VA Form 21-0960M-1 Amputations Disability Benefits Questionnaire

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

AMPUTATIONS
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.
NOTE: If the following are noted, complete the appropriate disability questionnaire.
1. For limited motion or instability in the joint above the amputation site, also complete the Disability Benefits Questionnaire for the specific joint.
2. For scars, or skin breakdown also complete the VA Form 21-0960F-1, Scars Disability Benefits Questionnaire.
3. For muscular injuries, also complete VA Form 21-0960M-10, Muscle Injury Disability Benefits Questionnaire.
4. For Osteomyelitis, also complete the VA Form 21-0960M-11, Osteomyelitis Disability Benefits Questionnaire.
5. For circulation conditions related to amputation, also complete VA Form 21-0960A-2, Arteries and Veins Disability Benefits Questionnaire.
6. For painful neuroma, also complete VA Form 21-0960C-1, Peripheral Nerve Disability Benefits Questionnaire.

SECTION I - DIAGNOSIS
1A. HAS AN AMPUTATION(S) BEEN PERFORMED?
YES

(If "Yes," complete Item 1B)

NO

1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO AMPUTATION(S)
AMPUTATION # 1 -

ICD CODE -

DATE OF AMPUTATION -

AMPUTATION # 2 -

ICD CODE -

DATE OF AMPUTATION -

AMPUTATION # 3 -

ICD CODE -

DATE OF AMPUTATION -

1C. IF ADDITIONAL AMPUTATION(S) EXIST, LIST USING ABOVE FORMAT

SECTION II - MEDICAL HISTORY

2. DESCRIBE THE ETIOLOGY OF EACH AMPUTATION LISTED IN SECTION I:

SECTION III - DOMINANT HAND

3. DOMINANT HAND
LEFT

RIGHT

AMBIDEXTROUS

4. AMPUTATION(S) SITE(S) (Check all that apply)

SECTION IV - AMPUTATION(S) SITE(S)

UPPER EXTREMITIES (not including the fingers)
FINGERS
LOWER EXTREMITIES (including the forefoot)
TOES

(If checked, complete the appropriate section below)
NOTE - Imaging studies are not required to document amputation(s)
SECTION V - AMPUTATION(S) OF THE UPPER EXTREMITY(IES) (NOT INCLUDING FINGERS)

5A. IS THERE AN AMPUTATION OF EITHER ARM?
YES

NO

(If "Yes," check all that apply)
RIGHT

LEFT
Amputation is below insertion of deltoid

Amputation is below insertion of deltoid

Amputation is above insertion of deltoid

Amputation is above insertion of deltoid

Disarticulation
Does the amputation site allow the use of a suitable
prosthetic appliance?
YES

VA FORM
JAN 2011

NO

21-0960M-1

Disarticulation
Does the amputation site allow the use of a suitable
prosthetic appliance?
YES

NO

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SECTION V - AMPUTATION(S) OF THE UPPER EXTREMITY(IES) (NOT INCLUDING FINGERS) (Continued)

5B. IS THERE AN AMPUTATION OF EITHER FOREARM?
YES

NO

(If "Yes," check all that apply)
RIGHT

LEFT
Amputation resulting in loss of use of the hand

Amputation resulting in loss of use of hand

Amputation below insertion of pronator teres

Amputation below insertion of pronator teres

Amputation above insertion of pronator teres

Amputation above insertion of pronator teres

Does the amputation site allow the use of a suitable
prosthetic appliance?
YES

NO

YES

6A. IS THERE AN AMPUTATION OF EITHER THUMB?
YES

Does the amputation site allow the use of a suitable
prosthetic appliance?

NO

NO

SECTION VI - AMPUTATION(S) OF FINGER(S)

(If "Yes," check all that apply)

LEFT

RIGHT

Amputation at the distal joint or through the distal
phalanx
Amputation at the metacarpophalangeal joint or
through the proximal phalanx
Amputation with metacarpal resection

Amputation at the distal joint or through the distal
phalanx
Amputation at the metacarpophalangeal joint or
through the proximal phalanx
Amputation with metacarpal resection

6B. IS THERE AN AMPUTATION OF EITHER INDEX FINGER?
YES

NO

(If "Yes," check all that apply)
RIGHT

LEFT
Amputation through the long phalanx or at the distal
joint

Amputation through the long phalanx or at the distal
joint

Amputation without metacarpal resection, at the
proximal interphalangeal joint or proximal thereto

Amputation without metacarpal resection, at the
proximal interphalangeal joint or proximal thereto

Amputation with metacarpal resection (more than onehalf the bone lost)

Amputation with metacarpal resection (more than onehalf the bone lost)

6C. IS THERE AN AMPUTATION OF EITHER LONG FINGER?
YES

NO

(If "Yes," check all that apply)

LEFT

RIGHT

Amputation without metacarpal resection, at the
proximal interphalangeal joint or proximal thereto

Amputation without metacarpal resection, at the
proximal interphalangeal joint or proximal thereto

Amputation with metacarpal resection (more than onehalf the bone lost)

Amputation with metacarpal resection (more than onehalf the bone lost)

6D. IS THERE AN AMPUTATION OF EITHER RING FINGER?
YES

NO

(If "Yes," check all that apply)
RIGHT

LEFT
Amputation without metacarpal resection, at the
proximal interphalangeal joint or proximal thereto
Amputation with metacarpal resection (more than onehalf the bone lost)

Amputation without metacarpal resection, at the
proximal interphalangeal joint or proximal thereto
Amputation with metacarpal resection (more than onehalf the bone lost)

6E. IS THERE AN AMPUTATION OF EITHER LITTLE FINGER?
NO (If "Yes," check all that apply)

YES
LEFT

RIGHT

Amputation without metacarpal resection, at the
proximal interphalangeal joint or proximal thereto
Amputation with metacarpal resection (more than onehalf the bone lost)

Amputation without metacarpal resection, at the
proximal interphalangeal joint or proximal thereto
Amputation with metacarpal resection (more than onehalf the bone lost)

SECTION VII - AMPUTATION(S) OF THE LOWER EXTREMITY(IES) (NOT INCLUDING THE TOES)
7A. IS THERE AN AMPUTATION ABOVE EITHER KNEE?
YES

NO

(If "Yes," check all that apply)

LEFT
Amputation of the middle or lower third
Amputation of the upper third, one-third of the distance
from the perineum to the knee joint, measured from the
perineum
Disarticulation with loss of extrinsic pelvic girdle muscles
Does the amputation site allow the use of a suitable
prosthetic appliance?
YES
NO
VA FORM 21-0960M-1, JAN 2011

RIGHT
Amputation of the middle or lower third
Amputation of the upper third, one-third of the distance
from the perineum to the knee joint, measured from the
perineum
Disarticulation with loss of extrinsic pelvic girdle muscles
Does the amputation site allow the use of a suitable
prosthetic appliance?
YES

NO

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SECTION VII - AMPUTATION(S) OF THE LOWER EXTREMITY(IES) (NOT INCLUDING THE TOES) (Continued)
7B. IS THERE AN AMPUTATION BELOW EITHER KNEE (TO INCLUDE FOREFOOT)?
YES

NO

(If "Yes," check all that apply)

LEFT
Amputation of the forefoot, which is proximal to the
metatarsal bones (more than one-half of metatarsal loss)

RIGHT
Amputation of the forefoot, which is proximal to the
metatarsal bones (more than one-half of metatarsal loss)

Amputation at a lower level (between the forefoot and
knee), permitting prosthesis

Amputation at a lower level (between the forefoot and
knee), permitting prosthesis

Amputation not improvable by prosthesis controlled by
natural knee action

Amputation not improvable by prosthesis controlled by
natural knee action

Amputation with defective stump and amputation of the
thigh recommended

Amputation with defective stump and amputation of the
thigh recommended

Does the amputation site allow the use of a suitable
prosthetic appliance?

Does the amputation site allow the use of a suitable
prosthetic appliance?
YES

NO

YES

NO

SECTION VIII - AMPUTATION(S) OF THE TOE(S)

8. IS THERE AN AMPUTATION OF A TOE(S) OF EITHER FOOT?
YES

NO

(If "Yes," check all that apply)
RIGHT

LEFT
Is there amputation of all toes without metatarsal loss?

Is there amputation of all toes without metatarsal loss?

YES
NO
Is there amputation of the great toe?

YES
NO
Is there amputation of the great toe?

YES

NO

YES

NO

(If "Yes," indicate which of the following apply):

(If "Yes," indicate which of the following apply):

Amputation without metatarsal involvement

Amputation without metatarsal involvement

Amputation with removal of the metatarsal head

Amputation with removal of the metatarsal head

Is there amputation of any lesser toe with removal of
the metatarsal head?

Is there amputation of any lesser toe with removal of
the metatarsal head?

YES

NO

YES

NO

(If "Yes," indicate which of the following apply):

(If "Yes," indicate which of the following apply):

Amputation of toes one or two

Amputation of toes one or two

Amputation without metatarsal involvement

Amputation without metatarsal involvement

Is there amputation of toes three or four without
metatarsal involvement?

Is there amputation of toes three or four without
metatarsal involvement?

YES

NO

YES

NO

(If "Yes," indicate which of the following apply):

(If "Yes," indicate which of the following apply):

Amputation not including great toe
Amputation including great toe

Amputation not including great toe
Amputation including great toe

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))

VA FORM 21-0960M-1, JAN 2011

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SECTION X - ASSISTIVE DEVICES

10. DOES THE VETERAN NEED REGULAR AND CONSTANT USE OF A WHEELCHAIR, BRACES, CRUTCHES OR CANES AS A NORMAL MODE OF LOCOMOTION,
ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS MAY BE POSSIBLE?
YES

NO

(If "Yes," identify the condition(s) causing the need for assistive device(s))

SECTION XI - DIAGNOSTIC TESTING
NOTE - Imaging studies are not required to document amputation(s)
11. DIAGNOSTIC TESTING - If there are significant diagnostic testing or imaging results, report results and date

SECTION XII - FUNCTIONAL IMPACT AND REMARKS
12. DOES THE VETERAN'S AMPUTATION IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe the impact of each of the veteran's amputations providing one or more examples)

13. REMARKS (If any)

SECTION XIII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
14A. PHYSICIAN'S SIGNATURE

14D. PHYSICIAN'S PHONE AND FAX NUMBER

14B. PHYSICIAN'S PRINTED NAME

14E. PHYSICIAN'S MEDICAL LICENSE NUMBER

14C. DATE SIGNED

14F. PHYSICIAN'S ADDRESS

NOTE - VA may obtain additional medical information, including an examination, 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-1, JAN 2011

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