Fillable VBA - Form 21-0960M-14 Back Conditions Disability Benefits Questionnaire

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VBA - Form 21-0960M-14 Back Conditions Disability Benefits Questionnaire

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BACK (THORACOLUMBAR SPINE) 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. 2900-0808
Respondent Burden: 45 minutes
Expiration Date: 12/31/2020
SECTION I - DIAGNOSIS
MEDICAL RECORD REVIEW
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.
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?
Degenerative scoliosis
Date of diagnosis:ICD Code:
Radiculopathy
Ankylosing spondylitis of the
thoracolumbar spine (back)
NOTE: If there are systemic or other constitutional manifestations of ankylosing spondylitis, ALSO complete the Non-degenerative Arthritis DBQ and the
appropriate DBQ for each affected system.
ICD Code: Date of diagnosis:
Vertebral fracture (vertebrae
of the back)
Date of diagnosis:ICD Code:
ICD Code:
Date of diagnosis:
Ankylosis of thoracolumbar spine
Date of diagnosis:ICD Code:
ICD Code:
Date of diagnosis:
Date of diagnosis:ICD Code:
ICD Code:
Date of diagnosis:
Date of diagnosis:ICD Code:
ICD Code:
Date of diagnosis:
Date of diagnosis:ICD Code:
ICD Code:
Date of diagnosis:
Date of diagnosis:ICD Code:
NO
YES
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.
Intervertebral disc syndrome
Spondylolysis/isthmic
spondylolisthesis
Degenerative spondylolisthesis
Foraminal/lateral recess/
central stenosis
Degenerative disc disease
Facet joint arthropathy
(degenerative joint disease
of lumbosacral spine)
Lumbosacral sprain/strain
Mechanical back pain
syndrome
Page 1
SUPERSEDES VA FORM 21-0960M-14, MAY 2013,
WHICH WILL NOT BE USED.
21-0960M-14
VA FORM
DEC 2017
NAME OF PATIENT/VETERAN
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
SECTION II - MEDICAL HISTORY
SECTION I - DIAGNOSIS
(Continued)
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S THORACOLUMBAR SPINE (back) 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 THORACOLUMBAR SPINE (back)?
2C. DOES THE VETERAN REPORT HAVING ANY FUNCTIONAL LOSS OR FUNCTIONAL IMPAIRMENT OF THE THORACOLUMBAR SPINE
(back) (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-14, DEC 2017 Page 2
N/A
NOYES
3A. INITIAL ROM MEASUREMENTS
Right Lateral
Rotation
(normal endpoint
= 30 degrees)
Not able to perform
Not indicated
Not indicated
Not able to perform
Not able to perform
Not indicated
Not able to perform
Not indicated
Not able to perform
Not indicated
Not indicated
Not able to perform
Joint Movement 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:
Forward Flexion
(normal endpoint
= 90 degrees)
Extension
(normal endpoint
= 30 degrees)
Right Lateral
Flexion
(normal endpoint
= 30 degrees)
Left Lateral
Flexion
(normal endpoint
= 30 degrees)
Left Lateral
Rotation
(normal endpoint
= 30 degrees)
BACK
1C. COMMENTS (if any):
ICD Code:
Date of diagnosis:
Date of diagnosis:ICD Code:
Other diagnosis #3:
Other diagnosis #2:
1B. SELECT DIAGNOSES ASSOCIATED WITH THE CLAIMED CONDITION(S)
(Check all that apply) (Continued):
ICD Code: Date of diagnosis:
Other diagnosis #1:
Other
(specify)
PATIENT/VETERAN'S SOCIAL SECURITY NO.
All Normal
SECTION III - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS (Continued)
Page 3VA FORM 21-0960M-14, DEC 2017
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 back
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 limitations in Section 7 below)
4A. POST-TEST ROM MEASUREMENTS
SECTION IV - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING
If no, provide reason below, then proceed to Section 5
If yes, perform repetitive-use testing
Forward Flexion
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
Extension
Left Lateral
Flexion
Right Lateral
Flexion
Is the veteran able to perform repetitive-use testing?
Is there additional limitation in ROM
after repetitive-use testing?
Joint Movement
Post-test ROM
Measurement
Left Lateral
Rotation
Right Lateral
Rotation
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 7 below)
4B. DO ANY POST-TEST ADDITIONAL LIMITATIONS OF ROMs NOTED ABOVE CONTRIBUTE TO FUNCTIONAL LOSS?
SECTION V - PAIN
5A. ROM MOVEMENTS PAINFUL ON ACTIVE, PASSIVE AND/OR REPETITIVE USE TESTING
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:
No
Yes
Yes (you will be asked to further describe
these limitations in Section 7 below)
No
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)
5B. PAIN WHEN USED IN WEIGHT-BEARING OR IN NON WEIGHT-BEARING
No
Yes (you will be asked to further describe
these limitations in Section 7 below)
Yes
No
5C. LOCALIZED TENDERNESS OR PAIN ON PALPATION
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:
No Yes
5D. COMMENTS, IF ANY:
PATIENT/VETERAN'S SOCIAL SECURITY NO.
Page 4VA FORM 21-0960M-14, DEC 2017
SECTION VI - GUARDING AND MUSCLE SPASM
6A. DOES THE VETERAN HAVE GUARDING OR MUSCLE SPASM OF THE THORACOLUMBAR SPINE (back)?
6B. GAIT:
Other, describe and provide etiology:
Guarding
Muscle spasm
Due to:
ABNORMAL
NORMAL
6C. SPINAL CONTOUR:
NO
NORMAL
ABNORMAL
UNABLE TO EVALUATE, PROVIDE REASON:
Due to:
Muscle spasm
Guarding
Other, describe and provide etiology:
YES
UNABLE TO EVALUATE, PROVIDE REASON:
7A. 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 VII - 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:
Interference with standing
Interference with sitting
Disturbance of locomotion
Instability of station
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.)
Incoordination, impaired ability to execute skilled movements smoothly
Swelling
Atrophy of disuse
Other, describe:
Deformity
Pain on movement
PATIENT/VETERAN'S SOCIAL SECURITY NO.
Page 5VA FORM 21-0960M-14, DEC 2017
YES (If yes, complete question 7C and 7D)
NO (If no, proceed to question 7D)
7B. 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.
7C. CONTRIBUTING FACTORS OF DISABILITY ASSOCIATED WITH LIMITATION OF MOTION
Extension
Left Lateral
Flexion
Est. ROM is
not feasible
Est. ROM is
not feasible
Est. ROM is
not feasible
Est. ROM is
not feasible
Right Lateral
Flexion
Forward
Flexion
Est. ROM is
not feasible
Est. ROM is
not feasible
NoYes
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?
Left Lateral
Rotation
Right Lateral
Rotation
SECTION VII - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION OF ROM (Continued)
7D. CONTRIBUTING FACTORS OF DISABILITY NOT ASSOCIATED WITH LIMITATION OF MOTION
NOYES
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?
SECTION VIII - MUSCLE STRENGTH TESTING
8A. 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
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
/5
/5
Ankle Plantar
Flexion
/5
Foot Abduction /5
Foot Adduction
Great Toe
Extension
/5
/5
Ankle
Dorsiflexion
/5
Knee Flexion
Hip Flexion
Knee Extension
RIGHT
NoYes Yes No
PATIENT/VETERAN'S SOCIAL SECURITY NO.
All Normal
Page 6VA FORM 21-0960M-14, DEC 2017
SECTION VIII - MUSCLE STRENGTH TESTING (Continued)
8B. DOES THE VETERAN HAVE MUSCLE ATROPHY?
IF YES, IS THE MUSCLE ATROPHY DUE TO THE CLAIMED CONDITION IN THE DIAGNOSIS SECTION?
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.
CMCIRCUMFERENCE OF ATROPHIED SIDE:CIRCUMFERENCE OF MORE NORMAL SIDE: CM
RIGHT LOWER EXTREMITY (specify location of measurement such as "10cm above or below elbow"):
LOCATION OF MUSCLE ATROPHY:
LEFT LOWER EXTREMITY (specify location of measurement such as "10cm above or below elbow"):
CMCIRCUMFERENCE OF MORE NORMAL SIDE: CIRCUMFERENCE OF ATROPHIED SIDE: CM
8A. MUSCLE STRENGTH - RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE (Continued):
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
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
/5
/5
Ankle Plantar
Flexion
/5
Foot Abduction /5
Foot Adduction
Great Toe
Extension
/5
/5
Ankle
Dorsiflexion
/5
Knee Flexion
Hip Flexion
Knee
Extension
LEFT
NoYes Yes No
8C. COMMENTS, IF ANY:
COMPLETE THIS SECTION IF VETERAN HAS ANKYLOSIS OF THE THORACOLUMBAR SPINE
(back).
9A. INDICATE SEVERITY OF ANKYLOSIS:
Unfavorable ankylosis of the entire spine (cervical and thoracolumbar)
No ankylosis
Unfavorable ankylosis of the entire thoracolumbar spine
Favorable ankylosis of the entire thoracolumbar spine
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
(0 degrees) always represents favorable ankylosis.
SECTION IX - ANKYLOSIS
9B. COMMENTS, IF ANY:
SECTION X - REFLEX EXAM
10A. DEEP TENDON REFLEXES - 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:
KNEE: ANKLE:
KNEE: ANKLE:
+
+ +
+
PATIENT/VETERAN'S SOCIAL SECURITY NO.
All Normal
All Normal
All Normal
Page 7VA FORM 21-0960M-14, DEC 2017
11C. OTHER SENSORY FINDINGS, IF ANY:
12. PROVIDE STRAIGHT LEG RAISING TEST RESULTS:
LEFT:
RIGHT:
IF YES, COMPLETE QUESTIONS 13B-13K, INCLUDING SYMPTOMS, SEVERITY OF RADICULOPATHY AND NERVE ROOTS INVOLVED
(check all that apply)
13A. DOES THE VETERAN HAVE RADICULAR PAIN OR ANY OTHER SUBJECTIVE SYMPTOMS DUE TO RADICULOPATHY?
13B. CONSTANT PAIN, AT TIMES EXCRUCIATING (subjective symptom)
13C. INTERMITTENT PAIN (subjective symptom)
Present
None
SevereModerateMildNone
Mild Moderate
Severe
If present, indicate location and severity:
Left lower extremity:
Right lower extremity:
Absent (does not occur) Pain is present, but not due to radiculopathy (if checked, provide rationale in question 13K below)
13D. DULL PAIN (subjective symptom)
IF THE VETERAN REPORTED RADICULAR-TYPE SYMPTOMS IN THE MEDICAL HISTORY SECTION ABOVE THAT YOU FIND ARE NOT DUE TO RADICULOPATHY,
PLEASE PROVIDE RATIONALE:
NOTE: Radiculopathy is considered to be any condition due to disease of the nerve roots and nerves located in the back.
NOTE: This test can be performed with the Veteran seated or supine. Raise each straightened leg until pain begins, typically at 30-70 degrees of elevation. The test is
positive if the pain radiates below the knee, not merely limited to the back or hamstring muscles. Pain is often increased on dorsiflexion of the foot, and relieved by
knee flexion. A positive test suggests radiculopathy, often due to disc herniation.
SECTION XI - SENSORY EXAM
Pain is present, but not due to radiculopathy (if checked, provide rationale in question 13K below)Absent (does not occur)
Right lower extremity:
Left lower extremity:
If present, indicate location and severity:
Severe
ModerateMild
None Mild Moderate
Severe
None
Present
DecreasedNormal
Absent Absent
Normal Decreased
DecreasedNormal
Absent
Absent
Normal DecreasedNormal
Absent
Decreased
Decreased
Absent
Normal DecreasedNormal
AbsentAbsent
AbsentDecreasedNormal Normal Decreased AbsentDecreasedNormalAbsent
Absent Normal Decreased AbsentDecreasedNormalNormal Decreased Absent
Normal Decreased
11A. RESULTS FOR SENSATION TO LIGHT TOUCH
(dermatome) TESTING:
11B. WERE OTHER SENSORY TESTS INDICATED AND PERFORMED?
IF YES, INDICATE RESULTS:
Not tested
Vibration Sensation
(place low-pitched tuning fork over
IP joint of great toe)
Not tested
Cold Sensation
(test distal extremities for cold sensation with
side of tuning fork or other cold object)
Not tested
YES NO
YES
NEGATIVE POSITIVE UNABLE TO PERFORM
NEGATIVE POSITIVE UNABLE TO PERFORM
Present
None
SevereModerateMildNone
Mild Moderate
Severe
If present, indicate location and severity:
Left lower extremity:
Right lower extremity:
Absent (does not occur) Pain is present, but not due to radiculopathy (if checked, provide rationale in question 13K below)
NO
RIGHT
Upper Anterior Thigh
(L2)
Side
Thigh/Knee
(L3/4) Lower Leg/Ankle (L4/L5/S1)
Foot/Toes (L5)
LEFT
Side
Position Sense
(grasp great toe on sides and ask patient
to identify up and down movement)
RIGHT
LEFT
10B. COMMENTS, IF ANY:
SECTION XIII - RADICULOPATHY
SECTION XII - STRAIGHT LEG RAISING TEST
SECTION X - REFLEX EXAM (Continued)
PATIENT/VETERAN'S SOCIAL SECURITY NO.
All Normal
All Normal
Page 8VA FORM 21-0960M-14, DEC 2017
Numbness is present, but not due to radiculopathy (if checked, provide rationale in question 13K below)
Not affected
SevereModerateMildNot affected
Mild Moderate
SevereLeft lower extremity:
Right lower extremity:
Absent (does not occur)
Right lower extremity:
Left lower extremity:
If present, indicate location and severity:
13G. DOES THE VETERAN HAVE ANY OBJECTIVE FINDINGS DUE TO RADICULOPATHY NOT ADDRESSED IN THE PHYSICAL EXAM SECTION?
13H. INDICATE SEVERITY OF RADICULOPATHY
(evaluate severity by incorporating the effects of subjective symptoms and objective findings, if any) AND SIDE
AFFECTED:
13I. SPECIFY NERVE ROOTS INVOLVED
(check all that apply):
IF YES, DESCRIBE:
SevereModerateMild
None Mild Moderate
Severe
None
Present
13F. NUMBNESS (subjective symptom)
SECTION XIII - RADICULOPATHY (Continued)
13E. PARESTHESIAS AND/OR DYSESTHESIAS (subjective symptom)
Present
None
SevereModerateMildNone
Mild Moderate
Severe
If present, indicate location and severity:
Left lower extremity:
Right lower extremity:
Absent (does not occur)
Paresthesias and/or dysesthesias are present, but not due to radiculopathy (if checked, provide rationale in
question 13K below)
NOYES
Both
OTHER NERVES (specify nerve root involved):
If checked, indicate side affected: LeftRight Both
RIGHT
LEFT
AMBIDEXTROUS
Right Left
If checked, indicate side affected:
INVOLVEMENT OF L4/L5/S1/S2/S3 NERVE ROOTS (sciatic nerve)
INVOLVEMENT OF L2/L3/L4 NERVE ROOTS (femoral nerve)
If checked, indicate side affected: LeftRight Both
SECTION XV - INTERVERTEBRAL DISC SYNDROME (IVDS) AND INCAPACITATING EPISODES
13K. COMMENTS, IF ANY:
IF YES, DESCRIBE CONDITION AND ITS RELATIONSHIP TO ANY CONDITION LISTED IN THE DIAGNOSIS SECTION:
15A. DOES THE VETERAN HAVE IVDS OF THE THORACOLUMBAR SPINE?
15C. IF YES TO QUESTION 15B ABOVE, PROVIDE THE TOTAL DURATION OF ALL INCAPACITATING EPISODES OVER THE PAST 12 MONTHS:
15B. IF YES TO QUESTION 15A ABOVE, HAS THE VETERAN HAD ANY INCAPACITATING EPISODES
(a period of acute signs and symptoms due to IVDS that requires
bed rest prescribed by a physician and treatment by a physician) OVER THE PAST 12 MONTHS?
NOTE: If there are neurological abnormalities other than those addressed in the Physical Exam or Radiculopathy sections above, ALSO complete appropriate
Disability Benefits Questionnaire for each condition identified.
NOTE: For VA purposes, IVDS is a group of signs and symptoms due to nerve root irritation 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.
SECTION XIV - OTHER NEUROLOGIC ABNORMALITIES
NO
YES NO
At least 1 week but less than 2 weeks
At least 2 weeks but less than 4 weeks
At least 4 weeks but less than 6 weeks
At least 6 weeks
YES
Less than 1 week
NO
YES
14. DOES THE VETERAN HAVE ANY OTHER OBJECTIVE NEUROLOGIC ABNORMALITIES OR FINDINGS (including, but not limited to bowel or bladder problems)
ASSOCIATED WITH A THORACOLUMBAR SPINE
(back) CONDITION?
13J. DOMINANT HAND
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION XVI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS AND SCARS
16A. 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?
16C. 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 16B-16D.
YES NO
IF YES, DESCRIBE
(brief summary):
YES NO
YES
16D. 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
16B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN THE DIAGNOSIS SECTION ABOVE?
17A. DOES THE VETERAN USE ANY ASSISTIVE DEVICES AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS
MAY BE POSSIBLE?
17B. 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 XVII - 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 XV - INTERVERTEBRAL DISC SYNDROME (IVDS) AND INCAPACITATING EPISODES (Continued)
15D. COMMENTS, IF ANY:
18. DUE TO THE VETERAN'S THORACOLUMBAR SPINE
(back) 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.)
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 XVIII - 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.
Page 9VA FORM 21-0960M-14, DEC 2017
PATIENT/VETERAN'S SOCIAL SECURITY NO.
19A. HAVE IMAGING STUDIES OF THE THORACOLUMBAR SPINE BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
19B. DOES THE VETERAN HAVE A VERTEBRAL FRACTURE?
19C. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS OR RESULTS?
19D. 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):
IF YES, PROVIDE PERCENT OF LOSS OF VERTEBRAL BODY HEIGHT: %
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. 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. 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.
SECTION XIX - DIAGNOSTIC TESTING
YES
IF YES, IS ARTHRITIS DOCUMENTED?
NO
YES NO
YES NO
YES NO
VA FORM 21-0960M-14, DEC 2017 Page 10
20. 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 XX - 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 11VA FORM 21-0960M-14, DEC 2017
21. REMARKS, IF ANY:
SECTION XXI - 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.
22C. DATE SIGNED
22E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER
22F. PHYSICIAN'S ADDRESS
22B. PHYSICIAN'S PRINTED NAME
(VA Regional Office FAX No.)
22A. 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 XXII - PHYSICIAN'S CERTIFICATION AND SIGNATURE
IMPORTANT - Physician please fax the completed form to
22D. PHYSICIAN'S PHONE AND FAX NUMBER
NOTE: VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.
PATIENT/VETERAN'S SOCIAL SECURITY NO.
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VBA - Form 21-0960M-14 Back Conditions Disability Benefits Questionnaire

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Completed 25 May 2020

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