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NECK (CERVICAL SPINE) CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE (U.S. Department of Veterans Affairs)

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Updated on June 17, 2020 ~v20_2
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Neck (Cervical Spine) Conditions Disability Benefits Questionnaire
Released March 2021
NECK (CERVICAL SPINE) CONDITIONS
DISABILITY BENEFITS QUESTIONNAIRE
Claimant/Veteran's Social Security NumberName of Claimant/Veteran
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 questionnaire:
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 the remarks 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.
Date of Examination
AmbidextrousLeftRight
Dominant hand:
DOMINANT HAND
Note - The Veteran 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. VA may obtain additional medical information, including an examination, if necessary, to complete VA's review of the
veteran's application. VA reserves the right to confirm the authenticity of ALL questionnaires completed by providers. It is intended that this questionnaire will be completed
by the Veteran's provider.
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.
Are you completing this Disability Benefits Questionnaire at the request of:
Veteran/Claimant
Other: please describe
Are you a VA Healthcare provider?
Is the Veteran regularly seen as a patient in your clinic?
Yes No
Yes No
Was the Veteran examined in person?
Yes No
If no, how was the examination conducted?
Please identify the evidence reviewed (e.g. service treatment records, VA treatment records, private treatment records) and the date range.
Evidence reviewed:
EVIDENCE REVIEW
No records were reviewed
Records reviewed
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Neck (Cervical Spine) Conditions Disability Benefits Questionnaire
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2B. Does the Veteran report flare-ups of the cervical spine?
2C. Does the Veteran report having any functional loss or functional impairment of the joint or extremity being evaluated on this questionnaire, including but not limited to after
repeated use over time?
If yes, document the Veteran's description of the flare-ups he/she experiences, including the frequency, duration, characteristics, precipitating and alleviating factors, severity,
and/or extent of functional impairment he/she experiences during a flare-up of symptoms:
If yes, document the Veteran's description of functional loss or functional impairment in his/her own words.
No
Yes No
Yes
SECTION II - MEDICAL HISTORY
2A. Describe the history (including onset and course) of the Veteran's cervical spine condition (brief summary):
1B. Select diagnoses associated with the claimed condition(s) (check all that apply):
Ankylosing spondylitis
Cervical strain
Intervertebral disc syndrome (Note: See VA definition of IVDS in Section X.)
Spinal fusion
Spinal stenosis
Spondylolisthesis
Date of diagnosis:
ICD Code:
ICD Code: Date of diagnosis:
ICD Code: Date of diagnosis:
Date of diagnosis:ICD Code:
Date of diagnosis:ICD Code:
ICD Code:
Degenerative arthritis
Vertebral dislocation
Vertebral fracture
ICD Code: Date of diagnosis:
ICD Code: Date of diagnosis:
Date of diagnosis:
Date of diagnosis:ICD Code:
Traumatic paralysis, complete
Date of diagnosis:ICD Code:
Degenerative disc disease other than intervertebral disc syndrome (IVDS) ICD Code:
Date of diagnosis:
1C. If there are additional diagnoses pertaining to cervical spine conditions, list using above format:
SECTION I - DIAGNOSIS (continued)
Segmental instability ICD Code: Date of diagnosis:
The Veteran does not have a current diagnosis associated with any claimed conditions listed above. (Explain your findings and reasons in the remarks section)
Other (specify)
ICD Code: Date of diagnosis:
Other diagnosis #1:
ICD Code: Date of diagnosis:
Other diagnosis #2:
ICD Code: Date of diagnosis:
Other diagnosis #3:
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3A. Initial ROM measurements
Unable to test
Not indicated
If "Unable to test" or "Not indicated", please explain:
All normal
Abnormal or outside of normal range
If ROM is outside of "normal" range, but is normal for the Veteran (for reasons other than a neck condition, such as age, body habitus, neurologic disease), please describe:
If yes, please explain:
No
Yes
If abnormal, does the range of motion itself contribute to a functional loss?
Right lateral rotation endpoint (80 degrees):
Forward flexion endpoint (45 degrees):
Extension endpoint (45 degrees):
Right lateral flexion endpoint (45 degrees):
Left lateral flexion endpoint (45 degrees):
Left lateral rotation endpoint (80 degrees):
degrees
degrees
degrees
degrees
degrees
degrees
Active Range of Motion (ROM) - Perform active range of motion and provide the ROM values.
SECTION III - RANGE OF MOTION (ROM) AND FUNCTIONAL LIMITATIONS
There are several separate parameters requested for describing function of a joint. The question "Does this ROM contribute to a functional loss?" asks if there is a functional
loss that can be ascribed to any documented loss of range of motion; and, unlike later questions, does not take into account the numerous other factors to be considered.
Subsequent questions take into account additional factors such as pain, fatigue, weakness, lack of endurance, or incoordination. If there is pain noted on examination, it is
important to understand whether or not that pain itself contributes to functional loss. Ideally, a claimant would be seen immediately after repetitive use over time or during a
flare-up; however, this is not always feasible.
Information regarding joint function on repetitive use is broken up into two subsets. The first subset is based on observed repetitive use, and the second is based on functional
loss associated with repeated use over time. The observed repetitive use section initially asks for objective findings after three or more repetitions of range of motion testing.
The second subset provides a more global picture of functional loss associated with repetitive use over time. The latter takes into account medical probability of additional
functional loss as a global view. This takes into account not only the objective findings noted on the examination, but also the subjective history provided by the claimant, as
well as review of the available medical evidence.
Optimally, a description of any additional loss of function should be provided - such as what the degrees of range of motion would be opined to look like after repetitive use
over time. However, when this is not feasible, an "as clear as possible" description of that loss should be provided. This same information (minus the three repetitions) is
asked to be provided with regards to flare-ups.
Note: For any joint condition, examiners should address pain on both passive and active motion, and on both weight-bearing and nonweight-bearing. If testing cannot be
performed or is medically contraindicated (such as it may cause the Veteran severe pain or the risk of further injury), an explanation must be given below. Please note any
characteristics of pain observed on examination (such as facial expression or wincing on pressure or manipulation).
No
YesCan testing be performed?
If no, provide an explanation:
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If noted on examination, which ROM exhibited pain (select all that apply):
Forward flexion
Extension
Left lateral flexion
Right lateral flexion
Right lateral rotation
Left lateral rotation
If any limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other; please note the degree(s) in which limitation of motion is specifically
attributable to the factors identified and describe.
Forward flexion
Extension Left lateral flexion
Right lateral flexion
Right lateral rotation
Left lateral rotation
Degree endpoint (if different than above)
Degree endpoint (if different than above)
Degree endpoint (if different than above)
Degree endpoint (if different than above)
Degree endpoint (if different than above)
Degree endpoint (if different than above)
SECTION III - RANGE OF MOTION (ROM) AND FUNCTIONAL LIMITATIONS (continued)
Right lateral rotation endpoint (80 degrees):
Forward flexion endpoint (45 degrees):
Extension endpoint (45 degrees):
Right lateral flexion endpoint (45 degrees):
Left lateral flexion endpoint (45 degrees):
Left lateral rotation endpoint (80 degrees):
degrees
degrees
degrees
degrees
degrees
degrees
Same as active ROM
Same as active ROM
Same as active ROM
Same as active ROM
Same as active ROM
Same as active ROM
Passive Range of Motion - Perform passive range of motion and provide the ROM values.
Was passive range of motion testing performed? No
Yes
If not, indicate why passive range of motion testing was not performed:
Medically contraindicated (e.g., it may cause the Veteran severe pain or the risk of further injury). It is not medically advisable to conduct passive range of
motion testing because (provide explanation).
Testing not necessary because (provide explanation).
Other (provide explanation).
Explanation:
If noted on examination, which passive ROM exhibited pain (select all that apply):
Forward flexion
Extension
Right lateral flexion
Left lateral flexion
Right lateral rotation
Left lateral rotation
Forward flexion
Extension
Left lateral flexion
Right lateral flexion
Right lateral rotation
Left lateral rotation
If any limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other; please note the degree(s) in which limitation of motion is specifically
attributable to the factors identified and describe.
Degree endpoint (if different than above)
Degree endpoint (if different than above)
Degree endpoint (if different than above)
Degree endpoint (if different than above)
Degree endpoint (if different than above)
Degree endpoint (if different than above)
Updated on June 17, 2020 ~v20_2
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SECTION III - RANGE OF MOTION (ROM) AND FUNCTIONAL LIMITATIONS (continued)
Is there objective evidence of crepitus? NoYes
If yes, describe location, severity, and relationship to condition(s):
No
YesIs there objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue?
Is there evidence of pain?
On rest/non-movement
Weight-bearing Nonweight-bearing Active motion Passive motion
Causes functional loss (if checked describe in the comments box below) Does not result in/cause functional loss
NoYes If yes check all that apply:
Comments:
Weakness
FatigabilityPain
N/A Incoordination
Lack of endurance
Select all factors that cause
this functional loss: (check
all that apply)
Other:
Right lateral rotation endpoint (80 degrees):
Forward flexion endpoint (45 degrees):
Extension endpoint (45 degrees):
Right lateral flexion endpoint (45 degrees):
Left lateral flexion endpoint (45 degrees):
Left lateral rotation endpoint (80 degrees):
degrees
degrees
degrees
degrees
degrees
degrees
Is there additional loss of function or range of motion after three repetitions?
If yes, please respond to the following after completion of the three repetitions:
No
Yes
If no, please explain:
Is the Veteran able to perform repetitive use testing with at least three repetitions? NoYes
3B. Observed repetitive use ROM
Updated on June 17, 2020 ~v20_2
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Neck (Cervical Spine) Conditions Disability Benefits Questionnaire
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SECTION III - RANGE OF MOTION (ROM) AND FUNCTIONAL LIMITATIONS (continued)
Note: When pain is associated with movement, the examiner must give a statement on whether pain could significantly limit functional ability during flare-ups and/or after
repeated use over time in terms of additional loss of range of motion. In the exam report, the examiner is requested to provide an estimate of decreased range of motion
(in degrees) that reflect frequency, duration, and during flare-ups - even if not directly observed during a flare-up and/or after repeated use over time.
3C. Repeated use over time
Is the Veteran being examined immediately after repeated use over time? NoYes
Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which
significantly limits functional ability with repeated use over time?
No
Yes
Weakness
FatigabilityPain
N/A Incoordination
Lack of endurance
Select all factors that cause
this functional loss: (check
all that apply)
Other:
Right lateral rotation endpoint (80 degrees):
Forward flexion endpoint (45 degrees):
Extension endpoint (45 degrees):
Right lateral flexion endpoint (45 degrees):
Left lateral flexion endpoint (45 degrees):
Left lateral rotation endpoint (80 degrees):
degrees
degrees
degrees
degrees
degrees
degrees
Estimate range of motion in degrees for this joint immediately after repeated use over time based on information procured from relevant sources including the lay
statements of the Veteran:
Please cite and discuss evidence. (Must be specific to the case and based on all procurable evidence):
The examiner should provide the estimated range of motion based on a review of all procurable information - to include the Veteran's statement on examination, case-specific
evidence (to include medical treatment records when applicable and lay evidence), and the examiner's medical expertise. If, after evaluation of the procurable and assembled
data, the examiner determines that it is not feasible to provide this estimate, the examiner should explain why an estimate cannot be provided. The explanation should not be
based on an examiner's shortcomings or a general aversion to offering an estimate on issues not directly observed.
Weakness
FatigabilityPain
N/A Incoordination
Lack of endurance
Select all factors that cause
this functional loss: (check
all that apply)
Other:
3D. Flare-ups
Is the Veteran being examined during a flare-up? No
Yes
Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which
significantly limits functional ability with flare-ups?
No
Yes
The examiner should provide the estimated range of motion based on a review of all procurable information - to include the Veteran's statement on examination, case-specific
evidence (to include medical treatment records when applicable and lay evidence), and the examiner's medical expertise. If, after evaluation of the procurable and assembled
data, the examiner determines that it is not feasible to provide this estimate, the examiner should explain why an estimate cannot be provided. The explanation should not be
based on an examiner's shortcomings or a general aversion to offering an estimate on issues not directly observed.
Please cite and discuss evidence. (Must be specific to the case and based on all procurable evidence):
Right lateral rotation endpoint (80 degrees):
Forward flexion endpoint (45 degrees):
Extension endpoint (45 degrees):
Right lateral flexion endpoint (45 degrees):
Left lateral flexion endpoint (45 degrees):
Left lateral rotation endpoint (80 degrees):
degrees
degrees
degrees
degrees
degrees
degrees
Estimate range of motion in degrees for this joint during flare-ups based on information procured from relevant sources including the lay statements of the Veteran:
Updated on June 17, 2020 ~v20_2
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Neck (Cervical Spine) Conditions Disability Benefits Questionnaire
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SECTION III - RANGE OF MOTION (ROM) AND FUNCTIONAL LIMITATIONS (continued)
3E. Guarding and muscle spasm
Does the Veteran have localized tenderness, guarding or muscle spasm of the cervical spine?
NoYes
Localized tenderness:
None
Not resulting in abnormal gait or abnormal spinal contour
Provide description and/or etiology:
Muscle spasm:
None
Resulting in abnormal gait or abnormal spine contour
Not resulting in abnormal gait or abnormal spinal contour
Unable to evaluate, describe below:
Provide description and/or etiology:
None
Guarding:
Resulting in abnormal gait or abnormal spine contour
Not resulting in abnormal gait or abnormal spinal contour
Unable to evaluate, describe below:
Provide description and/or etiology:
Updated on June 17, 2020 ~v20_2
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Neck (Cervical Spine) Conditions Disability Benefits Questionnaire
Released March 2021
SECTION IV- MUSCLE STRENGTH TESTING
4A. 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
Side
Flexion/
Extension
Rate
Strength
/5
/5
Wrist Flexion
/5
Finger Flexion /5
Wrist Extension
/5
Elbow Flexion
Elbow Extension
Right
Side
Flexion/
Extension
Rate
Strength
/5
/5
Wrist Flexion
/5
Finger Flexion /5
Wrist Extension
/5
Elbow Flexion
Elbow Extension
Left
Rate
Strength
Flexion/
Extension
Rate
Strength
Flexion/
Extension
Finger Abduction /5 Finger Abduction /5
SECTION III - RANGE OF MOTION (ROM) AND FUNCTIONAL LIMITATIONS (continued)
Other, describe:
Interference with standingInterference with sitting
Disturbance of locomotion
Instability of station
Atrophy of disuse
DeformitySwelling
More movement than normal Less movement than normal
None
3F. Additional factors contributing to disability
In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe:
Please describe additional contributing factors of disability:
Weakened movement
4B. Does the Veteran have muscle atrophy?
Yes No
4C. If yes, is the muscle atrophy due to the claimed condition in the diagnosis section?
Yes No
If no, provide rationale:
4D. For any muscle atrophy due to a diagnosis listed in Section I, indicate specific location of atrophy, providing measurements in centimeters of normal side and
corresponding atrophied side, measured at maximum muscle bulk.
Provide measurements in centimeters of normal side and atrophied side, measured at maximum muscle bulk.
cmCircumference of atrophied side:Circumference of normal side: cm
All Normal
All Normal
Updated on June 17, 2020 ~v20_2
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SECTION V - REFLEX EXAM
5A. Rate deep tendon reflexes (DTRs) according to the following scale:
0 Absent
1+ Hypoactive
2+ Normal
3+ Hyperactive without clonus
4+ Hyperactive with clonus
Right:
Left:
Bicep: Tricep:
Bicep: Tricep:
+
+ +
+
SECTION VI - SENSORY EXAM
Decreased
Normal
Absent
Absent
Normal DecreasedNormal
Absent
Decreased
Normal
Absent
Absent
Normal
Decreased
6A. Provide results for sensation to light touch (dermatome) testing:
Right
Shoulder Area (C5)Side Inner/Outer Forearm (C6-T1) Hand/Fingers (C6-8)
Left
Other sensory findings, if any:
Brachoradialis:
Brachoradialis: +
+
Absent
DecreasedNormal
Decreased
If yes, complete sections 7A - 7D.
Does the Veteran have radicular pain or any other signs or symptoms due to radiculopathy?
Yes No
SECTION VII - RADICULOPATHY
Note: For purposes of this examination, the diagnoses of IVDS and radiculopathy can be made by a history of characteristic radiating pain and/or sensory changes in the legs,
and objective clinical findings, which may include the asymmetrical loss or decrease of reflexes, decreased strength and/or abnormal sensation. Electromyography (EMG)
studies are rarely required to diagnose radiculopathy in the appropriate clinical setting.
Note: For VA purposes, when the involvement is wholly sensory, the evaluation should be mild, or no more than moderate.
Constant pain (may be excruciating at times):
Intermittent pain (usually dull):
7A. Indicate symptoms' location and severity (check all that apply):
Right upper extremity:
Left upper extremity: Severe
ModerateMild
None Mild Moderate
Severe
None
None
SevereModerateMildNone
Mild Moderate
SevereLeft upper extremity:
Right upper extremity:
Right upper extremity:
Left upper extremity: SevereModerateMild
None Mild Moderate Severe
None
Numbness:
Paresthesias and/or dysesthesias:
None
SevereModerateMildNone
Mild Moderate
SevereLeft upper extremity:
Right upper extremity:
7B. Does the Veteran have any other signs or symptoms of radiculopathy?
If yes, describe:
No
Yes
All Normal
All Normal
All Normal
All Normal
Updated on June 17, 2020 ~v20_2
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Neck (Cervical Spine) Conditions Disability Benefits Questionnaire
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7C. Indicate nerve roots involved (check all that apply):
Both
Involvement of C8/T1 nerve roots (lower radicular group):
If checked, indicate:
LeftRight Both
Right Left
If checked, indicate:
Involvement of C7 nerve root (middle radicular group):
Involvement of C5/C6 nerve roots (upper radicular group):
If checked, indicate:
LeftRight Both
SECTION VIII - ANKYLOSIS
Favorable ankylosis of the entire cervical spine
Unfavorable ankylosis of the entire cervical spine
Unfavorable ankylosis of the entire spine
NoYes
8A. Is there ankylosis of the spine?
If yes, describe condition and how it is related:
Note: If there are neurological abnormalities other than radiculopathy, also complete appropriate questionnaire for each condition identified.
SECTION IX - OTHER NEUROLOGIC ABNORMALITIES
NoYes
9A. Does the Veteran have any other neurologic abnormalities or findings (other than those identified in Sections 4 - 7) related to a cervical spine condition (such as bowel or
bladder problems/pathologic reflexes)?
8B. Comments, if any:
SECTION VII - RADICULOPATHY (continued)
If yes, indicate severity of ankylosis:
7D: For any abnormal or positive identified neurological findings identified in Sections 4-7, explain the likely cause of those identified symptoms:
SECTION X - INTERVERTEBRAL DISC SYNDROME (IVDS) AND EPISODES REQUIRING BED REST
10A. Does the Veteran have IVDS of the cervical spine?
Note: IVDS is a group of signs and symptoms due to disc herniation with compression and/or irritation of the adjacent nerve root that commonly includes back pain and
sciatica (pain along the course of the sciatic nerve) in the case of lumbar disc disease, and neck and arm or hand pain in the case of cervical disc disease. Imaging studies
are not required to make the diagnosis of IVDS.
Yes No
Note: For VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in
flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and
chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial
or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents
favorable ankylosis.
Updated on June 17, 2020 ~v20_2
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Neck (Cervical Spine) Conditions Disability Benefits Questionnaire
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10C. If yes to question 10B above, provide the following documentation that supports the yes response:
Medical history as described by the Veteran only, without documentation:
Medical history as shown and documented in the Veteran's file:
Individual date(s) of each treatment record(s) reviewed:
Facility/provider:
Describe treatment:
Other, describe:
11A. Does the Veteran use any assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible?
11B. If the Veteran uses any assistive devices, specify the condition, indicate the side, 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 XI - ASSISTIVE DEVICES
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
SECTION X - INTERVERTEBRAL DISC SYNDROME (IVDS) AND EPISODES REQUIRING BED REST (continued)
If yes select the total duration over the past 12 months:
10B. If yes to question 10A above, has the Veteran had any episodes of acute signs and symptoms due to IVDS that required bed rest prescribed by a physician and
treatment by a physician in the past 12 months?
With episodes of bed rest having a total duration of at least 1 week but less than 2 weeks during the past 12 months
With episodes of bed rest having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months
With episodes of bed rest having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months
With episodes of bed rest having a total duration of at least 6 weeks during the past 12 months
Yes
With no episodes of bed rest during the past 12 months
No
Updated on June 17, 2020 ~v20_2
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14A. Have imaging studies of the cervical spine been performed in conjunction with this examination?
Note: The diagnosis of degenerative arthritis (osteoarthritis) or post-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.
Imaging studies are not required to make the diagnosis of IVDS. Electromyography (EMG) studies are rarely required to diagnose radiculopathy in the appropriate clinical
setting.
SECTION XIV - DIAGNOSTIC TESTING
Yes
14B. If yes, is degenerative or post-traumatic arthritis documented?
No
Yes No
Yes No
If yes, complete appropriate dermatological questionnaire.
13B. Does the Veteran have any scars or other disfigurement of the skin related to any conditions or to the treatment of any conditions listed in the diagnosis section?
13C. Comments, if any:
SECTION XIII - OTHER PERTINENT PHYSICAL FINDINGS, SCARS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
13A. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the
diagnosis section above?
No
Yes
If yes, describe (brief summary):
SECTION XII - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
12A. Due to the Veteran's cervical spine condition, is there functional impairment of an extremity such that no effective function remains other than that which would be equally
well served by an amputation with prosthesis? Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance
and propulsion, etc.
No
Right upper Left upper
Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran
For each checked extremity, identify the condition causing loss of function, describe loss of effective function and provide specific examples (brief summary):
If yes, indicate extremities for which this applies:
Right lower Left lower
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 prosthesis. 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.
14C. If yes, provide type of test or procedure, date and results (brief summary):
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17C. Date signed
17E. National Provider Identifier (NPI) number 17F. Medical license number and state
17B. Examiner's printed name17A. Examiner's signature
Certification - To the best of my knowledge, the information contained herein is accurate, complete and current.
SECTION XVII - EXAMINER'S CERTIFICATION AND SIGNATURE
17D. Examiner's phone number
SECTION XV - FUNCTIONAL IMPACT
15A. Regardless of the Veteran's current employment status, do the conditions listed in the diagnosis section impact his/her ability to perform any type of occupational task
(such as standing, walking, lifting, sitting, etc.)?
No
If yes, describe the functional impact of each condition, providing one or more examples:
Yes
16A. Remarks (if any – please identify the section to which the remark pertains when appropriate).
SECTION XVI - REMARKS
17G. Examiner's address
Note: Provide the impact of only the diagnosed condition(s), without consideration of the impact of other medical conditions or factors, such as age.
SECTION XIV - DIAGNOSTIC TESTING
14D. Does the Veteran have imaging evidence of a cervical vertebral fracture with loss of 50 percent or more of height?
14E. Are there any other significant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es), that were reviewed in conjunction with
this examination?
If yes, provide type of test or procedure, date, and results (brief summary):
Yes No
Yes No
N/A
14F. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed conditions:
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NECK (CERVICAL SPINE) CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE (U.S. Department of Veterans Affairs)

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Completed 15 July 2021

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