OMB Approved No. 2900-0812
Respondent Burden: 30 minutes
Expiration Date: 06-30-2020
ELBOW AND FOREARM CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE
IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE
PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION ON
REVERSE BEFORE COMPLETING FORM.
NAME OF PATIENT/VETERAN
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
NOTE TO PHYSICIAN - The veteran or service member is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the
information you provide on this questionnaire as part of their evaluation in processing the claim. VA reserves the right to confirm the authenticity of ALL DBQs
completed by private health care providers.
MEDICAL RECORD REVIEW
WAS THE VETERAN'S VA CLAIMS FILE REVIEWED?
YES
NO
IF YES, LIST ANY RECORDS THAT WERE REVIEWED BUT WERE NOT INCLUDED IN THE VETERAN'S VA CLAIMS FILE:
IF NO, CHECK ALL RECORDS REVIEWED:
Military service treatment records
Department of Defense Form 214 Separation Documents
(VA treatment records)
Military service personnel records
Veterans Health Administration medical records
Military enlistment examination
Civilian medical records
(family and others who have known the veteran before and after military service)
Interviews with collateral witnesses
Military separation examination
Military post-deployment questionnaire
Other:
No records were reviewed
SECTION I - DIAGNOSIS
NOTE: These are condition(s) for which an evaluation has been requested on an exam request form (Internal VA) or for which the Veteran has requested medical
evidence be provided for submission to VA.
1A. LIST THE CLAIMED CONDITION(S) THAT PERTAIN TO THIS DBQ:
NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed above. If there is no diagnosis, if the diagnosis is different
from a previous diagnosis for this condition, or if there is a diagnosis of a complication due to the claimed condition, explain your findings and reasons in comments
section. Date of diagnosis can be the date of the evaluation if the clinician is making the initial diagnosis, or an approximate date determined through record review or
reported history.
(Check all that apply)
1B. SELECT DIAGNOSES ASSOCIATED WITH THE CLAIMED CONDITION(S)
:
(Explain your findings and reasons in comments section.)
The Veteran does not have a current diagnosis associated with any claimed condition listed above.
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Olecranon bursitis
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Tricep tendinitis
Lateral epicondylitis
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Medial epicondylitis
(medial/
Instability
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
posterolateral rotatory)
Dislocation, elbow
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Osteoarthritis, elbow
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Total elbow arthroplasty
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Ankylosis of elbow joint
(specify)
Other
Other diagnosis #1:
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Other diagnosis #2:
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Other diagnosis #3:
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
(if any)
1C. COMMENTS
:
21-0960M-4
VA FORM
SUPERSEDES VA FORM 21-0960M-4, MAY 2013,
Page 1
JUN 2017
WHICH WILL NOT BE USED.
OMB Approved No. 2900-0812
Respondent Burden: 30 minutes
Expiration Date: 06-30-2020
ELBOW AND FOREARM CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE
IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE
PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION ON
REVERSE BEFORE COMPLETING FORM.
NAME OF PATIENT/VETERAN
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
NOTE TO PHYSICIAN - The veteran or service member is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the
information you provide on this questionnaire as part of their evaluation in processing the claim. VA reserves the right to confirm the authenticity of ALL DBQs
completed by private health care providers.
MEDICAL RECORD REVIEW
WAS THE VETERAN'S VA CLAIMS FILE REVIEWED?
YES
NO
IF YES, LIST ANY RECORDS THAT WERE REVIEWED BUT WERE NOT INCLUDED IN THE VETERAN'S VA CLAIMS FILE:
IF NO, CHECK ALL RECORDS REVIEWED:
Military service treatment records
Department of Defense Form 214 Separation Documents
(VA treatment records)
Military service personnel records
Veterans Health Administration medical records
Military enlistment examination
Civilian medical records
(family and others who have known the veteran before and after military service)
Interviews with collateral witnesses
Military separation examination
Military post-deployment questionnaire
Other:
No records were reviewed
SECTION I - DIAGNOSIS
NOTE: These are condition(s) for which an evaluation has been requested on an exam request form (Internal VA) or for which the Veteran has requested medical
evidence be provided for submission to VA.
1A. LIST THE CLAIMED CONDITION(S) THAT PERTAIN TO THIS DBQ:
NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed above. If there is no diagnosis, if the diagnosis is different
from a previous diagnosis for this condition, or if there is a diagnosis of a complication due to the claimed condition, explain your findings and reasons in comments
section. Date of diagnosis can be the date of the evaluation if the clinician is making the initial diagnosis, or an approximate date determined through record review or
reported history.
(Check all that apply)
1B. SELECT DIAGNOSES ASSOCIATED WITH THE CLAIMED CONDITION(S)
:
(Explain your findings and reasons in comments section.)
The Veteran does not have a current diagnosis associated with any claimed condition listed above.
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Olecranon bursitis
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Tricep tendinitis
Lateral epicondylitis
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Medial epicondylitis
(medial/
Instability
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
posterolateral rotatory)
Dislocation, elbow
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Osteoarthritis, elbow
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Total elbow arthroplasty
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Ankylosis of elbow joint
(specify)
Other
Other diagnosis #1:
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Other diagnosis #2:
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
Other diagnosis #3:
Side affected:
Right
Left
Both
ICD Code:
Date of diagnosis:
(if any)
1C. COMMENTS
:
21-0960M-4
VA FORM
SUPERSEDES VA FORM 21-0960M-4, MAY 2013,
Page 1
JUN 2017
WHICH WILL NOT BE USED.
PATIENT/VETERAN'S SOCIAL SECURITY NO.
(Continued)
SECTION I - DIAGNOSIS
(internal VA only)
1D. WAS AN OPINION REQUESTED ABOUT THIS CONDITION
?
YES
NO
N/A
NOTE: In all forearm injuries, if there are impaired finger movements due to tendon, muscle or nerve injuries, ALSO complete appropriate additional DBQ(s) such as
the Hand, Peripheral Nerve and/or Muscle Injuries Disability Benefits Questionnaire.
SECTION II - MEDICAL HISTORY
(including onset and course)
OF THE VETERAN'S ELBOW OR FOREARM CONDITION (brief summary):
2A. DESCRIBE THE HISTORY
2B. DOMINANT HAND
RIGHT
LEFT
AMBIDEXTROUS
2C. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE ELBOW OR FOREARM?
YES
NO
IF YES, DOCUMENT THE VETERAN'S DESCRIPTION OF THE IMPACT OF FLARE-UPS IN HIS OR HER OWN WORDS:
2D. DOES THE VETERAN REPORT HAVING ANY FUNCTIONAL LOSS OR FUNCTIONAL IMPAIRMENT OF THE JOINT OR EXTREMITY BEING EVALUATED ON THIS
(regardless of repetitive use)
DBQ
?
YES
NO
IF YES, DOCUMENT THE VETERAN'S DESCRIPTION OF FUNCTIONAL LOSS OR FUNCTIONAL IMPAIRMENT IN HIS OR HER OWN WORDS:
(ROM)
SECTION III - INITIAL RANGE OF MOTION
MEASUREMENTS
Measure ROM with a goniometer. During the examination be cognizant of painful motion, which could be evidenced by visible behavior such as facial expression, wincing,
etc..., on pressure or manipulation. Document painful movement in Section 5.
Following the initial assessment of ROM, perform repetitive use testing. For VA purposes, repetitive use testing must be included in all joint exams. The VA has determined
that 3 repetitions of ROM (at a minimum) can serve as a representative test of the effect of repetitive use. After the initial measurement, reassess ROM after 3 repetitions.
Report post-test measurements in question 4A.
3A. INITIAL ROM MEASUREMENTS
If ROM testing is not indicated for the veteran's condition or not able to be performed,
Elbow
Joint Movement
ROM Measurement
please explain why, and then proceed to Section 5:
Flexion
Not indicated
(normal endpoint
= 145 degrees)
Not able to perform
Not indicated
Extension
RIGHT
ELBOW
Not able to perform
All Normal
Forearm
Supination
Not indicated
(normal endpoint
Not able to perform
= 85 degrees)
Forearm
Pronation
Not indicated
(normal endpoint
Not able to perform
= 80 degrees)
Flexion
Not indicated
(normal endpoint
= 145 degrees)
Not able to perform
Extension
Not indicated
LEFT
ELBOW
Not able to perform
All Normal
Forearm
Supination
Not indicated
(normal endpoint
Not able to perform
= 85 degrees)
Forearm
Pronation
Not indicated
(normal endpoint
Not able to perform
= 80 degrees)
VA FORM 21-0960M-4, JUN 2017
Page 2
PATIENT/VETERAN'S SOCIAL SECURITY NO.
(ROM)
(Continued)
SECTION III - INITIAL RANGE OF MOTION
MEASUREMENTS
3B. DO ANY ABNORMAL ROMs NOTED ABOVE CONTRIBUTE TO FUNCTIONAL LOSS?
(you will be asked to further describe these limitation in Section 6 below)
YES
NO, EXPLAIN WHY THE ABNORMAL ROMs DO NOT CONTRIBUTE:
(for reasons other than an elbow
3C. IF ROM DOES NOT CONFORM TO THE NORMAL RANGE OF MOTION IDENTIFIED ABOVE BUT IS NORMAL FOR THIS VETERAN
condition, such as age, body habitus, neurologic disease),
EXPLAIN:
SECTION IV - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING
4A. POST-TEST ROM MEASUREMENTS
Is there additional limitation in ROM
Post-test ROM
Elbow
Is the veteran able to perform repetitive-use testing?
Joint Movement
after repetitive-use testing?
Measurement
Flexion
Yes
If yes, perform repetitive-use testing
Yes
If no, provide reason below, then proceed to
No, there is no change in ROM
No
Extension
Section 6
after repetitive testing
RIGHT
Forearm
ELBOW
If yes, report ROM after a minimum
Supination
of 3 repetitions.
If no, documentation of ROM after
Forearm
repetitive-use testing is not required.
Pronation
Flexion
Yes
If yes, perform repetitive-use testing
Yes
If no, provide reason below, then proceed to
No, there is no change in ROM
No
Extension
Section 6
after repetitive testing
LEFT
Forearm
ELBOW
If yes, report ROM after a minimum
Supination
of 3 repetitions.
If no, documentation of ROM after
Forearm
repetitive-use testing is not required.
Pronation
4B. DO ANY POST-TEST ADDITIONAL LIMITATIONS OF ROMs NOTED ABOVE CONTRIBUTE TO FUNCTIONAL LOSS?
(you will be asked to further describe these limitations in Section 6 below)
YES
NO, EXPLAIN WHY THE POST-TEST ADDITIONAL LIMITATIONS OF ROMs DO NOT CONTRIBUTE:
SECTION V - PAIN
5A. ROM MOVEMENTS PAINFUL ON ACTIVE, PASSIVE AND/OR REPETITIVE USE TESTING
Are any ROM movements
painful on active, passive
(there are painful movements)
If yes
, does the
and/or repetitive use testing?
(the pain does not contribute to functional loss or additional
If no
Elbow
pain contribute to functional loss or
limitation of ROM)
, explain why the pain does not contribute:
(If yes, identify whether active,
additional limitation of ROM?
passive, and/or repetitive use in
question 5D)
(you will be asked to further describe
Yes
Yes
these limitations in Section 6 below)
RIGHT
ELBOW
No
No
(you will be asked to further describe
Yes
Yes
these limitations in Section 6 below)
LEFT
ELBOW
No
No
5B. PAIN WHEN USED IN WEIGHT-BEARING OR IN NON WEIGHT-BEARING
Is there pain when the joint is
used in weight-bearing or non
(there is pain when used in weight-bearing
If yes
weight-bearing?
(the pain does not contribute to functional loss or additional
If no
Elbow
or non weight-bearing)
, does the pain contribute
limitation of ROM)
, explain why the pain does not contribute:
(If yes, identify whether weight-
to functional loss or additional limitation of ROM?
bearing or non weight-bearing
in question 5D)
(you will be asked to further describe
Yes
Yes
these limitations in Section 6 below)
RIGHT
ELBOW
No
No
(you will be asked to further describe
Yes
Yes
these limitations in Section 6 below)
LEFT
ELBOW
No
No
VA FORM 21-0960M-4, JUN 2017
Page 3
PATIENT/VETERAN'S SOCIAL SECURITY NO.
(Continued)
SECTION V - PAIN
5C. LOCALIZED TENDERNESS OR PAIN ON PALPATION
Does the Veteran have localized tenderness
Elbow
If yes, describe including location, severity and relationship to condition(s) listed in the Diagnosis section:
or pain to palpation of joints or soft tissue?
RIGHT
Yes
No
ELBOW
LEFT
Yes
No
ELBOW
5D. COMMENTS, IF ANY:
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:
(check all that apply and indicate side affected)
6A. CONTRIBUTING FACTORS OF DISABILITY
:
No functional loss for left upper extremity attributable to claimed condition
No functional loss for right upper extremity attributable to claimed condition
(due to ankylosis, limitation or blocking, adhesions,
Less movement than normal
Right
Left
Both
tendon-tie-ups, contracted scars, etc.)
(from flail joints, resections, nonunion of fractures,
More movement than normal
Right
Left
Both
relaxation of ligaments, etc..)
(due to muscle injury, disease or injury of peripheral
Weakened movement
Right
Left
Both
nerves, divided or lengthened tendons, etc.)
Excess fatigability
Right
Left
Both
Incoordination, impaired ability to execute skilled movements smoothly
Right
Left
Both
Pain on movement
Right
Left
Both
Swelling
Right
Left
Both
Deformity
Right
Left
Both
Atrophy of disuse
Right
Left
Both
Instability of station
Right
Left
Both
Disturbance of locomotion
Right
Left
Both
Interference with sitting
Right
Left
Both
Interference with standing
Right
Left
Both
Other, describe:
NOTE: If any of the above factors is/are associated with limitation of motion, the examiner must give an opinion on whether pain, weakness, fatigability, or incoordination
could significantly limit functional ability during flare-ups or when the joint is used repeatedly over a period of time and that opinion, if feasible, should be expressed in
terms of the degree of additional ROM loss due to pain on use or during flare-ups. The following section will assist you in providing this required opinion.
6B. ARE ANY OF THE ABOVE FACTORS ASSOCIATED WITH LIMITATION OF MOTION?
(If yes, complete questions 6C and 6D)
YES
(If no, proceed to Section 6D)
NO
VA FORM 21-0960M-4, JUN 2017
Page 4
PATIENT/VETERAN'S SOCIAL SECURITY NO.
(Continued)
SECTION VI - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION OF ROM
6C. CONTRIBUTING FACTORS OF DISABILITY ASSOCIATED WITH LIMITATION OF MOTION
Can pain, weakness, fatigability, or
If there is a functional loss due to pain, during flare-ups and/or
If yes, please estimate ROM due to pain and/or
incoordination significantly limit functional
when the joint is used repeatedly over a period of time but the
Elbow
functional loss during flare-ups or when the
ability during flare-ups or when the joint is
limitation of ROM cannot be estimated, please describe
joint is used repeatedly over a period of time:
used repeatedly over a period of time?
the functional loss:
Est. ROM is
Flexion
not feasible
Est. ROM is
Extension
not feasible
RIGHT
Yes
No
ELBOW
Forearm
Est. ROM is
Supination
not feasible
Forearm
Est. ROM is
Pronation
not feasible
Est. ROM is
Flexion
not feasible
Est. ROM is
Extension
not feasible
LEFT
Yes
No
ELBOW
Forearm
Est. ROM is
Supination
not feasible
Forearm
Est. ROM is
Pronation
not feasible
CONTRIBUTING FACTORS OF DISABILITY NOT ASSOCIATED WITH LIMITATION OF MOTION
(not associated with limitation of motion)
6D. IS THERE ANY FUNCTIONAL LOSS
DURING FLARE-UPS OR WHEN THE JOINT IS USED REPEATEDLY OVER A
PERIOD OF TIME OR OTHERWISE?
RIGHT ELBOW
YES
NO
IF YES, DESCRIBE:
LEFT ELBOW
YES
NO
IF YES, DESCRIBE:
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
Flexion/
Rate
Is there a reduction in
If yes, is the reduction entirely due to the
If no (the reduction is not entirely due to the
Elbow
Extension
Strength
muscle strength?
claimed condition in the Diagnosis section?
claimed condition), provide rationale:
RIGHT ELBOW
Flexion
/5
Yes
No
Yes
No
All Normal
Extension
/5
LEFT ELBOW
Flexion
/5
Yes
No
Yes
No
All Normal
Extension
/5
7B. DOES THE VETERAN HAVE MUSCLE ATROPHY?
YES
NO
IF YES, IS THE MUSCLE ATROPHY DUE TO THE CLAIMED CONDITION IN THE DIAGNOSIS SECTION?
YES
NO
IF NO, PROVIDE RATIONALE:
FOR ANY MUSCLE ATROPHY DUE TO A DIAGNOSES LISTED IN SECTION 1, INDICATE SIDE AND SPECIFIC LOCATION OF ATROPHY, PROVIDING
MEASUREMENTS IN CENTIMETERS OF NORMAL SIDE AND CORRESPONDING ATROPHIED SIDE, MEASURED AT MAXIMUM MUSCLE BULK.
LOCATION OF MUSCLE ATROPHY:
(specify location of measurement such as "10cm above or below elbow")
RIGHT UPPER EXTREMITY
:
CIRCUMFERENCE OF MORE NORMAL SIDE:
cm
CIRCUMFERENCE OF ATROPHIED SIDE:
cm
(specify location of measurement such as "10cm above or below elbow")
LEFT UPPER EXTREMITY
:
CIRCUMFERENCE OF MORE NORMAL SIDE:
cm
CIRCUMFERENCE OF ATROPHIED SIDE:
cm
VA FORM 21-0960M-4, JUN 2017
Page 5
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