60
125

65
130

70
135

140 or greater

Select where post-test extension ends:
0 or any degree of hyperextension (check this box if there is no limitation of extension)
Unable to fully extend; extension ends at:
5

10

15

20

VA FORM 21-0960M-9, JAN 2011

25

30

35

40

45 or greater

Page 2

SECTION VI - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION IN ROM

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.
6A. DOES THE VETERAN HAVE ADDITIONAL LIMITATION IN ROM OF THE KNEE AND LOWER LEG FOLLOWING REPETITIVE-USE TESTING?
YES

NO

6B. DOES THE VETERAN HAVE ANY FUNCTIONAL LOSS AND/OR FUNCTIONAL IMPAIRMENT OF THE KNEE AND LOWER LEG?
YES

NO

6C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT OR ADDITIONAL LIMITATION OF ROM OF THE KNEE AND LOWER LEG AFTER
REPETITIVE USE, INDICATE THE CONTRIBUTING FACTORS OF DISABILITYBELOW (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
OTHER, DESCRIBE:

Right

Left

Both

SECTION VII - PAIN (PAIN ON PALPATION)
7. DOES THE VETERAN HAVE TENDERNESS OR PAIN TO PALPATION FOR JOINT LINE OR SOFT TISSUES OF EITHER KNEE?
YES

NO

(If "Yes," indicate side affected):

Right

Left

Both

SECTION VIII - PAINFUL MOTION, TENDERNESS AND STRENGTH TESTING
8. STRENGTH TESTING - RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE:
0/5 No muscle movement
1/5 Visible muscle movement, but no joint movement
2/5 No movement against gravity
3/5 No movement against resistance
4/5 Less than normal strength
5/5 Normal strength
Knee flexion:
Knee 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

SECTION IX - JOINT STABILITY TESTS
9A. ANTERIOR INSTABILITY (Lachman test):
Unable to test:

Right

Left

Both

Right:

Normal

1+(0-5 millimeters)

2+(5-10 millimeters)

3+(10-15 millimeters)

Left:

Normal

1+(0-5 millimeters)

2+(5-10 millimeters)

3+(10-15 millimeters)

9B. POSTERIOR INSTABILITY (Posterior drawer test):
Unable to test:

Right

Left

Both

Right:

Normal

1+(0-5 millimeters)

2+(5-10 millimeters)

3+(10-15 millimeters)

Left:

Normal

1+(0-5 millimeters)

2+(5-10 millimeters)

3+(10-15 millimeters)

9C. MEDIAL-LATERAL INSTABILITY (Apply valgus/varus pressure to knee in extension and 30 degrees of flexion):
Unable to test:

Right

Left

Both

Right:

Normal

1+(0-5 millimeters)

2+(5-10 millimeters)

3+(10-15 millimeters)

Left:

Normal

1+(0-5 millimeters)

2+(5-10 millimeters)

3+(10-15 millimeters)

VA FORM 21-0960M-9, JAN 2011

Page 3

SECTION X - PATELLAR SUBLUXATION/DISLOCATION
10. IS THERE EVIDENCE OR HISTORY OF RECURRENT PATELLAR SUBLUXATION/DISLOCATION?
YES

NO

(If "Yes," indicate severity and side affected):

Right:

None

Slight

Moderate

Severe

Left:

None

Slight

Moderate

Severe

SECTION XI - ADDITIONAL CONDITIONS
11. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER HAD "SHIN SPLINTS" (medial tibial stress syndrome), STRESS FRACTURES, CHRONIC
EXERTIONAL COMPARTMENT SYNDROME OR ANY OTHER TIBIAL AND/OR FIBULAR IMPAIRMENT?
YES

NO

(If "Yes," indicate condition and complete the appropriate sections below):
A. "SHIN SPLINTS" (medial tibial stress syndrome)

(If checked, indicate side affected):

Right

Left

Both

Left

Both

Describe current symptoms:
B. STRESS FRACTURE OF THE LOWER EXTREMITY

(If checked, indicate side affected):

Right

Describe current symptoms:
C. CHRINIC EXERTIONAL COMPARTMENT SYNDROME

(If checked, indicate side affected):

Right

Left

Both

Describe current symptoms:
D. EVIDENCE OF ACQUIRED, TRAUMATIC GENU RECURVATUM WITH WEAKNESS AND INSECURITY IN WEIGHT-BEARING

(If checked, indicate side affected):

Right

Left

Both

E. 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

Left leg:

cm

inches

SECTION XII - MENISCAL CONDITIONS AND MENISCAL SURGERY
12. HAS THE VETERAN HAD ANY MENISCAL CONDITIONS OR SURGICAL PROCEDURES FOR A MENISCAL CONDITION?
YES

NO

(If "Yes," complete the following section):
A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER HAD A MENISCUS (semilunar cartilage) CONDITION?
YES

NO

(If "Yes," indicate severity and frequency of symptoms, and side affected):
No symptoms

Right

Left

Both

Meniscal dislocation

Right

Left

Both

Meniscal tear

Right

Left

Both

Frequent episodes of joint "locking"

Right

Left

Both

Frequent episodes of joint pain

Right

Left

Both

Frequent episodes of joint effusion

Right

Left

Both

B. HAS THE VETERAN HAD A MENISCECTOMY?
YES

NO

(If "Yes," indicate side affected):

Right

Left

Both

Date of surgery:
C. DOES THE VETERAN HAVE ANY RESIDUAL SIGNS AND/OR SYMPTOMS DUE TO A MENISCECTOMY?
YES
NO (If "Yes," indicate side affected):
(If "Yes," describe residuals):

Right

Left

Both

SECTION XIII - JOINT REPLACEMENT AND OTHER SURGICAL PROCEDURES
13A. HAS THE VETERAN HAD A TOTAL KNEE JOINT REPLACEMENT?
YES

NO

(If "Yes," indicate side and severity of residuals)

Right knee
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:
VA FORM 21-0960M-9, JAN 2011

Page 4

SECTION XIII - JOINT REPLACEMENT AND OTHER SURGICAL PROCEDURES (Continued)
13A. HAS THE VETERAN HAD A TOTAL KNEE JOINT REPLACEMENT? (Continued)
Left knee
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:
13B. HAS THE VETERAN HAD ARTHROSCOPIC OR OTHER KNEE SURGERY NOT DESCRIBED ABOVE?
YES

NO

(If "Yes," indicate side affected)

Right

Left

Both

Date and type of surgery:
13C. DOES THE VETERAN HAVE ANY RESIDUAL SIGNS AND/OR SYMPTOMS DUE TO ARTHROSCOPIC OR OTHER KNEE SURGERY NOT DESCRIBED ABOVE?
YES

NO

(If "Yes," indicate side affected):

Right

Left

Both

(If "Yes," describe symptoms):

SECTION XIV - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS

14A. 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 9 square cm (6 square inches)?
YES

NO

(If "Yes," also complete VA Form 21-0960F-1, Scars/Disfigurement Questionnaire)
14B. 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 XV - ASSISTIVE DEVICES
15A. 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

Other:

Frequency of use:

Occasional

Regular

Constant

15B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:

VA FORM 21-0960M-9, JAN 2011

Page 5

SECTION XVI - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
16. DUE TO THE VETERANS KNEE AND/OR LOWER LEG 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 PROSTHESIS? (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 extremity(ies) 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 XVII - DIAGNOSTIC TESTING
NOTE: THE DIAGNOSIS OF DEGENERATIVE ARTHRITIS (osteoarthritis) OR TRAMATIC 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.
17A. HAVE IMAGING STUDIES OF THE KNEE BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

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

NO

(If "Yes," indicate knee)

Right

Left

Both

17B. DOES THE VETERAN HAVE X-RAY EVIDENCE OF PATELLAR SUBLUXATION?
YES

NO

(If "Yes," indicate affected side(s):

Right

Left

Both

17C. 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 XVIII - FUNCTIONAL IMPACT
18. DOES THE VETERAN'S KNEE AND/OR LOWER LEG CONDITION(S) IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe the impact of each of the veteran's knee and/or lower leg conditions providing one or more examples):

VA FORM 21-0960M-9, JAN 2011

Page 6

SECTION XIX - REMARKS
19. REMARKS (If any)

SECTION XX - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
20A. PHYSICIAN'S SIGNATURE

20B. PHYSICIAN'S PRINTED NAME

20D. PHYSICIAN'S PHONE AND FAX NUMBER

20E. PHYSICIAN'S MEDICAL LICENSE NUMBER

20C. DATE SIGNED

20F. 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-9, JAN 2011

Page 7


File Typeapplication/pdf
File TitleVA Form 21-0960M-9
SubjectKnee and Lower Leg Conditions - Disability Benefits Questionnaire
AuthorN. Kessinger
File Modified2011-12-29
File Created2011-02-14

© 2024 OMB.report | Privacy Policy