Form VA Form 21-0960M-2 VA Form 21-0960M-2 Ankle Conditions Disability Benefits Questionnaire

OMB Approved No. 2900-0806
Respondent Burden: 30 minutes
Expiration Date: XX/XX/XXXX

ANKLE 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 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?
YES

NO

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.)
Lateral collateral ligament
sprain (chronic/recurrent)

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Deltoid ligament sprain

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Osteochondritis dissecans to
include osteochondral fracture

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

posterior (or trigonum
syndrome)/anterolateral))
Tendonitis (achilles/peroneal/ Side affected:
posterior tibial)

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Right

Left

Both

ICD Code:

Date of diagnosis:

Retrocalcaneal bursitis

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Achilles tendon rupture

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Osteoarthritis of the ankle

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Avascular necrosis, talus

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Ankle joint replacement
Ankylosis of ankle, subtalar or
tarsal joint

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

(chronic/recurrent)

Impingement (anterior/

Other (specify)
Other diagnosis #1:
Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Right

Left

Both

ICD Code:

Date of diagnosis:

Other diagnosis #2:
Side affected:
VA FORM
XXX XXXX

21-0960M-2

SUPERSEDES VA FORM 21-0960M-2, MAY 2013,
WHICH WILL NOT BE USED.

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION I - DIAGNOSIS (Continued)
Other diagnosis #3:
Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

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 ANKLE CONDITION (brief summary):

2B. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE ANKLE?
YES

NO

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

2C. DOES THE VETERAN REPORT HAVING ANY FUNCTIONAL LOSS OR FUNCTIONAL IMPAIRMENT OF THE JOINT OR EXTREMITY 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 - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS
Measure ROM with a goniometer. During the examination be cognizant of painful motion, which could be evidenced by visible behavior such as facial expression, wincing,
etc..., on pressure or manipulation. Document painful movement in Section 5.
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 question 4A.
3A. INITIAL ROM MEASUREMENTS
Ankle

RIGHT
ANKLE
All Normal

LEFT
ANKLE
All Normal

Joint Movement

ROM Measurement

Plantar Flexion
(normal endpoint
= 45 degrees)

Not indicated

Dorsiflexion
(normal endpoint
= 20 degrees)

Not indicated

Plantar Flexion
(normal endpoint
= 45 degrees)

Not indicated

Dorsiflexion
(normal endpoint
= 20 degrees)

Not indicated

If ROM testing is not indicated for the veteran's condition or not able to be performed,
please explain why, and then proceed to Section 5:

Not able to perform

Not able to perform

Not able to perform

Not able to perform

3B. DO ANY ABNORMAL ROMs NOTED ABOVE CONTRIBUTE TO FUNCTIONAL LOSS?
YES (you will be asked to further describe these limitation in Section 6 below)
NO, EXPLAIN WHY THE ABNORMAL ROMs DO NOT CONTRIBUTE:

3C. IF ROM DOES NOT CONFORM TO THE NORMAL RANGE OF MOTION IDENTIFIED ABOVE BUT IS NORMAL FOR THIS VETERAN
(for reasons other than an ankle condition, such as age, body habitus, neurologic disease), EXPLAIN:

VA FORM 21-0960M-2, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION IV - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING
4A. POST-TEST ROM MEASUREMENTS
Ankle

Is there additional limitation in ROM
after repetitive-use testing?

Is the veteran able to perform repetitive-use testing?
Yes

If yes, perform repetitive-use testing

Yes

No

If no, provide reason below, then proceed to
Section 5

No, there is no change in ROM
after repetitive testing

RIGHT
ANKLE

If yes, report ROM after a minimum
of 3 repetitions.
If no, documentation of ROM after
repetitive-use testing is not required.
Yes

If yes, perform repetitive-use testing

Yes

No

If no, provide reason below, then proceed to
Section 5

No, there is no change in ROM
after repetitive testing

LEFT
ANKLE

If yes, report ROM after a minimum
of 3 repetitions.
If no, documentation of ROM after
repetitive-use testing is not required.

Joint Movement

Post-test ROM
Measurement

Plantar Flexion

Dorsiflexion

Plantar Flexion

Dorsiflexion

4B. DO ANY POST-TEST ADDITIONAL LIMITATIONS OF ROMs NOTED ABOVE CONTRIBUTE TO FUNCTIONAL LOSS?
YES (you will be asked to further describe these limitations in Section 6 below)
NO, EXPLAIN WHY THE POST-TEST ADDITIONAL LIMITATIONS OF ROMs DO NOT CONTRIBUTE:

SECTION V - PAIN
5A. ROM MOVEMENTS PAINFUL ON ACTIVE, PASSIVE AND/OR REPETITIVE USE TESTING

Ankle

Are any ROM movements
painful on active, passive
and/or repetitive use testing?

(If yes, identify whether active,
passive, and/or repetitive use in
question 5D)

If yes (there are painful movements), does the
pain contribute to functional loss or
additional limitation of ROM?

RIGHT
ANKLE

Yes

Yes (you will be asked to further describe
these limitations in Section 6 below)

No

No

LEFT
ANKLE

Yes

Yes (you will be asked to further describe
these limitations in Section 6 below)

No

No

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

5B. PAIN WHEN USED IN WEIGHT-BEARING OR IN NON WEIGHT-BEARING

Ankle

Is there pain when the joint is
used in weight-bearing or non
weight-bearing?

If yes (there is pain when used in weight-bearing
or non weight-bearing), does the pain contribute
(If yes, identify whether weight- to functional loss or additional limitation of ROM?

bearing or non weight-bearing
in question 5D)

RIGHT
ANKLE

Yes

Yes (you will be asked to further describe
these limitations in Section 6 below)

No

No

LEFT
ANKLE

Yes

Yes (you will be asked to further describe
these limitations in Section 6 below)

No

No

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

5C. LOCALIZED TENDERNESS OR PAIN ON PALPATION
Ankle

Does the Veteran have localized tenderness
or pain to palpation of joints or soft tissue?

RIGHT
ANKLE

Yes

No

LEFT
ANKLE

Yes

No

If yes, describe including location, severity and relationship to condition(s) listed in the Diagnosis section:

5D. COMMENTS, IF ANY:

VA FORM 21-0960M-2, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION VI - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION OF ROM
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:
6A. 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

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:

NOTE: If any of the above factors is/are associated with limitation of motion, the examiner must give an opinion on whether pain, weakness, fatigability, or incoordination
could significantly limit functional ability during flare-ups or when the joint is used repeatedly over a period of time and that opinion, if feasible, should be expressed in
terms of the degree of additional ROM loss due to pain on use or during flare-ups. The following section will assist you in providing this required opinion.
6B. ARE ANY OF THE ABOVE FACTORS ASSOCIATED WITH LIMITATION OF MOTION?
YES (If yes, complete questions 6C and 6D)
NO (If no, proceed to question 6D)
6C. CONTRIBUTING FACTORS OF DISABILITY ASSOCIATED WITH LIMITATION OF MOTION

Ankle

RIGHT
ANKLE

LEFT
ANKLE

Can pain, weakness, fatigability, or
incoordination significantly limit functional
ability during flare-ups or when the joint is
used repeatedly over a period of time?

Yes

Yes

No

No

If yes, please estimate ROM due to pain and/or
functional loss during flare-ups or when the
joint is used repeatedly over a period of time:
Plantar
Flexion

Est. ROM is
not feasible

Dorsiflexion

Est. ROM is
not feasible

Plantar
Flexion

Est. ROM is
not feasible

Dorsiflexion

Est. ROM is
not feasible

If there is a functional loss due to pain, during flare-ups and/or
when the joint is used repeatedly over a period of time but the
limitation of ROM cannot be estimated, please describe
the functional loss:

CONTRIBUTING FACTORS OF DISABILITY NOT ASSOCIATED WITH LIMITATION OF MOTION
6D. IS THERE ANY FUNCTIONAL LOSS (not associated with limitation of motion) DURING FLARE-UPS OR WHEN THE JOINT IS USED REPEATEDLY OVER A
PERIOD OF TIME OR OTHERWISE?
RIGHT ANKLE
YES
NO IF YES, DESCRIBE:

LEFT ANKLE

YES

VA FORM 21-0960M-2, XXX XXXX

NO

IF YES, DESCRIBE:

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION VII - MUSCLE STRENGTH TESTING
7A. MUSCLE STRENGTH - 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
Rate
Strength

Ankle

Flexion

RIGHT ANKLE

Plantar Flexion

/5

All Normal

Dorsiflexion

/5

LEFT ANKLE

Plantar Flexion

/5

All Normal

Dorsiflexion

/5

Is there a reduction in
muscle strength?

If yes, is the reduction entirely due to the
claimed condition in the Diagnosis section?

Yes

No

Yes

No

Yes

No

Yes

No

If no (the reduction is not entirely due to the
claimed condition), provide rationale:

7B. DOES THE VETERAN HAVE MUSCLE ATROPHY?
YES

NO

IF YES, IS THE MUSCLE ATROPHY DUE TO THE CLAIMED CONDITION IN THE DIAGNOSIS SECTION?
YES

NO

IF NO, PROVIDE RATIONALE:

FOR ANY MUSCLE ATROPHY DUE TO A DIAGNOSES LISTED IN SECTION 1, INDICATE SIDE AND SPECIFIC LOCATION OF ATROPHY, PROVIDING
MEASUREMENTS IN CENTIMETERS OF NORMAL SIDE AND CORRESPONDING ATROPHIED SIDE, MEASURED AT MAXIMUM MUSCLE BULK.
LOCATION OF MUSCLE ATROPHY:
RIGHT LOWER EXTREMITY (specify location of measurement such as "10cm above or below elbow"):

CIRCUMFERENCE OF MORE NORMAL SIDE:

cm

CIRCUMFERENCE OF ATROPHIED SIDE:

cm

LEFT LOWER EXTREMITY (specify location of measurement such as "10cm above or below elbow"):

CIRCUMFERENCE OF MORE NORMAL SIDE:

cm

CIRCUMFERENCE OF ATROPHIED SIDE:

cm

7C. COMMENTS, IF ANY:

SECTION VIII - ANKYLOSIS
COMPLETE THIS SECTION IF VETERAN HAS ANKYLOSIS OF THE ANKLE.

NOTE: Ankylosis is the immobilization and consolidation of a joint due to disease, injury or surgical procedure.
8A. INDICATE SEVERITY OF ANKYLOSIS AND SIDE AFFECTED (check all that apply):
RIGHT SIDE:
In plantar flexion

LEFT SIDE:
In plantar flexion

If checked, provide degrees:

If checked, provide degrees:

In dorsiflexion

In dorsiflexion

If checked, provide degrees:

If checked, provide degrees:

With an abduction deformity

With an abduction deformity

With an inversion deformity

With an inversion deformity

With an eversion deformity

With an eversion deformity

In good weight-bearing position

In good weight-bearing position

In poor weight-bearing position

In poor weight-bearing position

No ankylosis

No ankylosis

8B. COMMENTS, IF ANY:

VA FORM 21-0960M-2, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION IX - JOINT STABILITY
If yes, complete the following:

Is ankle instability or
dislocation suspected?

Ankle

Anterior Drawer Test
Is there laxity compared with opposite side?

Talar Tilt Test (inversion/eversion stress)
Is there laxity compared with opposite side?

RIGHT ANKLE

YES

NO

YES

NO

UNABLE TO TEST

YES

NO

LEFT ANKLE

YES

NO

YES

NO

UNABLE TO TEST

YES

NO

SECTION X - ADDITIONAL COMMENTS
10. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER HAD "SHIN SPLINTS", STRESS FRACTURES, ACHILLES TENDONITIS, ACHILLES TENDON
RUPTURE, MALUNION OF CALCANEUS (os calcis) OR TALUS (astragalus), OR HAS THE VETERAN HAD A TALECTOMY (astragalectomy)?
YES

NO

IF YES, INDICATE CONDITION AND COMPLETE THE APPROPRIATE SECTIONS BELOW:
SHIN SPLINTS (medical tibial stress syndrome)
INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

DOES THIS CONDITION AFFECT ROM OF ANKLE?
YES (If "yes," complete ROM section of ankle on this DBQ)
NO
DOES THIS CONDITION AFFECT ROM OF KNEE?
YES (If "yes," complete VA Form 21-0960M-9 Knee and Lower Leg Conditions)
NO
DESCRIBE CURRENT SYMPTOMS:

STRESS FRACTURE OF THE LOWER LEG
INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

DESCRIBE CURRENT SYMPTOMS:

ACHILLES TENDONITIS OR ACHILLES TENDON RUPTURE
INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

DESCRIBE CURRENT SYMPTOMS:

MALUNION OF CALCANEOUS (os calcis) OR TALUS (astragalus)
INDICATE SEVERITY AND SIDE AFFECTED:
MODERATE DEFORMITY

RIGHT

LEFT

BOTH

MARKED DEFORMITY

RIGHT

LEFT

BOTH

RIGHT

LEFT

BOTH

TALECTOMY
INDICATE SIDE AFFECTED:
DESCRIBE CURRENT SYMPTOMS:

VA FORM 21-0960M-2, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION XI - SURGICAL PROCEDURES
11. INDICATE ANY SURGICAL PROCEDURES THAT THE VETERAN HAS HAD PERFORMED AND PROVIDE THE ADDITIONAL INFORMATION AS REQUESTED
(check all that apply):
RIGHT SIDE:

LEFT SIDE:

TOTAL ANKLE JOINT REPLACEMENT

TOTAL ANKLE JOINT REPLACEMENT

DATE OF SURGERY:

DATE OF SURGERY:

RESIDUALS:

RESIDUALS:

None

None

Intermediate degrees of residual weakness, pain or limitation of motion

Intermediate degrees of residual weakness, pain or limitation of motion

Chronic residuals consisting of severe painful motion or weakness

Chronic residuals consisting of severe painful motion or weakness

Other, describe:

Other, describe:

ARTHROSCOPIC OR OTHER ANKLE SURGERY

ARTHROSCOPIC OR OTHER ANKLE SURGERY

TYPE OF SURGERY:

TYPE OF SURGERY:

DATE OF SURGERY:

DATE OF SURGERY:

RESIDUALS OF ARTHROSCOPIC OR OTHER ANKLE SURGERY

RESIDUALS OF ARTHROSCOPIC OR OTHER ANKLE SURGERY

DESCRIBE RESIDUALS:

DESCRIBE RESIDUALS:

SECTION XII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS AND SCARS
12A. 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 12B-12D.

12B. 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

12C. 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.
12D. COMMENTS, IF ANY:

SECTION XIII - ASSISTIVE DEVICES
13A. 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

13B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:

VA FORM 21-0960M-2, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION XIV - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
14A. DUE TO THE VETERAN'S ANKLE CONDITIONS, IS THERE FUNCTIONAL IMPAIRMENT OF AN EXTREMITY SUCH THAT NO EFFECTIVE FUNCTIONS 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 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.
SECTION XV - DIAGNOSTIC TESTING
NOTE: Testing listed below is not indicated for every condition. 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.
15A. HAVE IMAGING STUDIES OF THE ANKLE BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

IF YES, IS DEGENERATIVE OR TRAUMATIC ARTHRITIS DOCUMENTED?
YES

NO

IF YES, INDICATE ANKLE:

RIGHT

LEFT

BOTH

15B. 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):

15C. IS THERE OBJECTIVE EVIDENCE OF CREPITUS?
YES

NO

IF YES, INDICATE ANKLE:

RIGHT

LEFT

BOTH

15D. IF ANY TEST RESULTS ARE OTHER THAN NORMAL, INDICATE RELATIONSHIP OF ABNORMAL FINDINGS TO DIAGNOSED CONDITIONS:

SECTION XVI - 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.
16. 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:

VA FORM 21-0960M-2, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION XVII - REMARKS
17. REMARKS, IF ANY:

SECTION XVIII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
18A. PHYSICIAN'S SIGNATURE
18D. PHYSICIAN'S PHONE AND FAX NUMBER

18B. PHYSICIAN'S PRINTED NAME

18C. DATE SIGNED

18E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER 18F. 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-2, XXX XXXX

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