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Respondent Burden: 30 minutes
ELBOW AND FOREARM 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 AN ELBOW OR FOREARM CONDITION?
YES
NO (If "Yes," complete Item 1B)
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO ELBOW AND FOREARM CONDITION(S):
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 ELBOW AND FOREARM CONDITIONS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S ELBOW AND FOREARM CONDITION (brief summary)
2B. DOMINANT HAND
RIGHT
AMBIDEXTROUS
LEFT
SECTION III - FLARE-UPS
3. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE ELBOW AND/OR FOREARM?
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
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 5.
4A. RIGHT ELBOW FLEXION
Select where flexion ends (normal endpoint is 145 degrees):
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145 or greater
Select where objective evidence of painful motion begins:
No objective evidence of painful motion
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145 or greater
50
55
60
65
70
50
55
60
65
70
4B. RIGHT ELBOW EXTENSION
Select where extension ends:
0 or any degree of hyperextension (no limitation of extension)
Unable to fully extend; extension ends at:
5
10
15
20
25
30
35
40
75
80
85
90
95
100
105
110 or greater
45
Select where objective evidence of painful motion begins:
No objective evidence of painful motion
0 or any degree of hyperextension (no limitation of extension)
Unable to fully extend; extension ends at:
5
10
15
20
25
30
35
40
75
80
85
90
95
100
105
110 or greater
VA FORM
JAN 2011
21-0960M-4
45
Page 1
SECTION IV - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS (continued)
4C. LEFT ELBOW FLEXION
Select where flexion ends (normal endpoint is 145 degrees):
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145 or greater
Select where objective evidence of painful motion begins:
No objective evidence of painful motion
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145 or greater
50
55
60
65
70
50
55
60
65
70
4D. LEFT ELBOW EXTENSION
Select where extension ends:
0 or any degree of hyperextension (no limitation of extension)
Unable to fully extend; extension ends at:
5
10
15
20
25
30
35
40
75
80
85
90
95
100
105
110 or greater
45
Select where objective evidence of painful motion begins:
No objective evidence of painful motion
0 or any degree of hyperextension (no limitation of extension)
Unable to fully extend; extension ends at:
5
10
15
20
25
30
35
40
75
80
85
90
95
100
105
110 or greater
45
4E. IF ROM DOES NOT CONFORM TO THE NORMAL RANGE OF MOTION IDENTIFIED ABOVE BUT IS NORMAL FOR THIS VETERAN (for reasons other than an elbow
condition, such as age, body habitus, neurologic disease), EXPLAIN:
SECTION V - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING
5A. IS THE 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 TO PERFORM REPETITIVE-USE TESTING, MEASURE AND REPORT ROM AFTER A MINIMUM OF 3 REPETITIONS:
5B. RIGHT ELBOW POST-TEST ROM
Select where post-test flexion ends:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145 or greater
50
55
60
65
70
Select where post-test extension ends:
0 or any degree of hyperextension (no limitation of extension)
Unable to fully extend; extension ends at:
5
10
15
20
25
30
35
40
75
80
85
90
95
100
105
110 or greater
45
5C. LEFT ELBOW POST-TEST ROM
Select where post-test flexion ends:
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145 or greater
50
55
60
65
70
Select where post-test extension ends:
0 or any degree of hyperextension (no limitation of extension)
Unable to fully extend; extension ends at:
5
10
15
20
25
30
35
40
75
80
85
90
95
100
105
110 or greater
45
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 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 ELBOW AND FOREARM FOLLOWING REPETITIVE-USE TESTING?
YES
NO
6B. DOES THE VETERAN HAVE ANY FUNCTIONAL LOSS AND/OR FUNCTIONAL IMPAIRMENT OF THE ELBOW AND FOREARM?
YES
NO
VA FORM 21-0960M-4, JAN 2011
Page 2
SECTION VI - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION IN ROM (continued)
6C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT AND/OR ADDITIONAL LIMITATION OF ROM OF THE ELBOW AND FOREARM AFTER
REPETITIVE USE, INDICATE THE CONTRIBUTING FACTORS OF DISABILITY BELOW (check all that apply and indicate side affected):
No functional loss for right upper extremity
No functional loss for left upper 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
Pain on movement
Right
Left
Right
Left
Both
Both
Swelling
Right
Left
Both
Deformity
Right
Left
Both
Atrophy of disuse
Right
Left
Both
SECTION VII - PAIN (pain on palpation)
7. DOES THE VETERAN HAVE LOCALIZED TENDERNESS OR PAIN ON PALPATION OF JOINTS/SOFT TISSUE OF EITHER ELBOW OR FOREARM?
YES
IF YES, SIDE AFFECTED:
NO
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 elimiated
3/5 Active movement against gravity
4/5 Active movement against some resistance
5/5 Normal strength
Elbow flexion:
Elbow 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 - ANKYLOSIS
9. DOES THE VETERAN HAVE ANKYLOSIS OF THE ELBOW?
YES
NO
IF YES, INDICATE SIDE AND SEVERITY:
At an angle of more than 90 degrees
Right
Left
Both
At an angle between 90 and 70 degrees
Right
Left
Both
At an angle between 70 and 50 degrees
Right
Left
Both
At an angle of less than 50 degrees
Right
Left
Both
SECTION X - ADDITIONAL CONDITIONS
10. DOES THE VETERAN HAVE FLAIL JOINT, JOINT FRACTURE AND/OR IMPAIRMENT OF SUPINATION OR PRONATION?
YES
NO
IF YES, INDICATE CONDITION AND COMPLETE THE APPROPRIATE SECTIONS BELOW.
A. FLAIL JOINT OF THE ELBOW.
If checked, indicate side:
Right
Left
Both
B. INTRA-ARTICULAR FRACTURE (joint fracture) WITH MARKED VARUS OR VALGUS DEFORMITY?
If checked, indicate side:
Right
Left
Both
C. INTRA-ARTICULAR FRACTURE (joint fracture) WITH UNUNITED FRACTURE OF THE HEAD OF THE RADIUS?
If checked, indicate side:
Right
Left
Both
D. IMPAIRMENT OF SUPINATION OR PRONATION
If checked, indicate severity and side
Supination limited to 30 degrees or less
Right
Left
Both
Limited pronation with motion lost beyond the last quarter of the arc;
hand does not approach full pronation
Right
Left
Both
Limited pronation with motion lost beyond the middle of the arc
Right
Left
Both
Hand is fixed near the middle of the arc or moderate pronation due to bone fusion
Right
Left
Both
Hand fixed in full pronation due to bone fusion
Right
Left
Both
Hand fixed in supination or hyperpronation due to bone fusion
Right
Left
Both
VA FORM 21-0960M-4, JAN 2011
Page 3
SECTION XI - JOINT REPLACEMENT AND/OR OTHER SURGICAL PROCEDURES
11A. HAS THE VETERAN HAD A TOTAL ELBOW JOINT REPLACEMENT?
YES
NO
IF YES, INDICATE SIDE AND SEVERITY OF RESIDUALS
Right elbow
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 elbow
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 ELBOW SURGERY?
YES
NO
Right
IF YES, INDICATE SIDE AFFECTED:
Left
Both
Date of surgery:
11C. DOES THE VETERAN HAVE ANY RESIDUAL SIGNS AND/OR SYMPTOMS DUE TO ARTHROSCOPIC OR OTHER ELBOW SURGERY?
YES
NO
Right
IF YES, INDICATE SIDE AFFECTED:
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 THE
DIAGNOSIS SECTION ABOVE?
YES
NO
IF YES, ARE ANY OF THE SCARS PAINFUL/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.
12B. 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):
NOTE: In all forearm injuries, if there are impaired finger movements due to tendon, muscle or nerve injuries, also complete the appropriate disability Questionnaire(s),
such as the VA Form 21-0960M-7, Hand and/or Finger Conditions Disability Benefits Questionnaire or VA Form 21-0960C-10, Peripheral Nerves Conditions (Not
including Diabetic Sensory-Motor Peripheral Neuropathy) Disability Benefits Questionnaire.
SECTION XIII - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
13. DUE TO THE SERVICE-CONNECTED DISABLING 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 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 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):
VA FORM 21-0960M-4, JAN 2011
Page 4
SECTION XIV - DIAGNOSTIC TESTING
NOTE: 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 ELBOW BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES
NO
IF YES, IS DEGENERATIVE OR TRAUMATIC ARTHRITIS DOCUMENTED?
YES
NO
IF YES, INDICATE ELBOW:
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):
SECTION XV - FUNCTIONAL IMPACT
15. DOES THE VETERAN'S ELBOW/FOREARM CONDITION IMPACT HIS OR HER ABILITY TO WORK?
YES
NO
IF YES DESCRIBE THE IMPACT OF EACH OF THE VETERAN'S CONDITIONS PROVIDING ONE OR MORE EXAMPLES:
SECTION XVI - REMARKS
16. 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.
17A. PHYSICIAN'S SIGNATURE
17B. PHYSICIAN'S PRINTED NAME
17D. PHYSICIAN'S PHONE AND FAX NUMBER 17E. PHYSICIAN'S MEDICAL LICENSE NUMBER
17C. DATE SIGNED
17F. 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-4, JAN 2011
Page 5
| File Type | application/pdf |
| File Title | VA Form 21-0960M-4 |
| Subject | Elbow and Forearm - Disability Benefits Questionnaire |
| Author | N. Kessinger |
| File Modified | 2011-12-30 |
| File Created | 2011-01-31 |