Va Form 21 0960M 12 PDF Details

Are you a veteran looking for benefits? Have you heard of the form 21 0960M 12 from VA? This document is an important piece of paperwork needed to claim veterans’ disability benefits. Knowing what it is, how to get it, and how to use it can be crucial in making sure your needs are met. Read on for more information about this very important VA form!

Question	Answer
Form Name	Va Form 21 0960M 12
Form Length	9 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 15 sec
Other names	INFRASPINATUS, OMB, JAN, va form 21 0960m 12

Form Preview Example

OMB Approved No. 2900-0802

Respondent Burden: 30 minutes

Expiration Date: 04/30/2017

SHOULDER AND ARM 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

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 Military service personnel records Military enlistment examination Military separation examination Military post-deployment questionnaire

Department of Defense Form 214 Separation Documents

Veterans Health Administration medical records (VA treatment records)

Civilian medical records

Interviews with collateral witnesses (family and others who have known the veteran before and after military service)

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.

1B. SELECT DIAGNOSES ASSOCIATED WITH THE CLAIMED CONDITION(S) (Check all that apply):

The Veteran does not have a current diagnosis associated with any claimed condition listed above. (Explain your findings and reasons in comments section.)

Shoulder strain	Side affected:	Right	Left	Both	ICD Code:
Shoulder impingement syndrome	Side affected:	Right	Left	Both	ICD Code:
Shoulder impingement syndrome	Side affected:	Right	Left	Both	ICD Code:
Bicipital tendonitis
Bicipital tendonitis	Side affected:	Right	Left	Both	ICD Code:
Bicipital tendon tear	Side affected:	Right	Left	Both	ICD Code:
Bicipital tendon tear	Side affected:	Right	Left	Both	ICD Code:
Rotator cuff tendonitis
Rotator cuff tendonitis	Side affected:	Right	Left	Both	ICD Code:
Rotator cuff tear	Side affected:	Right	Left	Both	ICD Code:
Rotator cuff tear	Side affected:	Right	Left	Both	ICD Code:
Labral tear, including SLAP	Side affected:	Right	Left	Both	ICD Code:
Labral tear, including SLAP
(Superior labral anterior-
(Superior labral anterior-
posterior lesion)

Date of diagnosis: Date of diagnosis: Date of diagnosis: Date of diagnosis: Date of diagnosis: Date of diagnosis: Date of diagnosis:

	Subacromial/subdeltoid bursitis	Side affected:
	Glenohumeral joint osteoarthritis	Side affected:

	Acromioclavicular joint	Side affected:

	osteoarthritis

	Ankylosis of glenohumeral	Side affected:

	articulations (shoulder joint)

	Glenohumeral joint instability	Side affected:

	Glenohumeral joint dislocation	Side affected:

	Shoulder joint replacement (total

	shoulder arthroplasty/

	hemiarthroplasty)	Side affected:

	Acromioclavicular joint separation	Side affected:

Right	Left	Both	ICD Code:
Right	Left	Both	ICD Code:

Right	Left	Both	ICD Code:

Right	Left	Both	ICD Code:

Right	Left	Both	ICD Code:

Right	Left	Both	ICD Code:

Right	Left	Both	ICD Code:

Right	Left	Both	ICD Code:

Date of diagnosis: Date of diagnosis: Date of diagnosis:

Date of diagnosis:

Date of diagnosis: Date of diagnosis:

VA FORM	21-0960M-12	SUPERSEDES VA FORM 21-0960M-12, OCT 2012,	Page 1
MAY 2013	21-0960M-12	WHICH WILL NOT BE USED.

SECTION I - DIAGNOSIS (Continued)

Other (specify)

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:

1C. COMMENTS (if any):

1D. WAS AN OPINION REQUESTED ABOUT THIS CONDITION (internal VA only)?

YES

N/A

SECTION II - MEDICAL HISTORY

2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S SHOULDER OR ARM CONDITION (brief summary):

2B. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE SHOULDER OR ARM?

YES

IF YES, DOCUMENT THE VETERAN'S DESCRIPTION OF THE IMPACT OF FLARE-UPS IN HIS OR HER OWN WORDS:

2C. DOES THE VETERAN REPORT HAVING ANY FUNCTIONAL LOSS OR FUNCTIONAL IMPAIRMENT OF THE JOINT OR EXTREMITY BEING EVALUATED ON THIS

DBQ (regardless of repetitive use)?

YES

IF YES, DOCUMENT THE VETERAN'S DESCRIPTION OF FUNCTIONAL LOSS OR FUNCTIONAL IMPAIRMENT IN HIS OR HER OWN WORDS:

SECTION III - INITIAL RANGE OF MOTION (ROM) 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

Shoulder	Joint Movement	ROM Measurement		If ROM testing is not indicated for the veteran's condition or not able to be performed,
Shoulder	Joint Movement	ROM Measurement		please explain why, and then proceed to Section 5:
				please explain why, and then proceed to Section 5:

	Flexion
			Not indicated

	(normal endpoint
	= 180 degrees)		Not able to perform
	= 180 degrees)


RIGHT	Abduction
			Not indicated

	(normal endpoint
SHOULDER	(normal endpoint
	= 180 degrees)		Not able to perform




	External Rotation
			Not indicated

	(normal endpoint
	= 90 degrees)		Not able to perform
	= 90 degrees)


	Internal Rotation
			Not indicated

	(normal endpoint
	= 90 degrees)		Not able to perform
	= 90 degrees)

VA FORM 21-0960M-12, MAY 2013

Page 2

			SECTION III - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS (Continued)
3A. INITIAL ROM MEASUREMENTS

		Shoulder	Joint Movement	ROM Measurement		If ROM testing is not indicated for the veteran's condition or not able to be performed,
		Shoulder	Joint Movement	ROM Measurement			please explain why, and then proceed to Section 5:
							please explain why, and then proceed to Section 5:

			Flexion
					Not indicated

			(normal endpoint
			= 180 degrees)		Not able to perform
			= 180 degrees)


		LEFT	Abduction
					Not indicated

			(normal endpoint
	SHOULDER		(normal endpoint
			= 180 degrees)		Not able to perform




			External Rotation
					Not indicated

			(normal endpoint
			= 90 degrees)		Not able to perform
			= 90 degrees)


			Internal Rotation
					Not indicated

			(normal endpoint
			= 90 degrees)		Not able to perform
			= 90 degrees)


3B. DO ANY ABNORMAL ROMs NOTED ABOVE CONTRIBUTE TO FUNCTIONAL LOSS?
		YES (you will be asked to further describe these limitations in Section 6 below)

		NO, EXPLAIN WHY THE ABNORMAL ROMs DO NOT CONTRIBUTE:
		NO, EXPLAIN WHY THE ABNORMAL ROMs DO NOT CONTRIBUTE:

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

shoulder or arm condition, such as age, body habitus, neurologic disease), EXPLAIN:

SECTION IV - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING

4A. POST-TEST ROM MEASUREMENTS

Shoulder

Is the veteran able to perform repetitive-use testing?

Is there additional limitation in ROM

Joint Movement

Post-test ROM

after repetitive-use testing?

Measurement

Yes

Flexion

No, there is no change in ROM

If yes, perform repetitive-use testing

after repetitive testing

Abduction

RIGHT

If no, provide reason below, then proceed to Section 5

If yes, report ROM after a minimum

SHOULDER

of 3 repetitions.

External Rotation

If no, documentation of ROM after

repetitive-use testing is not required.

Internal Rotation

Yes

Flexion

No, there is no change in ROM

If yes, perform repetitive-use testing

after repetitive testing

Abduction

LEFT

If no, provide reason below, then proceed to Section 5

If yes, report ROM after a minimum

SHOULDER

of 3 repetitions.

External Rotation

If no, documentation of ROM after

repetitive-use testing is not required.

Internal Rotation

4B. DO ANY POST-TEST ADDITIONAL LIMITATIONS OF ROMs NOTED ABOVE CONTRIBUTE TO FUNCTIONAL LOSS?

YES (you will be asked to further describe these limitations in Section 6 below)

NO, EXPLAIN WHY THE POST-TEST ADDITIONAL LIMITATIONS OF ROMs DO NOT CONTRIBUTE:

VA FORM 21-0960M-12, MAY 2013

Page 3

SECTION V - PAIN

5A. ROM MOVEMENTS PAINFUL ON ACTIVE, PASSIVE AND/OR REPETITIVE USE TESTING

	Are any ROM movements painful on active,					If no (the pain does not contribute to functional loss
	passive and/or repetitive use testing?			If yes (there are painful movements), does the		If no (the pain does not contribute to functional loss
Shoulder	(If yes, identify whether active, passive,				pain contribute to functional loss or	or additional limitation of ROM), explain why the pain
	(If yes, identify whether active, passive,				additional limitation of ROM?	does not contribute:
	and/or repetitive use in question 5D)				additional limitation of ROM?	does not contribute:
	and/or repetitive use in question 5D)

RIGHT		Yes			Yes (you will be asked to further describe
					Yes (you will be asked to further describe
					these limitations in Section 6 below)

SHOULDER
SHOULDER		No			No
		No			No

LEFT		Yes			Yes (you will be asked to further describe
					Yes (you will be asked to further describe
					these limitations in Section 6 below)

SHOULDER
SHOULDER		No			No
		No			No

5B. PAIN WHEN USED IN WEIGHT-BEARING OR IN NON WEIGHT-BEARING

	Is there pain when the joint is used in		If yes (there is pain when used in weight-bearing			If no (the pain does not contribute to functional loss
	weight-bearing or non weight-bearing?		If yes (there is pain when used in weight-bearing			If no (the pain does not contribute to functional loss
Shoulder	(If yes, identify whether weight-bearing or			or non weight-bearing), does the pain contribute		or additional limitation of ROM), explain why the pain
	(If yes, identify whether weight-bearing or			to functional loss or additional limitation of ROM?		does not contribute:
	non weight-bearing in question 5D)			to functional loss or additional limitation of ROM?		does not contribute:
	non weight-bearing in question 5D)

RIGHT		Yes			Yes (you will be asked to further describe
					Yes (you will be asked to further describe
					these limitations in Section 6 below)

SHOULDER
SHOULDER		No			No
		No			No

LEFT		Yes			Yes (you will be asked to further describe


					these limitations in Section 6 below)

SHOULDER
SHOULDER		No			No
		No			No

5C. LOCALIZED TENDERNESS OR PAIN ON PALPATION

Does the Veteran have localized tenderness

Shoulder

or pain to palpation of joints or soft tissue?

If yes, describe including location, severity and relationship to condition(s) listed in the Diagnosis section:

RIGHT

SHOULDER

Yes

LEFT	Yes	No
LEFT
SHOULDER
SHOULDER

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:

6A. CONTRIBUTING FACTORS OF DISABILITY (check all that apply and indicate side affected):

No functional loss for left upper extremity attributable to claimed condition
No functional loss for right upper extremity attributable to claimed condition
Less movement than normal (due to ankylosis, limitation or blocking, adhesions,	Right

Left

Both

tendon-tie-ups, contracted scars, etc.)

More movement than normal (from flail joints, resections, nonunion of fractures, relaxation of ligaments, etc.)

Weakened movement (due to muscle injury, disease or injury of peripheral 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:

Right

Left

Both

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.

VA FORM 21-0960M-12, MAY 2013

Page 4

SECTION VI - FUNCTIONAL LOSS AND ADDITIONAL LIMITATION OF ROM (Continued)

6B. ARE ANY OF THE ABOVE FACTORS ASSOCIATED WITH LIMITATION OF MOTION?

YES (If yes, complete questions 6C and 6D)

NO (If no, proceed to question 6D)

6C. 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

Shoulder

incoordination significantly limit functional

when the joint is used repeatedly over a period of time but the

ability during flare-ups or when the joint is

functional loss during flare-ups or when the

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:

Flexion

Est. ROM is

not feasible

Yes

Abduction

Est. ROM is

not feasible

RIGHT

SHOULDER

External

Est. ROM is

Rotation

not feasible

Internal

Est. ROM is

Rotation

not feasible

Flexion

Est. ROM is

not feasible

Yes

Abduction

Est. ROM is

not feasible

LEFT

SHOULDER

External

Est. ROM is

Rotation

not feasible

Internal

Est. ROM is

Rotation

not feasible

6D. CONTRIBUTING FACTORS OF DISABILITY NOT ASSOCIATED WITH LIMITATION OF MOTION

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?

RIGHT SHOULDER	Yes	No	If yes, describe:
LEFT SHOULDER	Yes	No	If yes, describe:
LEFT SHOULDER	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

Shoulder

Forward 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

/Abduction

Strength

muscle strength?

claimed condition in the Diagnosis section?

claimed condition), provide rationale:

RIGHT

Forward

SHOULDER

Flexion

Yes

Abduction

LEFT

Forward

SHOULDER

Flexion

Yes

Abduction

7B. DOES THE VETERAN HAVE MUSCLE ATROPHY?

YES

IF YES, IS THE MUSCLE ATROPHY DUE TO THE CLAIMED CONDITION IN THE DIAGNOSIS SECTION?

YES

NO IF NO, PROVIDE RATIONALE:

VA FORM 21-0960M-12, MAY 2013

Page 5

SECTION VII - MUSCLE STRENGTH TESTING (Continued)

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:

RIGHT UPPER EXTREMITY (specify location of measurement such as "10cm above or below elbow"):

CIRCUMFERENCE OF MORE NORMAL SIDE:

cm CIRCUMFERENCE OF ATROPHIED SIDE:

LEFT UPPER EXTREMITY (specify location of measurement such as "10cm above or below elbow"):

CIRCUMFERENCE OF MORE NORMAL SIDE:

cm CIRCUMFERENCE OF ATROPHIED SIDE:

7C. COMMENTS, IF ANY:

SECTION VIII - ANKYLOSIS

NOTE: Ankylosis is the immobilization and consolidation of a joint due to disease, injury or surgical procedure.

COMPLETE THIS SECTION IF THE VETERAN HAS ANKYLOSIS OF SCAPULOHUMERAL (glenohumeral) ARTICULATION (shoulder joint) (i.e., the scapula and humerus move as one piece).

8A. INDICATE SEVERITY OF ANKYLOSIS AND SIDE AFFECTED (check all that apply):

RIGHT SIDE:		LEFT SIDE:
	Ankylosis in abduction up to 60 degrees; can reach mouth and head		Ankylosis in abduction up to 60 degrees; can reach mouth and head

	(Favorable ankylosis)		(Favorable ankylosis)
	(Favorable ankylosis)		(Favorable ankylosis)

Ankylosis in abduction between favorable and unfavorable

(Intermediate ankylosis)

Ankylosis in abduction at 25 degrees or less from side (Unfavorable

ankylosis)

Ankylosis in abduction between favorable and unfavorable

(Intermediate ankylosis)

Ankylosis in abduction at 25 degrees or less from side (Unfavorable

ankylosis)

No ankylosis

8B. COMMENTS, IF ANY:

SECTION IX - ROTATOR CUFF CONDITIONS

9. ROTATOR CUFF CONDITIONS

SHOULDER

IS ROTATOR CUFF

IF "YES" COMPLETE THE FOLLOWING

CONDITION

HAWKINS' IMPINGEMENT TEST

EMPTY-CAN TEST

EXTERNAL ROTATION/

LIFT-OFF

SUSPECTED?

(Forward flex the arm to 90

(Abduct arm to 90 degrees and

INFRASPINATUS

SUBSCAPULARIS TEST

STRENGTH TEST

degrees with the elbow bent to 90

forward flex 30 degrees.

(Patient internally rotates arm

degrees. Internally rotate arm.

Patient turns thumbs down and

(Patient holds arms at side with

behind lower back, pushes

Pain on internal rotation

resists downward force applied

elbow flexed 90 degrees. Patient

against examiner's hand.

indicates a positive test; may

by the examiner. Weakness

externally rotates against

Weakness indicates a positive

signify rotator cuff tendinopathy

indicates a positive test; may

resistance. Weakness indicates a

test; may indicate subscapularis

or tear)

indicate rotator cuff pathology,

positive test; may be associated

tendinopathy or tear)

including supraspinatus

with infraspinatus tendinopathy

tendinopathy or tear)

or tear)

Yes

Positive

RIGHT

Negative

SHOULDER

Unable to perform

N/A

Yes

Positive

LEFT

Negative

SHOULDER

Unable to perform

N/A

SECTION X - SHOULDER INSTABILITY, DISLOCATION OR LABRAL PATHOLOGY

10A. IS SHOULDER INSTABILITY, DISLOCATION OR LABRAL PATHOLOGY SUSPECTED?

YES

IF YES, COMPLETE QUESTIONS 10B - 10D BELOW:

10B. IS THERE A HISTORY OF MECHANICAL SYMPTOMS (clicking, catching, etc.)?

YES

INDICATE SIDE AFFECTED:

Right

Left

Both

10C. IS THERE A HISTORY OF RECURRENT DISLOCATION (subluxation) OF THE GLENOHUMERAL (scapulohumeral) JOINT?

YES

IF YES, INDICATE FREQUENCY, SEVERITY AND SIDE AFFECTED (check all that apply):

Both

Infrequent episodes

Right

Left

Frequent episodes

Right

Left

Both

Guarding of movement only at shoulder level Guarding of all arm movement

Right Right

Left Left

Both Both

VA FORM 21-0960M-12, MAY 2013

Page 6

Left

Both

Right

Left

Both

Right

SECTION X - SHOULDER INSTABILITY, DISLOCATION OR LABRAL PATHOLOGY (Continued)

10D. CRANK APPREHENSION AND RELOCATION TEST (with patient supine, abduct patient's arm to 90 degrees and flex elbow 90 degrees. Pain and sense of instability with further external rotation may indicate shoulder instability.)

POSITIVE NEGATIVE IF POSITIVE, SIDE AFFECTED:

UNABLE TO PERFORM			N/A
Right	Left	Both
Right	Left	Both

SECTION XI - CLAVICLE, SCAPULA, ACROMIOCLAVICULAR (AC) JOINT AND STERNOCLAVICULAR JOINT CONDITIONS

11A. IS A CLAVICLE, SCAPULA, ACROMIOCLAVICULAR (AC) JOINT OR STERNOCLAVICULAR JOINT CONDITION SUSPECTED?

	YES	NO	IF YES, COMPLETE QUESTIONS 11B - 11D BELOW.

11B. DOES THE VETERAN HAVE AN AC JOINT CONDITION OR ANY OTHER IMPAIRMENT OF THE CLAVICLE OR SCAPULA?
	YES	NO
	YES	NO

IF YES, INDICATE SEVERITY AND SIDE AFFECTED:

Malunion of clavicle or scapula

Nonunion of clavicle or scapula without loose movement

Nonunion of clavicle or scapula with loose movement

Dislocation (acromioclavicular separation or sternoclavicular dislocation)

Other (Describe)

11C. IS THERE TENDERNESS ON PALPATION OF THE AC JOINT?
YES	NO IF YES, INDICATE SIDE:	Right	Left

Both

11D. CROSS-BODY ADDUCTION TEST (Passively adduct arm across the patient's body toward the contralateral shoulder. Pain may indicate acromioclavicular joint

pathology)

POSITIVE NEGATIVE IF POSITIVE, SIDE AFFECTED:

UNABLE TO PERFORM			N/A
Right	Left	Both
Right	Left	Both

SECTION XII - CONDITIONS OR IMPAIRMENTS OF THE HUMERUS

12A. DOES THE VETERAN HAVE LOSS OF HEAD (flail shoulder), NONUNION (false flail shoulder), OR FIBROUS UNION OF THE HUMERUS?

	YES	NO
IF YES, CHECK ALL THAT APPLY:
	Loss of head (flail shoulder)		Right	Left	Both
	Loss of head (flail shoulder)		Right	Left	Both
	Nonunion (false flail shoulder)		Right	Left	Both
	Nonunion (false flail shoulder)		Right	Left	Both
	Fibrous union		Right	Left	Both
	Fibrous union		Right	Left	Both

12B. DOES THE VETERAN HAVE MALUNION OF THE HUMERUS WITH MODERATE OR MARKED DEFORMITY?
	YES	NO
	YES	NO
IF YES, CHECK ALL THAT APPLY:
	Moderate deformity		Right	Left	Both
	Moderate deformity		Right	Left	Both
	Marked deformity		Right	Left	Both
	Marked deformity		Right	Left	Both

12C. COMMENTS, IF ANY:

SECTION XIII - SURGICAL PROCEDURES

13. INDICATE ANY SURGICAL PROCEDURES THAT THE VETERAN HAS HAD PERFORMED AND PROVIDE THE ADDITIONAL INFORMATION AS REQUESTED

(check all that apply):

RIGHT SIDE:

TOTAL SHOULDER JOINT REPLACEMENT

DATE OF SURGERY:

RESIDUALS:

None

Intermediate degrees of residual weakness, pain or limitation of motion

Chronic residuals consisting of severe painful motion or weakness

Other, describe:

ARTHROSCOPIC OR OTHER SHOULDER SURGERY

TYPE OF SURGERY:

DATE OF SURGERY:

RESIDUALS OF ARTHROSCOPIC OR OTHER SHOULDER SURGERY DESCRIBE RESIDUALS:

LEFT SIDE:

TOTAL SHOULDER JOINT REPLACEMENT

DATE OF SURGERY:

RESIDUALS:

None

Intermediate degrees of residual weakness, pain or limitation of motion

Chronic residuals consisting of severe painful motion or weakness

Other, describe:

ARTHROSCOPIC OR OTHER SHOULDER SURGERY

TYPE OF SURGERY:

DATE OF SURGERY:

RESIDUALS OF ARTHROSCOPIC OR OTHER SHOULDER SURGERY DESCRIBE RESIDUALS:

VA FORM 21-0960M-12, MAY 2013

Page 7

SECTION XIV - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS AND SCARS

14A. 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?

YES

IF YES, COMPLETE QUESTIONS 14B-14D.

14B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS RELATED TO ANY CONDITIONS LISTED IN THE DIAGNOSIS SECTION ABOVE?

YES

IF YES, DESCRIBE (brief summary):

14C. 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?

YES

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

IF YES, ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT.

IF NO, PROVIDE LOCATION AND MEASUREMENTS OF SCAR IN CENTIMETERS.

Location:

Measurements: length

cm X width

cm.

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.

14D. COMMENTS, IF ANY:

SECTION XV - ASSISTIVE DEVICES

15A. DOES THE VETERAN USE ANY ASSISTIVE DEVICES?

YES

Brace

Other:

NO	IF YES, IDENTIFY ASSISTIVE DEVICES USED (check all that apply and indicate frequency):
		Frequency of use:	Occasional	Regular	Constant
		Frequency of use:	Occasional	Regular	Constant
		Frequency of use:	Occasional	Regular	Constant
		Frequency of use:	Occasional	Regular	Constant

15B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:

SECTION XVI - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES

16A. DUE TO THE VETERAN'S SHOULDER OR ARM CONDITIONS, IS THERE FUNCTIONAL IMPAIRMENT OF AN EXTREMITY SUCH THAT NO EFFECTIVE FUNCTIONS REMAIN OTHER THAN THAT WHICH WOULD BE EQUALLY WELL SERVED BY AN AMPUTATION WITH PROSTHESIS? (Functions of the upper

extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.)

YES, FUNCTIONING IS SO DIMINISHED THAT AMPUTATION WITH PROTHESIS WOULD EQUALLY SERVE THE VETERAN.

IF YES, INDICATE EXTREMITIES FOR WHICH THIS APPLIES:

RIGHT UPPER

LEFT UPPER

FOR EACH CHECKED EXTREMITY, IDENTIFY THE CONDITION CAUSING LOSS OF FUNCTION, DESCRIBE LOSS OF EFFECTIVE FUNCTION AND PROVIDE SPECIFIC EXAMPLES (brief summary):

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 XVII - DIAGNOSTIC TESTING

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.

17A. HAVE IMAGING STUDIES OF THE SHOULDER BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?

YES NO

IF YES, IS DEGENERATIVE OR TRAUMATIC ARTHRITIS DOCUMENTED?

YES

IF YES, INDICATE SHOULDER:

RIGHT

LEFT

BOTH

VA FORM 21-0960M-12, MAY 2013

Page 8

			SECTION XVII - DIAGNOSTIC TESTING (Continued)
17B. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS OR RESULTS?
	YES	NO	IF YES, PROVIDE TYPE OF TEST OR PROCEDURE, DATE AND RESULTS (brief summary):
	YES	NO

17C. IS THERE OBJECTIVE EVIDENCE OF CREPITUS?

YES

IF YES, INDICATE SHOULDER:

RIGHT

LEFT

BOTH

17D. IF ANY TEST RESULTS ARE OTHER THAN NORMAL, INDICATE RELATIONSHIP OF ABNORMAL FINDINGS TO DIAGNOSED CONDITIONS:

SECTION XVIII - FUNCTIONAL IMPACT

NOTE: Provide the impact of only the diagnosed condition(s), without consideration of the impact of other medical conditions or factors, such as age.

18.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.)?

YES

IF YES, DESCRIBE THE FUNCTIONAL IMPACT OF EACH CONDITION, PROVIDING ONE OR MORE EXAMPLES:

SECTION XIX - REMARKS

19. REMARKS, IF ANY:

SECTION XX - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.

20A. PHYSICIAN'S SIGNATURE

20B. PHYSICIAN'S PRINTED NAME

20C. DATE SIGNED

20D. PHYSICIAN'S PHONE NUMBER

20E. PHYSICIAN'S MEDICAL LICENSE NUMBER

20F. PHYSICIAN'S ADDRESS

NOTE: VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.

IMPORTANT - Physician please fax the completed form to

(VA Regional Office FAX No.)

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.

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.

VA FORM 21-0960M-12, MAY 2013

Page 9

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