VA Form 21-0960M-3 Non-Degenerative Arthritis (Including inflammatory, Auto

OMB Approved No. 2900-0778
Respondent Burden: 15 minutes

NON-DEGENERATIVE ARTHRITIS (INCLUDING INFLAMMATORY,
AUTOIMMUNE, CRYSTALLINE AND INFECTIOUS ARTHRITIS) AND
DYSBARIC OSTEONECROSIS 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: Complete this Questionnaire if the veteran has an inflammatory, autoimmune, crystalline or infectious arthritis, or dysbaric osteonecrosis (Caisson disease of
bone).
If the veteran has degenerative arthritis (osteoarthritis) or traumatic arthritis, do not complete this Questionnaire, INSTEAD complete the joint Questionnaire for the
affected area (e.g., if the diagnosis is osteoarthritis of the knee, complete VA Form 21-0960M-9, Knee and Lower Leg Disability Benefits Questionnaire).
If the veteran has arthritis due to systemic lupus erythematosus (SLE), instead complete the VA Form 21-0960I-4, Systemic Lupus Erthematosus (SLE) and Other
Autoimmune Diseases Disability Benefits Questionnaire.
SECTION I - DIAGNOSIS

1A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER BEEN DIAGNOSED WITH INFLAMMATORY, AUTOIMMUNE, CRYSTALLINE OR INFECTIOUS ARTHRITIS
OR DYSBARIC OSTEONECROSIS (Caisson disease)?
NO

YES

1B. IF YES, INDICATE THE DIAGNOSIS:
GOUT

ICD CODE(S):

DATE OF DIAGNOSIS:

RHEUMATOID ARTHRITIS (atrophic)

ICD CODE(S):

DATE OF DIAGNOSIS:

GONORRHEAL ARTHRITIS

ICD CODE(S):

DATE OF DIAGNOSIS:

PNEUMOCOCCIC ARTHRITIS

ICD CODE(S):

DATE OF DIAGNOSIS:

TYPHOID ARTHRITIS

ICD CODE(S):

DATE OF DIAGNOSIS:

SYPHILITIC ARTHRITIS

ICD CODE(S):

DATE OF DIAGNOSIS:

STREPTOCOCCIC ARTHRITIS

ICD CODE(S):

DATE OF DIAGNOSIS:

DYSBARIC OSTEONECROSIS (Caisson Disease of Bone)

ICD CODE(S):

DATE OF DIAGNOSIS:

OTHER
IF CHECKED, PROVIDE ONLY DIAGNOSES THAT PERTAIN TO INFLAMMATORY, AUTOIMMUNE, CRYSTALLINE OR INFECTIOUS ARTHRITIS:
OTHER DIAGNOSIS #1:

ICD CODE:

DATE OF DIAGNOSIS:

OTHER DIAGNOSIS #2:

ICD CODE:

DATE OF DIAGNOSIS:

OTHER DIAGNOSIS #3:

ICD CODE:

DATE OF DIAGNOSIS:

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO INFLAMMATORY, AUTOIMMUNE, CRYSTALLINE OR INFECTIOUS ARTHRITIS, LIST USING ABOVE
FORMAT:

SECTION II - MEDICAL HISTORY
2A. DESCRIBE HISTORY (including onset and course) OF THE VETERAN'S INFLAMMATORY, AUTOIMMUNE, CRYSTALLINE OR INFECTIOUS ARTHRITIS OR
DYSBARIC OSTEONECROSIS (brief summary):

2B. DOES THE VETERAN REQUIRE CONTINUOUS USE OF MEDICATION FOR THIS ARTHRITIS CONDITION?
YES

NO

IF YES, LIST ONLY THOSE MEDICATIONS USED FOR THIS ARTHRITIS:
2C. HAS THE VETERAN LOST WEIGHT DUE TO THIS ARTHRITIS CONDITION?
YES

NO

IF YES, PROVIDE BASELINE WEIGHT (average weight for 2-year period preceding onset of disease):

, AND CURRENT WEIGHT

IF YES, DOES THE VETERAN'S WEIGHT LOSS ATTRIBUTABLE TO THIS ARTHRITIS CONDITION CAUSE IMPAIRMENT OF HEALTH?
YES

NO

IF YES, DESCRIBE THE IMPAIRMENT:
VA FORM
FEB 2011

21-0960M-3

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SECTION II - MEDICAL HISTORY (Continued)
2D. DOES THE VETERAN HAVE ANEMIA DUE TO THIS ARTHRITIS CONDITION?
YES

NO

IF YES, DOES THE VETERAN'S ANEMIA ATTRIBUTABLE TO THIS ARTHRITIS CONDITION CAUSE IMPAIRMENT OF HEALTH?
YES

NO

IF YES, DESCRIBE THE IMPAIRMENT (also provide CBC under diagnostic testing section #9):

SECTION III - JOINT INVOLVEMENT
3A. DOES THE VETERAN HAVE PAIN (with or without joint movement) ATTRIBUTABLE TO THIS ARTHRITIS CONDITION?
YES

NO

IF YES, INDICATE AFFECTED JOINTS (check all that apply):
THORACOLUMBAR SPINE

CERVICAL SPINE

SACROILIAC JOINTS

RIGHT:

SHOULDER

ELBOW

WRIST

HAND/FINGERS

HIP

KNEE

ANKLE

FOOT/TOES

LEFT:

SHOULDER

ELBOW

WRIST

HAND/FINGERS

HIP

KNEE

ANKLE

FOOT/TOES

FOR ALL CHECKED JOINTS, DESCRIBE INVOLVEMENT (brief summary). ALSO COMPLETE A QUESTIONNAIRE FOR EACH AFFECTED JOINT, IF INDICATED.

3B. DOES THE VETERAN HAVE ANY LIMITATION OF JOINT MOVEMENT ATTRIBUTABLE TO THIS ARTHRITIS CONDITION?
YES

NO

IF YES, INDICATE AFFECTED JOINTS (check all that apply):
THORACOLUMBAR SPINE

CERVICAL SPINE

SACROILIAC JOINTS

RIGHT:

SHOULDER

ELBOW

WRIST

HAND/FINGERS

HIP

KNEE

ANKLE

FOOT/TOES

LEFT:

SHOULDER

ELBOW

WRIST

HAND/FINGERS

HIP

KNEE

ANKLE

FOOT/TOES

FOR ALL CHECKED JOINTS, DESCRIBE LIMITATION OF MOVEMENT (brief summary). ALSO COMPLETE A QUESTIONNAIRE FOR EACH AFFECTED JOINT, IF
INDICATED.

3C. DOES THE VETERAN HAVE ANY JOINT DEFORMITIES ATTRIBUTABLE TO THIS ARTHRITIS CONDITION?
YES

NO

IF YES, INDICATE AFFECTED JOINTS (check all that apply):
THORACOLUMBAR SPINE

CERVICAL SPINE

SACROILIAC JOINTS

RIGHT:

SHOULDER

ELBOW

WRIST

HAND/FINGERS

HIP

KNEE

ANKLE

FOOT/TOES

LEFT:

SHOULDER

ELBOW

WRIST

HAND/FINGERS

HIP

KNEE

ANKLE

FOOT/TOES

FOR ALL CHECKED JOINTS, DESCRIBE DEFORMITIES (brief summary). ALSO COMPLETE A QUESTIONNAIRE FOR EACH AFFECTED JOINT, IF INDICATED.

SECTION IV - SYSTEMIC INVOLVEMENT OTHER THAN JOINTS
4. DOES THE VETERAN HAVE ANY INVOLVEMENT OF ANY SYSTEMS, OTHER THAN JOINTS, ATTRIBUTABLE TO THIS ARTHRITIS CONDITION?
YES

NO

IF YES, INDICATE SYSTEMS INVOLVED (check all that apply):
SKIN AND MUCOUS MEMBRANES

OPHTHALMOLOGICAL
NEUROLOGIC

RENAL

GASTROINTESTINAL

HEMATOLOGIC

PULMONARY

CARDIAC

VASCULAR

FOR ALL CHECKED SYSTEMS, DESCRIBE INVOLVEMENT (brief summary). ALSO COMPLETE THE APPROPRIATE QUESTIONNAIRE IF INDICATED.

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SECTION V - INCAPACITATING AND NON-INCAPACITATING EXACERBATIONS
5A. DUE TO THE ARTHRITIS CONDITION, DOES THE VETERAN HAVE EXACERBATIONS WHICH ARE NOT INCAPACITATING?
YES

NO

IF YES, INDICATE FREQUENCY OF NON-INCAPACITATING EXACERBATIONS PER YEAR:
1

0

2

3

4 OR MORE

Date of most recent non-incapacitating exacerbation:
Duration of most recent non-incapacitating exacerbation:
Describe non-incapacitating exacerbation:
5B. DUE TO THE ARTHRITIS CONDITION, DOES THE VETERAN HAVE EXACERBATIONS WHICH ARE INCAPACITATING?
YES

NO

IF YES, DESCRIBE:
INDICATE FREQUENCY OF INCAPACITATING EXACERBATIONS PER YEAR:
0

1

2

3

4 OR MORE

Date of most recent incapacitating exacerbation:
Duration of most recent incapacitating exacerbation:
Describe incapacitating exacerbation:
5C. DUE TO THE ARTHRITIS CONDITION, DOES THE VETERAN HAVE CONSTITUTIONAL MANIFESTATIONS ASSOCIATED WITH ACTIVE JOINT INVOLVEMENT
WHICH ARE TOTALLY INCAPACITATING?
YES

NO

IF YES, HAS THE VETERAN BEEN TOTALLY INCAPACITATED DUE TO THIS DURING THE PAST 12 MONTHS?
YES

NO

IF YES, INDICATE THE TOTAL DURATION OF INCAPACITATION OVER THE PAST 12 MONTHS:
< 1 WEEK
1 WEEK TO < 2 WEEKS
2 WEEKS TO < 4 WEEKS
4 WEEKS TO < 6 WEEKS
6 WEEKS OR MORE
DESCRIBE CONSTITUTIONAL MANIFESTATIONS AND THE MANNER IN WHICH THOSE MANIFESTATIONS CAUSE INCAPACITATION:

SECTION VI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
6A. 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 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.

6B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN THE DIAGNOSIS SECTION ABOVE?
YES

NO

IF YES, DESCRIBE (brief summary):

SECTION VII - ASSISTIVE DEVICES
7A. 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:

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SECTION VII - ASSISTIVE DEVICES (Continued)
7B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION

SECTION VIII - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
8. DUE TO THE VETERAN'S INFLAMMATORY, AUTOIMMUNE, CRYSTALLINE OR INFECTIOUS ARTHRITIS OR DYSBARIC OSTEONECROSIS, 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

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 IX - 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.
9A. HAVE IMAGING STUDIES BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

IF YES, INDICATE TYPE OF STUDY:
X-RAY

Area imaged:

Date:

Results:

Area imaged:

Date:

Results:

OTHER, SPECIFY:

9B. HAVE LABORATORY STUDIES BEEN PERFORMED?
NOTE: ONCE A DIAGNOSIS HAS BEEN CONFIRMED, LABORATORY STUDIES ARE NOT INDICATED FOR A DISABILITY EXAM.
YES

NO

IF YES, CHECK ALL THAT APPLY:
ERYTHROCYTE SEDIMENTATION RATE (ESR)

Date of test:

Results:

C-REACTIVE PROTEIN

Date of test:

Results:

RHEUMATOID FACTOR (RF)

Date of test:

Results:

ANTI-DNA ANTIBODIES

Date of test:

Results:

ANTINUCLEAR ANTIBODIES (ANA)

Date of test:

Results:

ANTI-CYCLIC CITRULLINATED PEPTIDE (ANTI-CCP) ANTIBODIES

Date of test:

Results:

CBC

Date of test:

Hemoglobin:

Hematocrit:

White blood cell count:

Platelets:

URIC ACID TEST

Date of test:

Results:

OTHER, SPECIFY:

Date of test:

Results:

9C. HAS THE VETERAN HAD A JOINT ASPIRATION/SYNOVIAL FLUID ANALYSIS?
NOTE: ONCE A DIAGNOSIS HAS BEEN CONFIRMED, TESTING IS NOT INDICATED FOR A DISABILITY EXAM.
YES

NO

IF YES, INDICATE JOINT ASPIRATED, DATE AND RESULTS:
9D. HAS THE VETERAN HAD A BIOPSY (e.g., skin, nerve, fat, rectum, kidney)?
NOTE: ONCE A DIAGNOSIS HAS BEEN CONFIRMED, TESTING IS NOT INDICATED FOR A DISABILITY EXAM.
YES

NO

IF YES, INDICATE AREA BIOPSIED, DATE AND RESULTS
9E. 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):

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SECTION X - FUNCTIONAL IMPACT
10. DOES THE VETERAN'S INFLAMMATORY, AUTOIMMUNE, CRYSTALLINE OR INFECTIOUS ARTHRITIS CONDITION OR DYSBARIC OSTEONECROSIS IMPACT HIS
OR HER ABILITY TO WORK?
YES

NO

IF YES, DESCRIBE THE IMPACT OF EACH OF THE VETERAN'S ARTHRITIS OR OSTEONECROSIS CONDITIONS, PROVIDING ONE OR MORE EXAMPLES:

SECTION XI - REMARKS
11. REMARKS (If any)

SECTION XII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
12A. PHYSICIAN'S SIGNATURE

12D. PHYSICIAN'S PHONE AND FAX NUMBER

12B. PHYSICIAN'S PRINTED NAME

12E. PHYSICIAN'S MEDICAL LICENSE NUMBER

12C. DATE SIGNED

12F. 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 15 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
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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-3, FEB 2011

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