VA Form 21-0960M-13 "Neck (Cervical Spine) Conditions Disability Benefits Questionnaire"

VA Form 21-0960M-13 or the "Neck (cervical Spine) Conditions Disability Benefits Questionnaire" is a form issued by the U.S. Department of Veterans Affairs.

Download a PDF version of the VA Form 21-0960M-13 down below or find it on the U.S. Department of Veterans Affairs Forms website.

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Download VA Form 21-0960M-13 "Neck (Cervical Spine) Conditions Disability Benefits Questionnaire"

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OMB Approved No. 2900-0807
Respondent Burden: 45 Minutes
Expiration Date: 03/31/2021
NECK (CERVICAL SPINE) 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)
Veterans Health Administration medical records
Military service personnel records
Military enlistment examination
Civilian medical records
(family and others who have known the veteran before and after military service)
Military separation examination
Interviews with collateral witnesses
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.
Mechanical cervical pain
ICD Code:
Date of diagnosis:
syndrome
Cervical sprain/strain
ICD Code:
Date of diagnosis:
Cervical spondylosis
ICD Code:
Date of diagnosis:
(degenerative joint disease
of cervical spine)
Degenerative disc disease
ICD Code:
Date of diagnosis:
Foraminal stenosis/central
ICD Code:
Date of diagnosis:
stenosis
Intervertebral disc syndrome
ICD Code:
Date of diagnosis:
Radiculopathy
ICD Code:
Date of diagnosis:
Myelopathy
ICD Code:
Date of diagnosis:
Ankylosis of the cervical spine
ICD Code:
Date of diagnosis:
Ankylosing spondylitis of the
ICD Code:
Date of diagnosis:
neck)
cervical spine (
vertebrae
Vertebral fracture (
ICD Code:
Date of diagnosis:
of the neck)
(specify)
Other
Other diagnosis #1:
ICD Code:
Date of diagnosis:
Other diagnosis #2:
ICD Code:
Date of diagnosis:
21-0960M-13
VA FORM
SUPERSEDES VA FORM 21-0960M-13, MAY 2013,
Page 1
MAR 2018
WHICH WILL NOT BE USED.
OMB Approved No. 2900-0807
Respondent Burden: 45 Minutes
Expiration Date: 03/31/2021
NECK (CERVICAL SPINE) 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)
Veterans Health Administration medical records
Military service personnel records
Military enlistment examination
Civilian medical records
(family and others who have known the veteran before and after military service)
Military separation examination
Interviews with collateral witnesses
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.
Mechanical cervical pain
ICD Code:
Date of diagnosis:
syndrome
Cervical sprain/strain
ICD Code:
Date of diagnosis:
Cervical spondylosis
ICD Code:
Date of diagnosis:
(degenerative joint disease
of cervical spine)
Degenerative disc disease
ICD Code:
Date of diagnosis:
Foraminal stenosis/central
ICD Code:
Date of diagnosis:
stenosis
Intervertebral disc syndrome
ICD Code:
Date of diagnosis:
Radiculopathy
ICD Code:
Date of diagnosis:
Myelopathy
ICD Code:
Date of diagnosis:
Ankylosis of the cervical spine
ICD Code:
Date of diagnosis:
Ankylosing spondylitis of the
ICD Code:
Date of diagnosis:
neck)
cervical spine (
vertebrae
Vertebral fracture (
ICD Code:
Date of diagnosis:
of the neck)
(specify)
Other
Other diagnosis #1:
ICD Code:
Date of diagnosis:
Other diagnosis #2:
ICD Code:
Date of diagnosis:
21-0960M-13
VA FORM
SUPERSEDES VA FORM 21-0960M-13, MAY 2013,
Page 1
MAR 2018
WHICH WILL NOT BE USED.
PATIENT/VETERAN'S SOCIAL SECURITY NO.
(Continued)
SECTION I - DIAGNOSIS
Other diagnosis #3:
ICD Code:
Date of diagnosis:
(if any)
:
1C. COMMENTS
(internal VA only)
1D. WAS AN OPINION REQUESTED ABOUT THIS CONDITION
?
YES
NO
N/A
SECTION II - MEDICAL HISTORY
(including onset and course)
(neck)
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S CERVICAL SPINE
CONDITION (brief summary):
2B. DOMINANT HAND:
RIGHT
LEFT
AMBIDEXTROUS
(neck)
2C. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE CERVICAL SPINE
?
YES
NO
IF YES, DOCUMENT THE VETERAN'S DESCRIPTION OF THE IMPACT OF FLARE-UPS IN HIS OR HER OWN WORDS:
(neck) (regardless of repetitive use)
2D. DOES THE VETERAN REPORT HAVING ANY FUNCTIONAL LOSS OR FUNCTIONAL IMPAIRMENT OF THE CERVICAL SPINE
?
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,
Joint Movement
ROM Measurement
please explain why, and then proceed to Section 5:
Forward Flexion
Not indicated
(normal endpoint
= 45 degrees)
Not able to perform
Extension
Not indicated
(normal endpoint
= 45 degrees)
Not able to perform
Right Lateral
Flexion
NECK
Not indicated
(normal endpoint
Not able to perform
= 45 degrees)
All Normal
Left Lateral
Flexion
Not indicated
(normal endpoint
Not able to perform
= 45 degrees)
Right Lateral
Rotation
Not indicated
(normal endpoint
Not able to perform
= 80 degrees)
Left Lateral
Rotation
Not indicated
(normal endpoint
Not able to perform
= 80 degrees)
VA FORM 21-0960M-13, MAR 2018
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 limitations in Section 7 below)
YES
NO, EXPLAIN WHY THE ABNORMAL ROMs DO NOT CONTRIBUTE:
(for reasons other than a neck
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
Is the veteran able to perform repetitive-use testing?
Joint Movement
after repetitive-use testing?
Measurement
Forward Flexion
Yes
If yes, perform repetitive-use testing
Yes
No, there is no change in ROM
No
If no, provide reason below, then proceed to Section 5
Extension
after repetitive testing
Left Lateral
If yes, report ROM after a minimum
Flexion
of 3 repetitions.
Right Lateral
Flexion
If no, documentation of ROM after
Left Lateral
repetitive-use testing is not required.
Rotation
Right Lateral
Rotation
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 7 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 limitation of ROM)
If no
,
pain contribute to functional loss or
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 7 below)
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
(there is pain when used in weight-bearing
If yes
non weight-bearing?
(the pain does not contribute to functional loss or additional limitation of ROM)
If no
,
or non weight-bearing)
, does the pain contribute
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 7 below)
No
No
5C. LOCALIZED TENDERNESS OR PAIN ON PALPATION
Does the Veteran have localized tenderness
If yes, describe including location, severity and relationship to condition(s) listed in the Diagnosis section:
or pain on palpation of joints or soft tissue?
Yes
No
5D. COMMENTS, IF ANY:
VA FORM 21-0960M-13, MAR 2018
Page 3
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION VI - GUARDING AND MUSCLE SPASM
(neck)
6A. DOES THE VETERAN HAVE GUARDING OR MUSCLE SPASM OF THE CERVICAL SPINE
?
YES
NO
6B. GAIT:
NORMAL
ABNORMAL
Due to:
Muscle spasm
Guarding
Other, describe and provide etiology:
UNABLE TO EVALUATE, PROVIDE REASON:
6C. SPINAL CONTOUR:
NORMAL
ABNORMAL
Due to:
Muscle spasm
Guarding
Other, describe and provide etiology:
UNABLE TO EVALUATE, PROVIDE REASON:
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:
(check all that apply and indicate side affected)
7A. CONTRIBUTING FACTORS OF DISABILITY
:
(due to ankylosis, limitation or blocking, adhesions,
Less movement than normal
tendon-tie-ups, contracted scars, etc.)
(from flail joints, resections, nonunion of fractures,
More movement than normal
relaxation of ligaments, etc.)
(due to muscle injury, disease or injury of peripheral
Weakened movement
nerves, divided or lengthened tendons, etc.)
Excess fatigability
Incoordination, impaired ability to execute skilled movements smoothly
Pain on movement
Swelling
Deformity
Atrophy of disuse
Instability of station
Disturbance of locomotion
Interference with sitting
Interference with standing
Other, describe:
VA FORM 21-0960M-13, MAR 2018
Page 4
PATIENT/VETERAN'S SOCIAL SECURITY NO.
(Continued)
SECTION VII - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION OF ROM
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.
7B. ARE ANY OF THE ABOVE FACTORS ASSOCIATED WITH LIMITATION OF MOTION?
(If yes, complete question 7C and 7D)
YES
(If no, proceed to question 7D)
NO
7C. CONTRIBUTING FACTORS OF DISABILITY ASSOCIATED WITH LIMITATION OF MOTION
Can pain, weakness, fatigability, or
If yes, please estimate ROM due to pain and/or
If there is a functional loss due to pain, during flare-ups and/or when the joint is
incoordination significantly limit functional
functional loss during flare-ups or when the
used repeatedly over a period of time but the limitation of ROM cannot be
ability during flare-ups or when the joint is
joint is used repeatedly over a period of time:
estimated, please describe the functional loss:
used repeatedly over a period of time?
Forward
Est. ROM is
Flexion
not feasible
Est. ROM is
Extension
not feasible
Right Lateral
Est. ROM is
Flexion
not feasible
Yes
No
Left Lateral
Est. ROM is
Flexion
not feasible
Right Lateral
Est. ROM is
Rotation
not feasible
Left Lateral
Est. ROM is
Rotation
not feasible
7D. CONTRIBUTING FACTORS OF DISABILITY NOT ASSOCIATED WITH LIMITATION OF MOTION
(not associated with limitation of motion)
IS THERE ANY FUNCTIONAL LOSS
DURING FLARE-UPS OR WHEN THE JOINT IS USED REPEATEDLY OVER A PERIOD
OF TIME OR OTHERWISE?
YES
NO
IF YES, DESCRIBE:
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
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
Side
Extension
Strength
muscle strength?
claimed condition in the Diagnosis section?
claimed condition), provide rationale:
Shoulder
/5
Adduction
Shoulder
/5
Abduction
Shoulder
/5
Flexion
Shoulder
RIGHT
/5
Rotation
Elbow
/5
All Normal
Yes
No
Yes
No
Flexion
Elbow
/5
Extension
Wrist
/5
Flexion
Wrist
/5
Extension
Finger
/5
Flexion
Finger
/5
Abduction
VA FORM 21-0960M-13, MAR 2018
Page 5
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