Va Form 21 0960M 13 – Fill Out and Use This PDF

OMB Control No. 2900-0779

Respondent Burden: 45 minutes

NECK (CERVICAL SPINE) 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 BEFORE COMPLETING THIS FORM.

NOTE TO PHYSICIAN - Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you provide on this questionnaire as part of their evaluation in processing the veteran's claim.

SECTION I - DIAGNOSIS

1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH A CERVICAL SPINE (neck) CONDITION?

YES NO

1B. PROVIDE DIAGNOSES THAT PERTAIN TO CERVICAL SPINE (neck) CONDITION(S):

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO CERVICAL SPINE (neck) CONDITIONS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY

2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S CERVICAL SPINE (neck) CONDITION (brief summary):

2B. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE CERVICAL SPINE (neck)?

YES

NO (If "Yes," document the veteran's description of the impact of flare-ups in his or her own words):

SECTION III - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS

3.MEASURE ROM WITH A GONIOMETER, ROUNDING EACH MEASUREMENT TO THE NEAREST 5 DEGREES. DURING THE MEASUREMENTS, OBSERVE THE POINT AT WHICH PAINFUL MOTION BEGINS, EVIDENCED BY VISIBLE BEHAVIOR SUCH AS FACIAL EXPRESSION, WINCING, ETC. REPORT INITIAL MEASUREMENTS BELOW.

NOTE: Following the initial assessment of ROM, perform repetitive use testing. For VA purposes, repetitive use testing must be included in all exams. The VA has determined that 3 repetitions of ROM 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 Section IV.

A. SELECT WHERE FORWARD FLEXION ENDS (normal endpoint is 45 degrees)

VA FORM	21-0960M-13	SUPERSEDES VA FORM 21-0960M-13, DEC 2010,
OCT 2012		WHICH WILL NOT BE USED.	Page 1

SECTION III - INITIAL RANGE OF MOTION (ROM) MEASUREMENTS (CONTINUED)

E. SELECT WHERE RIGHT LATERAL ROTATION ENDS (normal endpoint is 80 degrees)
				5		10		15		20		25		30		35			40		45
		0
														80 or greater
		50		55		60		65		70		75
SELECT WHERE OBJECTIVE EVIDENCE OF PAINFUL MOTION BEGINS:
		NO OBJECTIVE EVIDENCE OF PAINFUL MOTION
		0		5		10		15		20		25		30		35			40		45
														80 or greater
		50		55		60		65		70		75
F. SELECT WHERE LEFT LATERAL ROTATION ENDS (normal endpoint is 80 degrees)
				5		10		15		20		25		30		35			40		45
		0
														80 or greater
		50		55		60		65		70		75
SELECT WHERE OBJECTIVE EVIDENCE OF PAINFUL MOTION BEGINS:
		NO OBJECTIVE EVIDENCE OF PAINFUL MOTION
																35			40
		0		5		10		15		20		25		30							45
		50		55		60		65		70		75		80 or greater

G. If ROM does not conform to the normal range of motion identified above but is normal for this veteran (for reasons other than a cervical spine (neck) condition, such as

age, body habitus, neurologic disease), explain:

				SECTION IV - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING
4.A. IS A VETERAN ABLE TO PERFORM REPETITIVE-USE TESTING WITH 3 REPETITIONS?
		YES		NO (If unable, provide reason):
(If		veteran is unable to perform repetitive-use testing, skip to Section V)
(If		veteran is able to perform repetitive-use testing, measure and report ROM after a minimum of 3 repetitions)

SECTION V - FUNCTIONAL LOSS

NOTE: The following section addresses reasons for functional loss, if present, and additional loss of ROM after repetitive-use testing, if present. The VA defines functional loss as the inability to perform normal working movements of the body with normal excursion, strength, speed, coordination and/or endurance.

5A. DOES THE VETERAN HAVE ADDITIONAL LIMITATION IN ROM OF THE CERVICAL SPINE (neck) FOLLOWING REPETITIVE-USE TESTING?

YES NO

5B. DOES THE VETERAN HAVE ANY FUNCTIONAL LOSS AND/OR FUNCTIONAL IMPAIRMENT OF THE CERVICAL SPINE (neck)?

YES NO

5C. IF THE VETERAN HAS FUNCTIONAL LOSS, FUNCTIONAL IMPAIRMENT AND/OR ADDITIONAL LIMITATION OF ROM OF THE CERVICAL SPINE (neck) AFTER REPETITIVE USE, INDICATE THE CONTRIBUTING FACTORS OF DISABILITY BELOW.

No

ITEM

YES

NO

1Less movement than normal

2More movement than normal

3Weakened movement

4Excess fatigability

5Incoordination, impaired ability to execute skilled movements smoothly

6Pain on movement

7Swelling

8Deformity

9Atrophy of disuse

10Instability of station

11Disturbance of locomotion

12Interference with sitting, standing and/or weight-bearing

13Other, describe:

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SECTION VI - PAIN AND MUSCLE SPASM (PAIN ON PALPATION, EFFECT OF MUSCLE SPASM ON GAIT)

6A. DOES THE VETERAN HAVE LOCALIZED TENDERNESS OR PAIN TO PALPATION FOR JOINTS/SOFT TISSUE OF THE CERVICAL SPINE (neck)?

YES NO

6B. DOES THE VETERAN HAVE GUARDING OR MUSCLE SPASM OF THE CERVICAL SPINE (neck)?

YES

NO (If "Yes," is it severe enough to result in): (Check all that apply)

Abnormal gait

Abnormal spinal contour

Guarding or muscle spasm is present, but do not result in abnormal gait or spinal contour

SECTION VII - MUSCLE STRENGTH

7A. MUSCLE STREGTH TRAINING - 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

7B. DOES THE VETERAN HAVE MUSCLE ATROPHY?
		YES		NO (If muscle atrophy is present, indicate location:
and provide measurements in centimeters of normal side and atrophied side, measured at maximum muscle bulk: Normal side:							cm. Atrophied side:		cm.

SECTION VIII - REFLEX EXAM

8.REFLEX EXAM - RATE DEEP TENDON REFLEXES (DTRs) ACCORDING TO THE FOLLOWING SCALE: 0 Absent

1+ Hypoactive

2+ Normal

3+ Hyperactive without clonus

4+ Hyperactive with clonus

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SECTION IX - SENSORY EXAM

9. SENSORY EXAM - PROVIDE RESULTS FOR SENSATION TO LIGHT TOUCH (dermatomes) TESTING:

SECTION X - RADICULOPATHY HISTORY AND NEUROLOGIC EXAM

10A. DOES THE VETERAN HAVE RADICULAR PAIN OR ANY OTHER SIGNS OR SYMPTOMS DUE TO RADICULOPATHY?

	YES		NO (If "Yes,"		complete this section, check all that apply) (If "No," skip to section XI)
	CONSTANT PAIN (may be excruciating at times)
									Moderate
	Right upper extremity:				None		Mild				Severe
					None		Mild		Moderate
	Left upper extremity:										Severe

10B. DOES THE VETERAN HAVE ANY OTHER SIGNS OR SYMPTOMS OF RADICULOPATHY?

YES

NO (If "Yes," describe):

10C. INDICATE NERVE ROOTS INVOLVED: (Check all that apply)

Involvement of C5/C6 nerve roots (upper radicular group)

Involvement of C7 nerve roots (middle radicular group)

Involvement of C8/T1 nerve roots (lower radicular group)

10D. INDICATE SEVERITY OF RADICULPATHY AND SIDE AFFECTED:

(NOTE: For VA purposes, when the involvement is wholly sensory, the evaluation should be for the mild, or at most, the moderate degree)

SECTION XI - OTHER NEUROLOGIC ABNORMALITIES

11.DOES THE VETERAN HAVE ANY OTHER NEUROLOGIC ABNORMALITIES RELATED TO A CERVICAL SPINE (neck) CONDITION (such as bowel or bladder problems due to cervical myelopathy)?

				SECTION XII - INTERVERTEBRAL DISC SYNDROME (IVDS)
12A. DOES THE VETERAN HAVE IVDS OF THE CERVICAL SPINE?
		YES		NO (If "Yes," complete Item 12B)
12B. HAS THE VETERAN HAD ANY INCAPACITATING EPISODES OVER THE PAST 12 MONTHS DUE TO IVDS?
		YES		NO (If "Yes," complete Item 12C)
Note: for VA			purposes, an incapacitating episode is a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician.

12C. PROVIDE THE TOTAL DURATION OVER THE PAST 12 MONTHS:

Less than 1 week

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

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SECTION XIII - ASSISTIVE DEVICES AND REMAINING FUNCTION OF THE EXTREMITIES

13A. DOES THE VETERAN USE ANY ASSISTIVE DEVICE(S) AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS MAY BE POSSIBLE?

(If "Yes," identify assistive device(s) used (check all that apply and indicate frequency))

	Wheelchair		Frequency of use:		Occasional		Regular		Constant
	Brace(s)		Frequency of use:		Occasional		Regular		Constant
	Crutch(es)		Frequency of use:		Occasional		Regular		Constant
	Cane(s)		Frequency of use:		Occasional		Regular		Constant
	Walker		Frequency of use:		Occasional		Regular		Constant
	Other:
			Frequency of use:		Occasional		Regular		Constant

13B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:

13C. DUE TO A CERVICAL SPINE (neck) 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.; functions of the lower extremity include balance and propulsion, etc.)

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

NO

(If "Yes," indicate extremity(ies) (check all extremities for which this applies)

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

14A. DOES THE VETERAN HAVE ANY SCARS (SURGICAL OR OTHERWISE) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN SECTION I, DIAGNOSIS?

(If yes, are any of the scars painful and/or unstable, or is the total area of all related scars greater than or equal to 39 square cm (6 square inches)?)

YES

NO (If "Yes," ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)

14B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS?

SECTION XV - DIAGNOSTIC TESTING

NOTE: The diagnosis of arthritis must be confirmed by imaging studies. Once arthritis has been documented, no further imaging studies are required by VA, even if arthritis has worsened.

Imaging studies are not required to make the diagnosis of IVDS; Electromyography (EMG) studies are rarely required to diagnose radiculopathy in the appropriate clinical setting.

For purposes of this examination, the diagnosis of IVDS and/or radiculopathy can be made by a history of characteristic radiating pain and/or sensory changes in the arms, and objective clinical findings, which may include the asymmetrical loss or decrease of reflexes, decreased strength and/or abnormal sensation.

15A. HAVE THE IMAGING STUDIES OF THE CERVICAL SPINE BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?

YES NO

(If "Yes," is arthritis (degenerative joint disease) documented?)

15B. DOES THE VETERAN HAVE A VERTEBRAL FRACTURE?

YES NO

(If "Yes," provide percent of loss of vertebral body):

15C. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?

YES NO

(If "Yes," provide type of test or procedure, date and results, in a brief summary):

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SECTION XVI - FUNCTIONAL IMPACT

16. DOES THE VETERAN'S CERVICAL SPINE (neck) CONDITION IMPACT HIS OR HER ABILITY TO WORK?

SECTION XVII - REMARKS

17. REMARKS (If any)

SECTION XVIII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

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

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.benefits.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, 58VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is voluntary. 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 45 minutes to review the instructions, find the information, and complete a 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-13, OCT 2012

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