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KNEE AND LOWER LEG CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE

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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.
KNEE AND LOWER LEG CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE
1B. SELECT DIAGNOSES ASSOCIATED WITH THE CLAIMED CONDITION(S) (Check all that apply):
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:
OMB Approved No. 2900-0813
Respondent Burden: 30 minutes
Expiration Date: 06-30-2020
SECTION I - DIAGNOSIS
MEDICAL RECORD REVIEW
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.
1A. LIST THE CLAIMED CONDITION(S) THAT PERTAIN TO THIS DBQ:
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.
WAS THE VETERAN'S VA CLAIMS FILE REVIEWED?
Side affected:
Side affected:
Side affected:
Side affected:
Side affected: BothRight Left Date of diagnosis:ICD Code:
ICD Code: Date of diagnosis:LeftRight BothSide affected:
BothRight Left
Date of diagnosis:ICD Code:
ICD Code: Date of diagnosis:LeftRight BothSide affected:
BothRight Left
Date of diagnosis:ICD Code:
ICD Code: Date of diagnosis:LeftRight BothSide affected:
BothRight Left
Date of diagnosis:ICD Code:
ICD Code: Date of diagnosis:LeftRight BothSide affected:
BothRight Left
Date of diagnosis:ICD Code:
NO
YES
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
NAME OF PATIENT/VETERAN
Other:
No records were reviewed
Interviews with collateral witnesses
(family and others who have known the veteran before and after military service)
Civilian medical records
Veterans Health Administration medical records
(VA treatment records)
Department of Defense Form 214 Separation Documents
Military post-deployment questionnaire
Military separation examination
Military enlistment examination
Military service personnel records
Military service treatment records
The Veteran does not have a current diagnosis associated with any claimed condition listed above.
(Explain your findings and reasons in comments section.)
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.
Knee joint ankylosis
Knee joint osteoarthritis
Patellar or quadriceps tendon
rupture
Knee posterior cruciate
ligament tear
Knee anterior cruciate
ligament tear
Knee meniscal tear
Knee tendonitis/tendonosis
Knee strain
Page 1
SUPERSEDES VA FORM 21-0960M-9, MAY 2013,
WHICH WILL NOT BE USED.
21-0960M-9
VA FORM
JUN 2017
Knee fracture
(including
patellar fracture)
Side affected: BothRight Left Date of diagnosis:ICD Code:
Stress fracture of tibia
Side affected: BothRight Left
Date of diagnosis:ICD Code:
Knee cartilage restoration
surgery
Side affected: BothRight Left
Date of diagnosis:ICD Code:
Patellofemoral pain syndrome
Side affected: BothRight Left
Date of diagnosis:ICD Code:
Shin splints (including tibia
and/or fibula stress fracture
and/or exertional
compartment syndrome)
Side affected: BothRight Left Date of diagnosis:ICD Code:
Patellar dislocation
Side affected: BothRight Left
Date of diagnosis:ICD Code:
Knee instability
Side affected: BothRight Left
Date of diagnosis:ICD Code:
Recurrent subluxation
Side affected: BothRight Left
Date of diagnosis:ICD Code:
Recurrent patellar dislocation
Side affected: BothRight Left
Date of diagnosis:ICD Code:
Tibia and/or Fibula fracture
SECTION II - MEDICAL HISTORY
SECTION I - DIAGNOSIS
(Continued)
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S KNEE AND/OR LOWER LEG CONDITION (brief summary):
1D. WAS AN OPINION REQUESTED ABOUT THIS CONDITION
(internal VA only)?
2B. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE KNEE AND/OR LOWER LEG?
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)?
IF YES, DOCUMENT THE VETERAN'S DESCRIPTION OF THE IMPACT OF FLARE-UPS IN HIS OR HER OWN WORDS:
IF YES, DOCUMENT THE VETERAN'S DESCRIPTION OF FUNCTIONAL LOSS OR FUNCTIONAL IMPAIRMENT IN HIS OR HER OWN WORDS:
NO
YES NO
YES
SECTION III - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS
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.
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.
VA FORM 21-0960M-9, JUN 2017 Page 2
N/A
NOYES
3A. INITIAL ROM MEASUREMENTS
Not able to perform
Not indicated
Not indicated
Not able to perform
Joint MovementKnee ROM Measurement
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:
Flexion
(normal endpoint
= 140 degrees)
Extension
LEFT
KNEE
1C. COMMENTS (if any):
Side affected:
ICD Code: Date of diagnosis:LeftRight BothSide affected:
BothRight Left
Date of diagnosis:ICD Code:
ICD Code: Date of diagnosis:LeftRight BothSide affected:
Other diagnosis #3:
Other diagnosis #2:
Other diagnosis #1:
Other
(specify)
Flexion
(normal endpoint
= 140 degrees)
Not able to perform
Not indicated
Not indicated
Not able to perform
RIGHT
KNEE
Extension
1B. SELECT DIAGNOSES ASSOCIATED WITH THE CLAIMED CONDITION(S)
(Check all that apply) (Continued)
PATIENT/VETERAN'S SOCIAL SECURITY NO.
All Normal
All Normal
3C. IF ROM DOES NOT CONFORM TO THE NORMAL RANGE OF MOTION IDENTIFIED ABOVE BUT IS NORMAL FOR THIS VETERAN (for reasons other than a knee
condition, such as age, body habitus, neurologic disease), EXPLAIN:
3B. DO ANY ABNORMAL ROMs NOTED ABOVE CONTRIBUTE TO FUNCTIONAL LOSS?
NO, EXPLAIN WHY THE ABNORMAL ROMs DO NOT CONTRIBUTE:
YES (you will be asked to further describe these limitation in Section 6 below)
SECTION III - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS (Continued)
4A. POST-TEST ROM MEASUREMENTS
Flexion
SECTION IV - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING
Yes
No
Yes
No, there is no change in ROM
after repetitive testing
If yes, report ROM after a minimum
of 3 repetitions.
If no, documentation of ROM after
repetitive-use testing is not required.
Flexion
Extension
Extension
If yes, perform repetitive-use testing
If no, provide reason below, then proceed to
Section 6
Is the veteran able to perform repetitive-use testing?Knee
Is there additional limitation in ROM
after repetitive-use testing?
Joint Movement
Post-test ROM
Measurement
RIGHT
KNEE
LEFT
KNEE
NO, EXPLAIN WHY THE POST-TEST ADDITIONAL LIMITATIONS OF ROMs DO NOT CONTRIBUTE:
YES (you will be asked to further describe these limitations in Section 6 below)
4B. DO ANY POST-TEST ADDITIONAL LIMITATIONS OF ROMs NOTED ABOVE CONTRIBUTE TO FUNCTIONAL LOSS?
Page 3VA FORM 21-0960M-9, JUN 2017
LEFT
KNEE
No
Yes
(you will be asked to further describe
these limitations in Section 6 below)
No
Yes
RIGHT
KNEE
If no
(the pain does not contribute to functional loss or additional
limitation of ROM), explain why the pain does not contribute:
If yes
(there is pain when used in weight-bearing
or non weight-bearing), does the pain contribute
to functional loss or additional limitation of ROM?
Is there pain when the joint is
used in weight-bearing or
non weight-bearing?
(If yes, identify whether weight-
bearing or non weight-bearing
in question 5D)
SECTION V - PAIN
5A. ROM MOVEMENTS PAINFUL ON ACTIVE, PASSIVE AND/OR REPETITIVE USE TESTING
5B. PAIN WHEN USED IN WEIGHT-BEARING OR IN NON WEIGHT-BEARING
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?
If no
(the pain does not contribute to functional loss or additional
limitation of ROM), explain why the pain does not contribute:
RIGHT
KNEE
Knee
Knee
Yes
No
Yes (you will be asked to further describe
these limitations in Section 6 below)
No
LEFT
KNEE
If no, provide reason below, then proceed to
Section 6
If yes, perform repetitive-use testing
If no, documentation of ROM after
repetitive-use testing is not required.
If yes, report ROM after a minimum
of 3 repetitions.
No, there is no change in ROM
after repetitive testing
Yes
No
Yes
No
Yes
Yes (you will be asked to further describe
these limitations in Section 6 below)
No
No
Yes (you will be asked to further describe
these limitations in Section 6 below)
Yes
No
PATIENT/VETERAN'S SOCIAL SECURITY NO.
Page 4VA FORM 21-0960M-9, JUN 2017
5C. LOCALIZED TENDERNESS OR PAIN ON PALPATION
Knee
Does the Veteran have localized tenderness
or pain to palpation of joints or soft tissue?
If yes, describe including location, severity and relationship to condition(s) listed in the Diagnosis section:
RIGHT
KNEE
Yes
No Yes
No
LEFT
KNEE
5D. COMMENTS, IF ANY:
SECTION V - PAIN (Continued)
6A. CONTRIBUTING FACTORS OF DISABILITY (check all that apply and indicate side affected):
Weakened movement (due to muscle injury, disease or injury of peripheral
nerves, divided or lengthened tendons, etc.)
Excess fatigability
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:
No functional loss for left lower extremity attributable to claimed condition
No functional loss for right lower extremity attributable to claimed condition
Both
Both
Both
Both
LeftRight Both
Interference with standing
Interference with sitting
BothRight Left
LeftRight Both
Disturbance of locomotion
Instability of station
BothRight Left
LeftRight Both
Right Left
LeftRight Both
Right Left
LeftRight Both
Right Left
LeftRight Both
Right Left
Less movement than normal (due to ankylosis, limitation or blocking, adhesions,
tendon-tie-ups, contracted scars, etc.)
More movement than normal (from flail joints, resections, nonunion of fractures,
relaxation of ligaments, etc.)
LeftRight Both
Incoordination, impaired ability to execute skilled movements smoothly
Swelling
Atrophy of disuse
Other, describe:
Deformity
Pain on movement
YES (If yes, complete questions 6C and 6D)
NO (If no, proceed to question 6D)
6B. ARE ANY OF THE ABOVE FACTORS ASSOCIATED WITH LIMITATION OF MOTION?
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.
PATIENT/VETERAN'S SOCIAL SECURITY NO.
Page 5VA FORM 21-0960M-9, JUN 2017
6C. CONTRIBUTING FACTORS OF DISABILITY ASSOCIATED WITH LIMITATION OF MOTION
Est. ROM is
not feasible
Est. ROM is
not feasible
Yes 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:
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:
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?
RIGHT
KNEE
Knee
LEFT
KNEE
Flexion
Extension
6D. CONTRIBUTING FACTORS OF DISABILITY NOT ASSOCIATED WITH LIMITATION OF MOTION
YES NO IF YES, DESCRIBE:
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?
LEFT KNEE
SECTION VI - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION OF ROM (Continued)
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
LEFT KNEE
Knee
Flexion/
Extension
Rate
Strength
Flexion
Is there a reduction in
muscle strength?
If yes, is the reduction entirely due to the
claimed condition in the Diagnosis section?
If no (the reduction is not entirely due to the
claimed condition), provide rationale:
/5
/5Extension
7B. DOES THE VETERAN HAVE MUSCLE ATROPHY?
IF YES, IS THE MUSCLE ATROPHY DUE TO THE CLAIMED CONDITION IN THE DIAGNOSIS SECTION?
Yes
NoYesNo
YES NO
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.
LEFT LOWER EXTREMITY (specify location of measurement such as "10cm above or below elbow"):
cmCIRCUMFERENCE OF MORE NORMAL SIDE: CIRCUMFERENCE OF ATROPHIED SIDE: cm
LOCATION OF MUSCLE ATROPHY:
Extension
Flexion
Est. ROM is
not feasible
Est. ROM is
not feasible
NoYes
NOYES IF YES, DESCRIBE:RIGHT KNEE
cmCIRCUMFERENCE OF ATROPHIED SIDE:CIRCUMFERENCE OF MORE NORMAL SIDE: cm
RIGHT LOWER EXTREMITY (specify location of measurement such as "10cm above or below elbow"):
/5
/5Extension
FlexionRIGHT KNEE
NoYes Yes No
7C. COMMENTS, IF ANY:
PATIENT/VETERAN'S SOCIAL SECURITY NO.
All Normal
All Normal
Page 6VA FORM 21-0960M-9, JUN 2017
8A. INDICATE SEVERITY OF ANKYLOSIS AND SIDE AFFECTED (check all that apply):
LEFT SIDE:
In flexion between 20 and 45 degrees
In flexion between 10 and 20 degrees
N/A, no ankylosis of knee joint
Favorable angle in full extension or in slight flexion
between 0 and 10 degrees
RIGHT SIDE:
Favorable angle in full extension or in slight flexion
between 0 and 10 degrees
NOTE: Ankylosis is the immobilization and consolidation of a joint due to disease, injury or surgical procedure.
SECTION VIII - ANKYLOSIS
8C. COMMENTS, IF ANY:
COMPLETE THIS SECTION IF THE VETERAN HAS ANKYLOSIS OF THE KNEE AND/OR LOWER LEG.
Extremely unfavorable, in flexion at an angle of 45
degrees or more
No ankylosis
No ankylosis
Extremely unfavorable, in flexion at an angle of 45
degrees or more
In flexion between 20 and 45 degrees
In flexion between 10 and 20 degrees
8B. INDICATE ANGLE OF ANKYLOSIS IN DEGREES:
LEFT SIDE:RIGHT SIDE:
N/A, no ankylosis of knee joint
SECTION IX - JOINT STABILITY TESTS
9A. IS THERE A HISTORY OF RECURRENT SUBLUXATION?
None
None
SevereSlightRight:
Severe
Moderate
ModerateSlightLeft:
YES NO
None
None
SevereSlightRight:
Severe
Moderate
ModerateSlightLeft:
NOTE: Subluxation and lateral instability refers only to the knee joint itself (tibio-femoral) and not to the patello-femoral portion of the joint.
9B. IS THERE A HISTORY OF LATERAL INSTABILITY?
9C. IS THERE A HISTORY OF RECURRENT EFFUSION?
IF YES, DESCRIBE:
9D. PERFORMANCE OF JOINT STABILITY TESTING
Anterior instability
(Lachman test)
Was joint stability testing performed?Knee
If joint stability testing
was performed is there
joint instability?
RIGHT
KNEE
Not Indicated
Indicated, but not able to perform
If joint stability is indicated, but unable
to test, provide reason:
No
Yes
No
Yes
3+(10-15 millimeters)
2+(5-10 millimeters)
1+(0-5 millimeters)
Normal
Posterior instability
(Posterior drawer
test)
Medial instability
(Apply valgus pressure to
knee in extension and with
30 degrees of flexion):
3+(10-15 millimeters)
2+(5-10 millimeters)
1+(0-5 millimeters)
Normal
Lateral instability
(Apply valgus pressure to
knee in extension and with
30 degrees of flexion):
3+(10-15 millimeters)
2+(5-10 millimeters)
1+(0-5 millimeters)
Normal
If yes (joint stability testing was performed), complete the section below:
3+(10-15 millimeters)
2+(5-10 millimeters)
1+(0-5 millimeters)
Normal
Anterior instability
(Lachman test)
LEFT
KNEE
Not Indicated
Indicated, but not able to perform
If joint stability is indicated, but unable
to test, provide reason:
No
Yes
No
Yes
3+(10-15 millimeters)
2+(5-10 millimeters)
1+(0-5 millimeters)
Normal
Posterior instability
(Posterior drawer
test)
Medial instability
(Apply valgus pressure to
knee in extension and with
30 degrees of flexion):
3+(10-15 millimeters)
2+(5-10 millimeters)
1+(0-5 millimeters)
Normal
Lateral instability
(Apply valgus pressure to
knee in extension and with
30 degrees of flexion):
3+(10-15 millimeters)
2+(5-10 millimeters)
1+(0-5 millimeters)
Normal
3+(10-15 millimeters)
2+(5-10 millimeters)
1+(0-5 millimeters)
Normal
degreesdegrees
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION IX - JOINT STABILITY TESTS (Continued)
9E. COMMENTS, IF ANY:
SECTION X - ADDITIONAL COMMENTS
IF YES, INDICATE CONDITION AND COMPLETE THE APPROPRIATE SECTIONS BELOW:
10A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER HAD RECURRENT PATELLAR DISLOCATION, "SHIN SPLINTS"
(medial tibial stress syndrome),
STRESS FRACTURES, CHRONIC EXERTIONAL COMPARTMENT SYNDROME OR ANY OTHER TIBIAL OR FIBULAR IMPAIRMENT?
YES NO
None
None
SevereSlightRight:
Severe
Moderate
ModerateSlightLeft:
IF CHECKED, INDICATE SEVERITY AND SIDE AFFECTED:
RECURRENT PATELLAR DISLOCATION
Describe current symptoms:
BothRight Left
Measurements: Right leg: Left leg: inchescminchescm
"SHIN SPLINTS" (medial tibial stress syndrome)
Describe current symptoms:
BothRight Left
STRESS FRACTURE OF THE LOWER LEG
Describe current symptoms:
BothRight Left
CHRONIC EXERTIONAL COMPARTMENT SYNDROME (an exercise-induced neuromuscular condition that can cause pain and swelling, especially after repetitive
movements such as marching)
BothRight Left
ACQUIRED AND/OR TRAUMATIC GENU RECURVATUM WITH OBJECTIVELY DEMONSTRATED WEAKNESS AND INSECURITY IN WEIGHT-BEARING.
(If checked, provide length of each lower extremity in inches (to the nearest 1/4 inch) or centimeters measuring from the anterior superior iliac spine
to the internal malleolus of the tibia.)
LEG LENGTH DISCREPANCY (shortening of any bones of the lower extremity)
INDICATE SIDE AFFECTED:
INDICATE SIDE AFFECTED:
Does this condition affect ROM of ankle?
Does this condition affect ROM of knee?
INDICATE SIDE AFFECTED:
INDICATE SIDE AFFECTED:
(If yes, complete ROM section of knee on this DBQ.)
(If yes, complete VA form 21-0960M-2 ANKLE CONDITIONS to document ROM of ankle.)
NoYes
NoYes
NoYes
Does this condition affect ROM of ankle?
(If yes, complete VA form 21-0960M-2 ANKLE CONDITIONS to document ROM of ankle.)
NoYes
Does this condition affect ROM of ankle?
(If yes, complete VA form 21-0960M-2 ANKLE CONDITIONS to document ROM of ankle.)
For any leg length discrepancy, please describe the relationship to the conditions listed in the Diagnosis section above:
10B. COMMENTS, IF ANY:
SECTION XI - MENISCAL CONDITIONS
Frequent episodes of joint effusion
No current symptoms
Meniscal tear
Meniscal dislocation
11A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER HAD A MENISCUS
(semilunar cartilage) CONDITION?
(If "Yes," indicate severity and frequency of symptoms, and side affected):
YES NO
Frequent episodes of joint "locking"
Frequent episodes of joint pain
Other
Frequent episodes of joint effusion
No current symptoms
Meniscal tear
Meniscal dislocation
Frequent episodes of joint "locking"
Frequent episodes of joint pain
Other
11B. FOR ALL CHECKED BOXES ABOVE, DESCRIBE:
Page 7VA FORM 21-0960M-9, JUN 2017
RIGHT SIDE: LEFT SIDE:
PATIENT/VETERAN'S SOCIAL SECURITY NO.
Page 8VA FORM 21-0960M-9, JUN 2017
SECTION XII - SURGICAL PROCEDURES
12. INDICATE ANY SURGICAL PROCEDURES THAT THE VETERAN HAS HAD PERFORMED AND PROVIDE THE ADDITIONAL INFORMATION AS REQUESTED
(check all that apply):
DATE OF SURGERY:
RIGHT SIDE:
DATE OF SURGERY:
Other, describe:
Chronic residuals consisting of severe painful motion or weakness
Intermediate degrees of residual weakness, pain or limitation of motion
None
RESIDUALS:
TYPE OF SURGERY:
MENISCECTOMY, ARTHROSCOPIC OR OTHER KNEE SURGERY NOT
DESCRIBED ABOVE:
RESIDUAL SIGNS OF SYMPTOMS DUE TO MENISCECTOMY,
ARTHROSCOPIC OR OTHER KNEE SURGERY NOT DESCRIBED ABOVE:
DESCRIBE RESIDUALS:
TOTAL KNEE JOINT REPLACEMENT
SECTION XIII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS AND SCARS
13A. 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?
13C. 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?
NO IF YES, COMPLETE QUESTIONS 13B-13D.
YES NO
IF YES, DESCRIBE
(brief summary):
YES NO
YES
13D. COMMENTS, IF ANY:
IF YES, ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT.
LOCATION MEASUREMENTS: length cm X width cm.
IF NO, PROVIDE LOCATION AND MEASUREMENTS OF SCAR IN CENTIMETERS.
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.
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
13B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN THE DIAGNOSIS SECTION ABOVE?
14A. DOES THE VETERAN USE ANY ASSISTIVE DEVICES AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS
MAY BE POSSIBLE?
14B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:
YES NO
IF YES, IDENTIFY ASSISTIVE DEVICES USED
(check all that apply and indicate frequency):
SECTION XIV - ASSISTIVE DEVICES
TOTAL KNEE JOINT REPLACEMENT
DESCRIBE RESIDUALS:
RESIDUAL SIGNS OF SYMPTOMS DUE TO MENISCECTOMY,
ARTHROSCOPIC OR OTHER KNEE SURGERY NOT DESCRIBED ABOVE:
MENISCECTOMY, ARTHROSCOPIC OR OTHER KNEE SURGERY NOT
DESCRIBED ABOVE:
TYPE OF SURGERY:
RESIDUALS:
None
Intermediate degrees of residual weakness, pain or limitation of motion
Chronic residuals consisting of severe painful motion or weakness
Other, describe:
DATE OF SURGERY:
LEFT SIDE:
DATE OF SURGERY:
Crutches
Walker Frequency of use: Occasional Regular Constant
ConstantRegularOccasionalFrequency of use:Cane
Frequency of use: Occasional Regular Constant
Wheelchair Frequency of use: Occasional Regular Constant
Frequency of use: Occasional Regular ConstantOther:
ConstantRegularOccasionalFrequency of use:Brace
PATIENT/VETERAN'S SOCIAL SECURITY NO.
15. DUE TO THE VETERAN'S KNEE OR LOWER LEG CONDITION(S), 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.)
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 - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
NO
RIGHT LOWER
FOR EACH CHECKED EXTREMITY, IDENTIFY THE CONDITION CAUSING LOSS OF FUNCTION, DESCRIBE LOSS OF EFFECTIVE FUNCTION AND PROVIDE
SPECIFIC EXAMPLES
(brief summary):
LEFT LOWERIF YES, INDICATE EXTREMITIES FOR WHICH THIS APPLIES:
YES, FUNCTIONING IS SO DIMINISHED THAT AMPUTATION WITH PROTHESIS WOULD EQUALLY SERVE THE VETERAN.
16A. HAVE IMAGING STUDIES OF THE KNEE BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
16B. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS OR RESULTS?
16D. IF ANY TEST RESULTS ARE OTHER THAN NORMAL, INDICATE RELATIONSHIP OF ABNORMAL FINDINGS TO DIAGNOSED CONDITIONS:
IF YES, PROVIDE TYPE OF TEST OR PROCEDURE, DATE AND RESULTS
(brief summary):
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.
SECTION XVI - DIAGNOSTIC TESTING
YES
IF YES, IS DEGENERATIVE OR TRAUMATIC ARTHRITIS DOCUMENTED?
NOYES LEFT BOTHRIGHTIF YES, INDICATE KNEE:
16C. IS THERE OBJECTIVE EVIDENCE OF CREPITUS?
IF YES, INDICATE KNEE: RIGHT
BOTHLEFT
NO
YES NO
YES NO
VA FORM 21-0960M-9, JUN 2017 Page 9
17. 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.)?
SECTION XVII - FUNCTIONAL IMPACT
NO IF YES, DESCRIBE THE FUNCTIONAL IMPACT OF EACH CONDITION, PROVIDING ONE OR MORE EXAMPLES:YES
NOTE: Provide the impact of only the diagnosed condition(s), without consideration of the impact of other medical conditions or factors, such as age.
PATIENT/VETERAN'S SOCIAL SECURITY NO.
Page 10VA FORM 21-0960M-9, JUN 2017
18. REMARKS, IF ANY:
SECTION XVIII - REMARKS
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.
19C. DATE SIGNED
19F. PHYSICIAN'S ADDRESS
19B. PHYSICIAN'S PRINTED NAME
(VA Regional Office FAX No.)
19A. PHYSICIAN'S SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
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.
SECTION XIX - PHYSICIAN'S CERTIFICATION AND SIGNATURE
IMPORTANT - Physician please fax the completed form to
19D. PHYSICIAN'S PHONE/FAX NUMBER
NOTE: VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.
19. E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER
PATIENT/VETERAN'S SOCIAL SECURITY NO.
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KNEE AND LOWER LEG CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE

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Completed 25 March 2021

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