Form 21-0960M-6 Foot Conditions, Including Flatfoot (Pes Planus) Disabil

OMB Approved No. 2900-0810
Respondent Burden: 30 minutes
Expiration Date: XXXXXXX

FOOT CONDITIONS, INCLUDING FLATFOOT (PES PLANUS)
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 ON
REVERSE BEFORE COMPLETING FORM.
NAME OF PATIENT/VETERAN

PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

NOTE TO PHYSICIAN - The veteran or service member 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 claim. VA reserves the right to confirm the authenticity of ALL DBQs
completed by private health care providers.
MEDICAL RECORD REVIEW
WAS THE VETERAN'S VA CLAIMS FILE REVIEWED?
NO

YES

IF YES, LIST ANY RECORDS THAT WERE REVIEWED BUT WERE NOT INCLUDED IN THE VETERAN'S VA CLAIMS FILE:
IF NO, CHECK ALL RECORDS REVIEWED:
Military service treatment records

Department of Defense Form 214 Separation Documents

Military service personnel records

Veterans Health Administration medical records (VA treatment records)

Military enlistment examination

Civilian medical records

Military separation examination

Interviews with collateral witnesses (family and others who have known the veteran before and after military service)

Military post-deployment questionnaire

Other:
No records were reviewed

SECTION I - DIAGNOSIS
NOTE: These are condition(s) for which an evaluation has been requested on an exam request form (Internal VA) or for which the Veteran has requested medical
evidence be provided for submission to VA.
1A. LIST THE CLAIMED CONDITION(S) THAT PERTAIN TO THIS DBQ:

NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed above. If there is no diagnosis, if the diagnosis is different
from a previous diagnosis for this condition, or if there is a diagnosis of a complication due to the claimed condition, explain your findings and reasons in comments
section.
Date of diagnosis can be the date of the evaluation if the clinician is making the initial diagnosis, or an approximate date determined through record review or reported
history.
1B. SELECT DIAGNOSES ASSOCIATED WITH THE CLAIMED CONDITION(S) (Check all that apply):
The Veteran does not have a current diagnosis associated with any claimed condition listed above. (Explain your findings and reasons in comments section.)
Flat foot (pes planus)

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Both

ICD Code:

Date of diagnosis:

Both

ICD Code:

Date of diagnosis:

Both

ICD Code:

Date of diagnosis:

Both

ICD Code:

Date of diagnosis:

Both

ICD Code:

Date of diagnosis:

Both

ICD Code:

Date of diagnosis:

Both

ICD Code:

Date of diagnosis:

Both

ICD Code:

Date of diagnosis:

(If checked, complete all of Section I, Section II, and Section III)
Morton's neuroma

Side affected:

Right

Left

(If checked, complete all of Section I, Section II, and Section IV)
Metatarsalgia

Side affected:

Right

Left

(If checked, complete all of Section I, Section II, and Section IV)
Hammer toes

Side affected:

Right

Left

(If checked, complete all of Section I, Section II, and Section V)
Hallux valgus

Side affected:

Right

Left

(If checked, complete all of Section I, Section II, and Section VI)
Hallux rigidus

Side affected:

Right

Left

(If checked, complete all of Section I, Section II, and Section VII)
Acquired pes cavus (claw foot) Side affected:

Right

Left

(If checked, complete all of Section I, Section II, and Section VIII)
Malunion/nonunion of tarsal/
metatarsal bones

Side affected:

Foot injury(ies) Specify:

Side affected:

Right

Left

(If checked, complete all of Section I, Section II, and Section IX)

VA FORM
XXXX

21-0960M-6

Right

Left

SUPERSEDES VA FORM 21-0960M-6,
MAY 2013, WHICH WILL NOT BE USED.

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION I - DIAGNOSIS (Continued)

1B. SELECT DIAGNOSES ASSOCIATED WITH THE CLAIMED CONDITION(S) (Check all that apply) (Continued):

(If checked, complete all of Section I, Section II, and Section X)
Plantar fasciitis
Other (specify)

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

(If checked, complete all of Section I, question #8 of Section II, and all of Section III)

Other diagnosis #1:
Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Right

Left

Both

ICD Code:

Date of diagnosis:

Right

Left

Both

ICD Code:

Date of diagnosis:

Other diagnosis #2:
Side affected:
Other diagnosis #3:
Side affected:
1C. COMMENTS (if any):

1D. WAS AN OPINION REQUESTED ABOUT THIS CONDITION (internal VA only)?
YES

NO

N/A

SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S FOOT CONDITION (brief summary):

2B. DOES THE VETERAN REPORT PAIN OF THE FOOT BEING EVALUATED ON THIS DBQ?
YES

NO

IF YES, DOCUMENT THE VETERAN'S DESCRIPTION OF PAIN IN HIS OR HER OWN WORDS:

2C. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE FOOT?
YES

NO

IF YES, DOCUMENT THE VETERAN'S DESCRIPTION OF THE IMPACT OF FLARE-UPS IN HIS OR HER OWN WORDS:

2D. DOES THE VETERAN REPORT HAVING ANY FUNCTIONAL LOSS OR FUNCTIONAL IMPAIRMENT OF THE FOOT BEING EVALUATED ON THIS DBQ (regardless
of repetitive use)?
YES

NO

IF YES, DOCUMENT THE VETERAN'S DESCRIPTION OF FUNCTIONAL LOSS OR FUNCTIONAL IMPAIRMENT IN HIS OR HER OWN WORDS:

SECTION III - FLATFOOT (PES PLANUS)
COMPLETE THIS SECTION IF THE VETERAN HAS FLATFOOT (PES PLANUS).
INDICATE ALL SIGNS AND SYMPTOMS THAT APPLY TO THE VETERAN'S FLATFOOT CONDITION, REGARDLESS OF WHETHER SIMILAR SIGNS AND SYMPTOMS
APPEAR MORE THAN ONCE IN DIFFERENT SECTIONS.
3A. DOES THE VETERAN HAVE PAIN ON USE OF THE FEET?
YES

NO

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

IF YES, IS THE PAIN ACCENTUATED ON MANIPULATION?
IF YES, INDICATE SIDE AFFECTED:

RIGHT

BOTH
YES

LEFT

NO
BOTH

3B. DOES THE VETERAN HAVE PAIN ON MANIPULATION OF THE FEET?
YES

NO

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

IF YES, IS THE PAIN ACCENTUATED ON MANIPULATION?
IF YES, INDICATE SIDE AFFECTED:
VA FORM 21-0960M-6, XXXX

RIGHT

LEFT

BOTH
YES

NO
BOTH
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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION III - FLATFOOT (Continued)
3C. IS THERE INDICATION OF SWELLING ON USE?
YES

NO

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

3D. DOES THE VETERAN HAVE CHARACTERISTIC CALLUSES?
YES

NO

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

3E. EFFECTS OF USE OF ARCH SUPPORTS, BUILT UP SHOES OR ORTHOTICS
Effecting Relief of Symptoms
Device

Tried But Remains Symptomatic

Side Relieved

Device

Side Not Relieved

Arch Supports

Right

Left

Both

Arch Supports

Right

Left

Both

Built-up Shoes

Right

Left

Both

Built-up Shoes

Right

Left

Both

Orthotics

Right

Left

Both

Orthotics

Right

Left

Both

3F. DOES THE VETERAN HAVE EXTREME TENDERNESS OF PLANTAR SURFACES ON ONE OR BOTH FEET?
YES

NO

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

IS THE TENDERNESS IMPROVED BY ORTHOPEDIC SHOES OR APPLIANCES?
RIGHT

YES

NO

N/A

LEFT

YES

NO

N/A

3G. DOES THE VETERAN HAVE DECREASED LONGITUDINAL ARCH HEIGHT OF ONE OR BOTH ON WEIGHT-BEARING?
YES

NO

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

3H. IS THERE OBJECTIVE EVIDENCE OF MARKED DEFORMITY OF ONE OR BOTH FEET (pronation, abduction etc.)?
YES

NO

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

3I. IS THERE MARKED PRONATION OF ONE FOOT OR BOTH FEET?
YES

NO

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

IS THE CONDITION IMPROVED BY ORTHOPEDIC SHOES OR APPLIANCES?
RIGHT

YES

NO

N/A

LEFT

YES

NO

N/A

3J. FOR ONE OR BOTH FEET, DOES THE WEIGHT-BEARING LINE FALL OVER OR MEDIAL TO THE GREAT TOE?
YES

NO

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

3K. IS THERE A LOWER EXTREMITY DEFORMITY OTHER THAN PES PLANUS, CAUSING ALTERATION OF THE WEIGHT-BEARING LINE?
YES

NO
RIGHT

IF YES, INDICATE SIDE AFFECTED:

LEFT

BOTH

DESCRIBE LOWER EXTREMITY DEFORMITY OTHER THAN PES PLANUS CAUSING ALTERATION OF THE WEIGHT BEARING LINE:
3L. DOES THE VETERAN HAVE "INWARD" BOWING OF THE ACHILLES' TENDON (i.e., hindfoot valgus, with lateral deviation of the heel) OF ONE OR BOTH FEET?
YES

NO

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

3M. DOES THE VETERAN HAVE MARKED INWARD DISPLACEMENT AND SEVERE SPASM OF THE ACHILLES' TENDON (rigid hindfoot) ON MANIPULATION OF ONE
OR BOTH FEET?
YES

NO

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

IS THE MARKED INWARD DISPLACEMENT AND SEVERE SPASM OF THE ACHILLES TENDON IMPROVED BY ORTHOPEDIC SHOES OR APPLIANCES?
RIGHT

YES

NO

N/A

LEFT

YES

NO

N/A

3N. COMMENTS, IF ANY:

VA FORM 21-0960M-6, XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION IV - MORTON'S NEUROMA (MORTON'S DISEASE) AND METATARSALGIA
COMPLETE THIS SECTION IF THE VETERAN HAS MORTON'S NEUROMA OR METATARSALGIA.
4A. DOES THE VETERAN HAVE MORTON'S NEUROMA?
YES

NO

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

LEFT

BOTH

4B. DOES THE VETERAN HAVE METATARSALGIA?
YES

NO

IF YES, INDICATE SIDE AFFECTED:

RIGHT

4C. COMMENTS, IF ANY:

SECTION V - HAMMER TOE
COMPLETE THIS SECTION IF THE VETERAN HAS HAMMER TOE.
5A. WHICH TOES ARE AFFECTED ON EACH SIDE?
RIGHT:

None

Great toe

Second toe

Third toe

Fourth toe

Little toe

LEFT:

None

Great toe

Second toe

Third toe

Fourth toe

Little toe

5B. COMMENTS, IF ANY:

SECTION VI - HALLUX VALGUS
COMPLETE THIS SECTION IF THE VETERAN HAS HALLUX VALGUS.
6A. DOES THE VETERAN HAVE SYMPTOMS DUE TO A HALLUX VALGUS CONDITION?
YES

NO

IF YES, INDICATE SEVERITY (check all that apply):
MILD OR MODERATE SYMPTOMS
SIDE AFFECTED:

RIGHT

LEFT

BOTH

SEVERE SYMPTOMS, WITH FUNCTION EQUIVALENT TO AMPUTATION OF GREAT TOE
SIDE AFFECTED:

RIGHT

LEFT

BOTH

6B. HAS THE VETERAN HAD SURGERY FOR HALLUX VALGUS?
YES

NO

IF YES, INDICATE TYPE AND DATE OF SURGERY AND SIDE AFFECTED:
RESECTION OF METATARSAL HEAD
DATE OF SURGERY:

SIDE AFFECTED:

RIGHT

LEFT

BOTH

METATARSAL OSTEOTOMY/METATARSAL HEAD OSTEOTOMY (equivalent to metatarsal head resection)
DATE OF SURGERY:

SIDE AFFECTED:

RIGHT

LEFT

BOTH

RIGHT

LEFT

BOTH

OTHER SURGERY FOR HALLUX VALGUS, DESCRIBE:
DATE OF SURGERY:

SIDE AFFECTED:

6C. COMMENTS, IF ANY:

SECTION VII - HALLUX RIGIDUS
COMPLETE THIS SECTION IF THE VETERAN HAS HALLUX RIGIDUS.
7A. DOES THE VETERAN HAVE SYMPTOMS DUE TO HALLUX RIGIDUS?
YES

NO

IF YES, INDICATE SEVERITY (check all that apply):
MILD OR MODERATE SYMPTOMS:
SIDE AFFECTED:

RIGHT

LEFT

BOTH

SEVERE SYMPTOMS, WITH FUNCTION EQUIVALENT TO AMPUTATION OF GREAT TOE
SIDE AFFECTED:

RIGHT

LEFT

BOTH

7B. COMMENTS, IF ANY:

VA FORM 21-0960M-6, XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION VIII - ACQUIRED PES CAVUS (CLAW FOOT)
COMPLETE THIS SECTION IF THE VETERAN HAS ACQUIRED PES CAVUS.
8A. EFFECT ON TOES DUE TO PES CAVUS (check all that apply):
None

Right

Left

Both

Great toe dorsiflexed

Right

Left

Both

All toes tending to dorsiflexion

Right

Left

Both

All toes hammer toes

Right

Left

Both

Other, describe (if there is an effect on toes due to other etiology than pes cavus, indicate other etiology):

8B. PAIN AND TENDERNESS DUE TO PES CAVUS (check all that apply):
None

Right

Left

Both

Definite tenderness under metatarsal heads

Right

Left

Both

Marked tenderness under metatarsal heads

Right

Left

Both

Very painful callosities

Right

Left

Both

Other, describe (if the veteran has pain and tenderness due to other etiology than pes cavus, indicate other etiology):

8C. EFFECT ON PLANTAR FASCIA DUE TO PES CAVUS (check all that apply):
None

Right

Left

Both

Shortened plantar fascia

Right

Left

Both

Marked contraction of plantar fascia with dropped forefoot

Right

Left

Both

Other, describe (if there is an effect on plantar fascia due to other etiology than pes cavus, indicate other etiology):

8D. DORSIFLEXION AND VARGUS DEFORMITY DUE TO PES CAVUS (check all that apply):
None

Right

Left

Both

Some limitation of dorsiflexion at ankle

Right

Left

Both

Limitation of dorsiflexion at ankle to right angle

Right

Left

Both

Marked varus deformity

Right

Left

Both

Other, describe (if the veteran has dorsiflexion and varus deformity due to other etiology than pes cavus, indicate other etiology):

8E. COMMENTS, IF ANY:

SECTION IX - MALUNION OR NONUNION OF TARSAL OR METATARSAL BONES
COMPLETE THIS SECTION IF THE VETERAN HAS MALUNION OR NONUNION OF TARSAL OR METATARSAL BONES.
9A. INDICATE SEVERITY AND SIDE AFFECTED FOR MALUNION OR NONUNION OF TARSAL OR METATARSAL BONES:
MODERATE
SIDE AFFECTED:

RIGHT

LEFT

BOTH

RIGHT

LEFT

BOTH

RIGHT

LEFT

BOTH

MODERATELY SEVERE
SIDE AFFECTED:
SEVERE
SIDE AFFECTED:
9B. COMMENTS, IF ANY:

SECTION X - FOOT INJURES AND OTHER CONDITIONS
COMPLETE THIS SECTION IF THE VETERAN HAS ANY FOOT INJURIES OR OTHER FOOT CONDITIONS (SUCH AS PLANTAR FASCIITIS OR "BILATERAL WEAK
FOOT"} NOT ALREADY DESCRIBED.

NOTE: For VA purposes "bilateral weak foot" describes a symptomatic condition secondary to many constitutional conditions, and is characterized by atrophy of the
musculature, disturbed circulation and weakness.
10A. DOES THE VETERAN HAVE ANY FOOT INJURIES OR OTHER FOOT CONDITIONS NOT ALREADY DESCRIBED?
NO
YES
IF YES, DESCRIBE THE FOOT INJURY OR OTHER FOOT CONDITIONS (including frequency and physical exam findings) AND COMPLETE QUESTION B (severity and
side affected).

VA FORM 21-0960M-6, XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION X - FOOT INJURES AND OTHER CONDITIONS (Continued)
10B. INDICATE SEVERITY AND SIDE AFFECTED.
Not Affected

Right

Left

Both

Mild

Right

Left

Both

Moderate

Right

Left

Both

Moderately severe

Right

Left

Both

Severe

Right

Left

Both

10C. DOES THE FOOT CONDITION CHRONICALLY COMPROMISE WEIGHT BEARING?
YES

NO

10D. DOES THE FOOT CONDITION REQUIRE ARCH SUPPORTS, CUSTOM ORTHOTIC INSERTS OR SHOE MODIFICATIONS?
YES

NO

10E. COMMENTS, IF ANY:

SECTION XI - SURGICAL PROCEDURES
COMPLETE THIS SECTION IF THE VETERAN HAS HAD ANY SURGICAL PROCEDURES FOR THE CLAIMED CONDITION THAT HAVE NOT ALREADY BEEN DESCRIBED.
11A. HAS THE VETERAN HAD FOOT SURGERY (arthroscopic or open)?
YES

NO

IF YES, INDICATE SIDE AFFECTED, TYPE OF PROCEDURE AND DATE OF SURGERY.
RIGHT FOOT PROCEDURE:
DATE OF SURGERY:
LEFT FOOT PROCEDURE:
DATE OF SURGERY:
11B. DOES THE VETERAN HAVE ANY RESIDUAL SIGNS OR SYMPTOMS DUE TO ARTHROSCOPIC OR OTHER FOOT SURGERY?
YES

NO

IF YES, DESCRIBE RESIDUALS:

SECTION XII - PAIN
Foot

RIGHT
FOOT

LEFT
FOOT

Is there pain
on physical
exam?

If no, but the veteran reported pain in
his/her medical history, please provide
rationale below.

If yes (there is pain on physical
exam), does the pain contribute to
functional loss?

Yes

Yes (you will be asked to
further describe these
limitations in Section 13)

No

No

Yes

Yes (you will be asked to

No

No

VA FORM 21-0960M-6, XXXX

If no (the pain does not contribute to functional loss or additional
limitations), explain why the pain does not contribute:

further describe these
limitations in Section 13)

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION XIII - FUNCTIONAL LOSS AND LIMITATION OF MOTION
NOTE: The VA defines functional loss as the inability, due to damage or infection in parts of the system, to perform normal working movements of the body with
normal excursion, strength, speed, coordination and/or endurance. As regards the joints, factors of disability reside in reductions of their normal excursion of
movements in different planes.
Using information from the history and physical exam, select the factors below that contribute to functional loss or impairment (regardless of repetitive use) or to
additional limitation of ROM after repetitive use for the joint or extremity being evaluated on this DBQ:
13A. CONTRIBUTING FACTORS OF DISABILITY (check all that apply and indicate side affected):
No functional loss for left lower extremity attributable to claimed condition
No functional loss for right lower extremity attributable to claimed condition
Less movement than normal (due to ankylosis, limitation or blocking, adhesions,

Right

Left

Both

More movement than normal (from flail joints, resections, nonunion of fractures,

Right

Left

Both

Weakened movement (due to muscle injury, disease or injury of peripheral

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

Pain on weight-bearing

Right

Left

Both

Pain on non weight-bearing

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

Right

Left

Both

Interference with standing

Right

Left

Both

tendon-tie-ups, contracted scars, etc.)
relaxation of ligaments, etc..)

nerves, divided or lengthened tendons, etc.)

Other, describe:

CONTRIBUTING FACTORS OF DISABILITY ASSOCIATED WITH LIMITATION OF MOTION
13B. IS THERE PAIN, WEAKNESS, FATIGABILITY, OR IN COORDINATION THAT SIGNIFICANTLY LIMITS FUNCTIONAL ABILITY DURING FLARE-UPS OR WHEN THE
FOOT IS USED REPEATEDLY OVER A PERIOD OF TIME OR OTHERWISE?
RIGHT FOOT

YES

NO

IF YES, (there is a functional loss due to pain, during flare-ups and/or when the joint is used repeatedly over a period of time) PLEASE DESCRIBE
THE FUNCTIONAL LOSS:

LEFT FOOT

YES

NO

IF YES, (there is a functional loss due to pain, during flare-ups and/or when the joint is used repeatedly over a period of time) PLEASE DESCRIBE
THE FUNCTIONAL LOSS:

13C. IS THERE ANY OTHER FUNCTIONAL LOSS DURING FLARE-UPS OR WHEN THE FOOT IS USED REPEATEDLY OVER A PERIOD OF TIME?
RIGHT FOOT

YES

NO

IF YES, DESCRIBE:

LEFT FOOT

YES

NO

IF YES, DESCRIBE:

VA FORM 21-0960M-6, XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION XIV - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS AND SCARS
14A. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS, OR 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, COMPLETE QUESTIONS 14B-14D.

14B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN THE DIAGNOSIS SECTION ABOVE?
YES

IF YES, DESCRIBE (brief summary):

NO

14C. 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 THESE SCARS PAINFUL OR UNSTABLE; HAVE A TOTAL AREA EQUAL TO OR GREATER THAN 39 SQUARE CM (6 square inches); OR ARE
LOCATED ON THE HEAD, FACE OR NECK?
YES

NO

IF YES, ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT.

IF NO, PROVIDE LOCATION AND MEASUREMENTS OF SCAR IN CENTIMETERS.
LOCATION:
MEASUREMENTS: Length

cm X width

cm.

NOTE: An "unstable scar" is one where, for any reason, there is frequent loss of covering of the skin over the scar. If there are multiple scars, enter additional locations
and measurements in Comment section below. It is not necessary to also complete a Scars DBQ.
14D. COMMENTS, IF ANY:

SECTION XV - ASSISTIVE DEVICES
15A. DOES THE VETERAN USE ANY ASSISTIVE DEVICES AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS
MAY BE POSSIBLE?
YES

NO

IF YES, IDENTIFY ASSISTIVE DEVICES USED (check all that apply and indicate frequency):

Wheelchair

Frequency of use:

Occasional

Regular

Brace

Frequency of use:

Occasional

Regular

Constant
Constant

Crutches

Frequency of use:

Occasional

Regular

Constant

Cane

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:

SECTION XVI - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
16A. DUE TO THE VETERAN'S FOOT CONDITIONS, IS THERE FUNCTIONAL IMPAIRMENT OF AN EXTREMITY SUCH THAT NO EFFECTIVE FUNCTIONS REMAIN
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 PROTHESIS WOULD EQUALLY SERVE THE VETERAN.
NO
IF YES, INDICATE EXTREMITIES 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):

NOTE: The intention of this section is to permit the examiner to quantify the level of remaining function; it is not intended to inquire whether the Veteran should
undergo an amputation with fitting of a prothesis. For example, if the functions of grasping (hand) or propulsion (foot) are as limited as if the Veteran had an
amputation and prosthesis, the examiner should check "yes" and describe the diminished functioning. The question simply asks whether the functional loss is to the
same degree as if there were an amputation of the affected limb.
VA FORM 21-0960M-6, XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION XVII - DIAGNOSTIC TESTING
NOTE: Testing listed below is not indicated for every condition. Plain or weight-bearing foot x-rays are not required to make the diagnosis of flatfoot. The diagnosis of
degenerative arthritis (osteoarthritis) or traumatic arthritis must be confirmed by imaging studies. Once such arthritis has been documented, even if in the past, no
further imaging studies are required by VA, even if arthritis has worsened.
17A. HAVE IMAGING STUDIES OF THE FOOT BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

IF YES, IS DEGENERATIVE OR TRAUMATIC ARTHRITIS DOCUMENTED?
YES

NO

IF YES, INDICATE FOOT:

RIGHT

LEFT

BOTH

17B. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS OR RESULTS?
YES

NO

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

17C. IF ANY TEST RESULTS ARE OTHER THAN NORMAL, INDICATE RELATIONSHIP OF ABNORMAL FINDINGS TO DIAGNOSED CONDITIONS:

SECTION XVIII - FUNCTIONAL IMPACT
NOTE: Provide the impact of only the diagnosed condition(s), without consideration of the impact of other medical conditions or factors, such as age.
18. REGARDLESS OF THE VETERAN'S CURRENT EMPLOYMENT STATUS, DO THE CONDITION(S) LISTED IN THE DIAGNOSIS SECTION IMPACT HIS OR HER
ABILITY TO PERFORM ANY TYPE OF OCCUPATIONAL TASK (such as standing, walking, lifting, sitting, etc.)?
YES

NO

IF YES, DESCRIBE THE FUNCTIONAL IMPACT OF EACH CONDITION, PROVIDING ONE OR MORE EXAMPLES:

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
20D. PHYSICIAN'S PHONE AND FAX NUMBER

20B. PHYSICIAN'S PRINTED NAME
20E. NATIONAL PROVIDER IDENTIFIER (NPI) 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-6, XXXX

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