VA Form 21-0960M-1 Back (Thoracolumbar Spine) Conditions Disability Benefit

OMB Approved No. 2900-0776
Respondent Burden: 45 minutes

BACK (THORACOLUMBAR SPINE) 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 BEEN DIAGNOSED WITH A THORACOLUMBAR SPINE (back) CONDITION?
YES

(If "Yes," complete Item 1B)

NO

1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO THORACOLUMBAR SPINE (back) CONDITIONS:
Diagnosis # 1 -

ICD code -

Date of diagnosis -

Diagnosis # 2 -

ICD code -

Date of diagnosis -

Diagnosis # 3 -

ICD code-

Date of diagnosis -

1C. THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO THORACOLUMBAR SPINE (back) CONDITIONS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY
2. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S THORACOLUMBAR SPINE (back) CONDITION (brief summary)

SECTION III - FLARE-UPS
3. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE THORACOLUMBAR SPINE (back)?
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) MEASUREMENT

4. MEASURE ROM WITH A GONIOMETER, ROUNDING EACH MEASUREMENT TO THE NEAREST 5 DEGREES. DURING THE MEASUREMENTS, OBSERVE THE POINT
AT WHICH PAINFUL MOTION BEGINS, EVIDENCED BY VISIBLE BEHAVIOR SUCH AS FACIAL EXPRESSION, WINCING, ETC. REPORT INITIAL MEASUREMENTS BELOW.

NOTE: Following the initial assessment of ROM, perform repetitive-use testing. For VA purposes, repetitive-use testing must be included in all exams. The VA has
determined that 3 repetitions of ROM (at 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.
A. SELECT WHERE FORWARD FLEXION ENDS (normal endpoint is 90):
0

5

10

15

20

25

30

35

40

50

55

60

65

70

75

80

85

90 or greater

45

SELECT WHERE OBJECTIVE EVIDENCE OF PAINFUL MOTION BEGINS:
No objective evidence of painful motion
0

5

10

15

20

25

30

35

40

50

55

60

65

70

75

80

85

90 or greater

45

B. SELECT WHERE EXTENSION ENDS (normal endpoint is 30):
0

5

10

15

20

25

30 or greater

SELECT WHERE OBJECTIVE EVIDENCE OF PAINFUL MOTION BEGINS:
No objective evidence of painful motion
0

5

10

15

20

25

30 or greater

C. SELECT WHERE RIGHT LATERAL FLEXION ENDS (normal endpoint is 30):
0

5

10

15

20

25

30 or greater

SELECT WHERE OBJECTIVE EVIDENCE OF PAINFUL MOTION BEGINS:
No objective evidence of painful motion
0
VA FORM
DEC 2010

5

10

21-0960M-14

15

20

25

30 or greater

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SECTION IV - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS (continued)
D. SELECT WHERE LEFT LATERAL FLEXION ENDS (normal endpoint is 30):
5

0

10

15

25

20

30 or greater

SELECT WHERE OBJECTIVE EVIDENCE OF PAINFUL MOTION BEGINS:
No objective evidence of painful motion
5

0

10

15

25

20

30 or greater

E. SELECT WHERE RIGHT LATERAL ROTATION ENDS (normal endpoint is 30):
5

0

10

15

25

20

30 or greater

SELECT WHERE OBJECTIVE EVIDENCE OF PAINFUL MOTION BEGINS:
No objective evidence of painful motion
5

0

10

15

25

20

30 or greater

F. SELECT WHERE LEFT LATERAL ROTATION ENDS (normal endpoint is 30):
5

0

10

15

25

20

30 or greater

SELECT WHERE OBJECTIVE EVIDENCE OF PAINFUL MOTION BEGINS:
No objective evidence of painful motion
5

0

10

15

25

20

30 or greater

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

SECTION V - ROM MEASUREMENT 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 PERFORM REPETITIVE-USE TESTING, MEASURE AND REPORT ROM AFTER A MINIMUM OF 3 REPETITIONS.
B. SELECT WHERE POST-TEST FORWARD FLEXION ENDS:
0

5

10

15

20

25

30

35

40

50

55

60

65

70

75

80

85

90 or greater

C. SELECT WHERE POST-TEST EXTENSION ENDS:
15
5
10
25
0
20

45

30 or greater

D. SELECT WHERE POST-TEST RIGHT LATERAL FLEXION ENDS:
15
5
10
25
30 or greater
0
20
E. SELECT WHERE POST-TEST LEFT LATERAL FLEXION ENDS:
5
10
15
25
30 or greater
0
20
F. SELECT WHERE POST-TEST RIGHT LATERAL ROTATION ENDS:
15
5
10
25
30 or greater
0
20
G. SELECT WHERE POST-TEST LEFT LATERAL ROTATION ENDS:
0
5
10
15
25
30 or greater
20

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 THORACOLUMBAR SPINE (back) FOLLOWING REPETITIVE-USE TESTING?
YES

NO

6B. DOES THE VETERAN HAVE ANY FUNCTIONAL LOSS AND/OR FUNCTIONAL IMPAIRMENT OF THE THORACOLUMBAR SPINE (back)?
YES

NO

6C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT AND/OR ADDITIONAL LIMITATION OF ROM OF THE THORACOLUMBAR SPINE (back)
AFTER REPETITIVE USE, INDICATE THE CONTRIBUTING FACTORS OF DISABILITY BELOW:
Less movement than normal
More movement than normal
Weakened movement
Excess fatigability
Incoordination, impaired ability to execute skilled movements smoothly
Pain on movement
Swelling
Deformity
Atrophy of disuse
Instability of station
Disturbance of locomotion
Interference with sitting, standing and/or weight-bearing
Other, describe:
VA FORM DEC 2010, 21-0960M-14

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SECTION VII - PAIN AND MUSCLE SPASM (pain on palpation, effect of muscle spasm on gait)
7A. DOES THE VETERAN HAVE LOCALIZED TENDERNESS OR PAIN TO PALPATION FOR JOINTS AND/OR SOFT TISSUE OF THE THORACOLUMBAR SPINE (back)?
YES

NO

IF YES, DESCRIBE:

7B. DOES THE VETERAN HAVE GUARDING OR MUSCLE SPASM OF THE THORACOLUMBAR SPINE (back)?
YES

NO

IF YES, IS IT SEVERE ENOUGH TO RESULT IN: (check all that apply)

Abnormal gait
Abnormal spinal contour, such as scoliosis, reversed lordosis, or abnormal kyphosis
Guarding or muscle spasm does not result in abnormal gait or spinal contour

SECTION VIII - MUSCLE STRENGTH TESTING
8A. 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
All normal
Hip flexion:

Knee extension:

Ankle plantar flexion:

Ankle dorsiflexion:

Great toe 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

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

8B. DOES THE VETERAN HAVE MUSCLE ATROPHY?
YES

NO

IF MUSCLE ATROPHY IS PRESENT, INDICATE LOCATION:
PROVIDE MEASUREMENTS IN CENTIMETERS OF NORMAL SIDE AND ATROPHIED SIDE, MEASURED AT MAXIMUM MUSCLE BULK:
NORMAL SIDE:

CM

ATROPHIED SIDE:

CM

SECTION IX - REFLEX EXAM
9. RATE DEEP TENDON REFLEXES (DTRs) ACCORDING TO THE FOLLOWING SCALE:
0 Absent
1+ Hypoactive
2+ Normal
3+ Hyperactive without clonus
4+ Hyperactive with clonus
All normal
Knee:

Ankle:

Right:

0

1+

2+

3+

4+

Left:

0

1+

2+

3+

4+

Right:

0

1+

2+

3+

4+

Left:

0

1+

2+

3+

4+

VA FORM DEC 2010, 21-0960M-14

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SECTION X - SENSORY EXAM
10. PROVIDE RESULTS FOR SENSATION TO LIGHT TOUCH (dermatomes) TESTING:
All normal
Upper anterior thigh (L2):
Thigh/knee (L3/4):
Lower leg/ankle (L4/L5/S1):
Foot/toes (L5):

Right

Normal

Decreased

Absent

Left

Normal

Decreased

Absent

Right

Normal

Decreased

Absent

Left

Normal

Decreased

Absent

Right

Normal

Decreased

Absent

Left

Normal

Decreased

Absent

Right

Normal

Decreased

Absent

Left

Normal

Decreased

Absent

Other sensory findings, if any:

SECTION XI - STRAIGHT LEG RAISING TEST
(This test can be performed with the Veteran seated or supine. Raise each straightened leg until pain begins, typically at 30-70 degrees of elevation. The test is positive
if the pain radiates below the knee, not merely in the back or hamstrings. Pain is often increased on dorsiflexion of the foot, and relieved by knee flexion. A positive test
suggests radiculopathy, often due to disc herniation).
11. PROVIDE STRAIGHT LEG RAISING TEST RESULTS:
Right:

Negative

Positive

Unable to perform

Left:

Negative

Positive

Unable to perform

SECTION XII - RADICULOPATHY
12A. DOES THE VETERAN HAVE RADICULAR PAIN OR ANY OTHER SIGNS OR SYMPTOMS DUE TO RADICULOPATHY?
YES

NO

IF YES, COMPLETE THE FOLLOWING SECTION:

12B. INDICATE SYMPTOMS' LOCATION AND SEVERITY (check all that apply):
Constant pain (may be excruciating at times)
Right lower extremity:

None

Mild

Moderate

Severe

Left lower extremity:

None

Mild

Moderate

Severe

Right lower extremity:

None

Mild

Moderate

Severe

Left lower extremity:

None

Mild

Moderate

Severe

Right lower extremity:

None

Mild

Moderate

Severe

Left lower extremity:

None

Mild

Moderate

Severe

Right lower extremity:

None

Mild

Moderate

Severe

Left lower extremity:

None

Mild

Moderate

Severe

Intermittent pain (usually dull)

Paresthesias and/or dysesthesias

Numbness

12C. DOES THE VETERAN HAVE ANY OTHER SIGNS OR SYMPTOMS OF RADICULOPATHY?
YES

NO

IF YES, DESCRIBE:

12D. INDICATE NERVE ROOTS INVOLVED: (check all that apply)
INVOLVEMENT OF L2/L3/L4 NERVE ROOTS (femoral nerve)
If checked, indicate:

Right

Left

Both

INVOLVEMENT OF L4/L5/S1/S2/S3 NERVE ROOTS (sciatic nerve)
If checked, indicate:

Right

Left

Both)

OTHER NERVES (specify nerve and side(s) affected):
12E. INDICATE SEVERITY OF RADICULOPATHY AND SIDE AFFECTED:
Right:

Not affected

Mild

Moderate

Severe

Left:

Not affected

Mild

Moderate

Severe

VA FORM DEC 2010, 21-0960M-14

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SECTION XIII - OTHER NEUROLOGIC ABNORMALITIES
13. DOES THE VETERAN HAVE ANY OTHER NEUROLOGIC ABNORMALITIES OR FINDINGS RELATED TO A THORACOLUMBAR SPINE (back) CONDITION (such as

bowel or bladder problems/pathologic reflexes)?
YES

NO

IF YES, DESCRIBE CONDITION AND HOW IT IS RELATED:

IF THERE ARE NEUROLOGICAL ABNORMALITIES OTHER THAN RADICULOPATHY, ALSO COMPLETE APPROPRIATE QUESTIONNAIRE FOR EACH CONDITION
IDENTIFIED.

SECTION XIV - INTERVERTEBRAL DISC SYNDROME (IVDS) AND INCAPACITATING EPISODES
14A. DOES THE VETERAN HAVE IVDS OF THE THORACOLUMBAR SPINE?
YES

NO

14B. IF YES, HAS THE VETERAN HAD ANY INCAPACITATING EPISODES OVER THE PAST 12 MONTHS DUE TO IVDS?
YES

NO

NOTE: For VA purposes, an incapacitating episode is a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician.
IF YES, PROVIDE THE TOTAL DURATION OF THE INCAPACITATING EPISODES OVER THE PAST 12 MONTHS:
Less than 1 week
At least 1 week but less than 2 weeks
At least 2 weeks but less than 4 weeks
At least 4 weeks but less than 6 weeks
At least 6 weeks

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

Frequency of use:

Occasional

Regular

Constant

Other:

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

SECTION XVI - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
16. DUE TO THORACOLUMBAR SPINE (back) CONDITION, 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.; functions of 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) (check all extremities for which this applies):
Right lower

Left lower

SECTION XVII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
17A. 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/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)
17B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS?
YES

NO

IF YES, DESCRIBE (brief summary):

VA FORM 21-0960M-14, DEC 2010

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SECTION XVIII - DIAGNOSTIC TESTING
NOTE: The diagnosis of arthritis must be confirmed by imaging studies. Once arthritis has been documented, no further imaging studies are required by VA, even if
arthritis has worsened.
Imaging studies are not required to make the diagnosis of IVDS; Electromyography (EMG) studies are rarely required to diagnose radiculopathy in the appropriate
clinical setting.
For purposes of this examination, the diagnosis of IVDS and/or radiculopathy can be made by a history of characteristic radiating pain and/or sensory changes in the legs,
and objective clinical findings, which may include the asymmetrical loss or decrease of reflexes, decreased strength and/or abnormal sensation.
18A. HAVE THE IMAGING STUDIES OF THE THORACOLUMBAR SPINE BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
NO
YES
IF YES, IS ARTHRITIS DOCUMENTED?
NO

YES

18B. DOES THE VETERAN HAVE A VERTEBRAL FRACTURE?
YES
NO
IF YES, PROVIDE PERCENT OF LOSS OF VERTEBRAL BODY:
18C. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES

NO

IF YES, PROVIDE TYPE OF TEST OF PROCEDURE, DATE AND RESULTS (brief summary):

SECTION XIX - FUNCTIONAL IMPACT
19. DOES THE VETERAN'S THORACOLUMBAR SPINE (back) CONDITION IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

IF YES DESCRIBE THE IMPACT OF EACH OF THE VETERAN'S THORACOLUMBAR SPINE (back) CONDITIONS PROVIDING ONE OR MORE EXAMPLES

SECTION XX - REMARKS
20. REMARKS (If any)

SECTION XXI - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
21A. PHYSICIAN'S SIGNATURE

21D. PHYSICIAN'S PHONE AND FAX NUMBER

21B. PHYSICIAN'S PRINTED NAME

21E. PHYSICIAN'S MEDICAL LICENSE NUMBER

21C. DATE SIGNED

21F. 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, 58VA21/22/28, 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 45 minutes to review the instructions, find the information, and complete a form. VA cannot conduct or
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get information on where to send comments or suggestions about this form.
VA FORM 21-0960M-14, DEC 2010

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