Va Form 21 0960M 6 – Fill Out and Use This PDF

The VA 21-0960M-6 form is an essential document for veterans seeking disability benefits for foot conditions, including but not limited to flatfoot (pes planus). It allows healthcare professionals to provide a comprehensive evaluation of the veteran's foot condition, covering diagnosis, medical history, and detailed symptomatology, which the U.S. Department of Veterans Affairs (VA) uses to assess disability claims. If you are a veteran experiencing foot conditions related to your service, completing this form accurately can be a critical step in securing your benefits. Click the button below to learn more about how to fill out and submit your form.

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Va Form 21 0960M 6 PDF Details

Understanding the intricate procedural aspects of applying for disability benefits through the Department of Veterans Affairs (VA) can be a challenging endeavor, especially when dealing with specific conditions such as foot-related disabilities. The VA Form 21-0960M-6, designated for Foot Conditions, including Flatfoot (Pes Planus), plays a pivotal role in this process. As an essential Disability Benefits Questionnaire, it serves as a comprehensive instrument for veterans or service members to substantiate their claims for disability benefits pertaining to foot conditions. The form meticulously captures detailed medical information, ranging from diagnosis to the severity of symptoms and the impact of conditions like Morton's neuroma, metatarsalgia, hammer toes, among others. It emphasizes the importance of providing accurate information about the veteran's foot condition, including any historical medical treatments and current symptoms, which are crucial for the VA to make an informed decision regarding the claim. Equally, it sets out clear instructions for healthcare providers on how to document the presence and extent of foot-related disabilities, ensuring that all requisite details are thoroughly communicated to the VA. Notably, the form underscores the VA's policy on not reimbursing expenses incurred in completing and submitting this form, urging careful attention to the Privacy Act and respondent burden information before proceeding.

Question	Answer
Form Name	Va Form 21 0960M 6
Form Length	9 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 15 sec
Other names	va foot disability benefits, 21 0960m6 pes online, va including flatfoot disability, conditions pes planus disability

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OMB Approved No. 2900-0810

Respondent Burden: 30 minutes

Expiration Date: 04-30-2017

FOOT CONDITIONS, INCLUDING FLATFOOT (PES PLANUS)

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.)

Flat foot (pes planus)	Side affected:	Right	Left	Both	ICD Code:	Date of diagnosis:

(If checked, complete all of Section I, Section II, and Section III)

Morton's neuroma	Side affected:	Right	Left	Both ICD Code:	Date of diagnosis:

(If checked, complete all of Section I, Section II, and Section IV)

Metatarsalgia	Side affected:	Right	Left	Both	ICD Code:	Date of diagnosis:

(If checked, complete all of Section I, Section II, and Section IV)

Hammer toes	Side affected:	Right	Left	Both ICD Code:	Date of diagnosis:

(If checked, complete all of Section I, Section II, and Section V)

Hallux valgus	Side affected:	Right	Left	Both	ICD Code:	Date of diagnosis:

(If checked, complete all of Section I, Section II, and Section VI)

Hallux rigidus	Side affected:	Right	Left	Both	ICD Code:	Date of diagnosis:

(If checked, complete all of Section I, Section II, and Section VII)

Acquired pes cavus (claw foot) Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

(If checked, complete all of Section I, Section II, and Section VIII)

	Malunion/nonunion of tarsal/	Side affected:		Right		Left		Both	ICD Code:		Date of diagnosis:
	metatarsal bones

(If checked, complete all of Section I, Section II, and Section IX)

Foot injury(ies) Specify:	Side affected:	Right	Left	Both	ICD Code:	Date of diagnosis:

(If checked, complete all of Section I, Section II, and Section X)

Plantar fasciitis	Side affected:	Right	Left	Both	ICD Code:	Date of diagnosis:

(If checked, complete all of Section I, Section II, and Section X)

VA FORM	21-0960M-6	SUPERSEDES VA FORM 21-0960M-5, OCT 2012 AND	Page 1
MAY 2013	21-0960M-6	21-0960M-6, OCT 2012, WHICH WILL NOT BE USED.

SECTION I - DIAGNOSIS (Continued)

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

Other (specify)

(If checked, complete all of Section I, question #8 of Section II, and all of Section III)

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 NO N/A

SECTION II - MEDICAL HISTORY

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

2B. DOES THE VETERAN REPORT PAIN OF THE FOOT BEING EVALUATED ON THIS DBQ?

YES

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

2C. DOES THE VETERAN REPORT THAT FLARE-UPS IMPACT THE FUNCTION OF THE FOOT?

YES

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 FOOT 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 - FLATFOOT (PES PLANUS)

COMPLETE THIS SECTION IF THE VETERAN HAS FLATFOOT (PES PLANUS).

INDICATE ALL SIGNS AND SYMPTOMS THAT APPLY TO THE VETERAN'S FLATFOOT CONDITION, REGARDLESS OF WHETHER SIMILAR SIGNS AND SYMPTOMS APPEAR MORE THAN ONCE IN DIFFERENT SECTIONS.

3A. DOES THE VETERAN HAVE PAIN ON USE OF THE FEET?

YES

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

IF YES, IS THE PAIN ACCENTUATED ON MANIPULATION?

YES

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

3B. DOES THE VETERAN HAVE PAIN ON MANIPULATION OF THE FEET?

YES

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

IF YES, IS THE PAIN ACCENTUATED ON MANIPULATION?

YES

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

VA FORM 21-0960M-6, MAY 2013

Page 2

SECTION III - FLATFOOT (Continued)

3C. IS THERE INDICATION OF SWELLING ON USE?

YES

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

3D. DOES THE VETERAN HAVE CHARACTERISTIC CALLUSES?

YES

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

3E. EFFECTS OF USE OF ARCH SUPPORTS, BUILT UP SHOES OR ORTHOTICS

Effecting Relief of Symptoms

Tried But Remains Symptomatic

Device

Side Relieved

Device

Side Not Relieved

Arch Supports

Right

Left

Both

Arch Supports

Right

Left

Both

Built-up Shoes

Right

Left

Both

Built-up Shoes

Right

Left

Both

Orthotics

Right

Left

Both

Orthotics

Right

Left

Both

3F. DOES THE VETERAN HAVE EXTREME TENDERNESS OF PLANTAR SURFACES ON ONE OR BOTH FEET?

YES

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

IS THE TENDERNESS IMPROVED BY ORTHOPEDIC SHOES OR APPLIANCES?

RIGHT

YES

N/A

LEFT

YES

N/A

3G. DOES THE VETERAN HAVE DECREASED LONGITUDINAL ARCH HEIGHT OF ONE OR BOTH ON WEIGHT-BEARING?

YES

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

3H. IS THERE OBJECTIVE EVIDENCE OF MARKED DEFORMITY OF ONE OR BOTH FEET (pronation, abduction etc.)?

YES

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

3I. IS THERE MARKED PRONATION OF ONE FOOT OR BOTH FEET?

YES

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

IS THE CONDITION IMPROVED BY ORTHOPEDIC SHOES OR APPLIANCES?

YES

N/A

RIGHT

LEFT

YES

N/A

3J. FOR ONE OR BOTH FEET, DOES THE WEIGHT-BEARING LINE FALL OVER OR MEDIAL TO THE GREAT TOE?

YES

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

3K. IS THERE A LOWER EXTREMITY DEFORMITY OTHER THAN PES PLANUS, CAUSING ALTERATION OF THE WEIGHT-BEARING LINE?

YES

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

DESCRIBE LOWER EXTREMITY DEFORMITY OTHER THAN PES PLANUS CAUSING ALTERATION OF THE WEIGHT BEARING LINE:

3L. DOES THE VETERAN HAVE "INWARD" BOWING OF THE ACHILLES' TENDON (i.e., hindfoot valgus, with lateral deviation of the heel) OF ONE OR BOTH FEET?

YES	NO
IF YES, INDICATE SIDE AFFECTED:		RIGHT	LEFT	BOTH
IF YES, INDICATE SIDE AFFECTED:		RIGHT	LEFT	BOTH

3M. DOES THE VETERAN HAVE MARKED INWARD DISPLACEMENT AND SEVERE SPASM OF THE ACHILLES' TENDON (rigid hindfoot) ON MANIPULATION OF ONE

OR BOTH FEET?

YES

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

IS THE MARKED INWARD DISPLACEMENT AND SEVERE SPASM OF THE ACHILLES TENDON IMPROVED BY ORTHOPEDIC SHOES OR APPLIANCES?

RIGHT

YES

N/A

LEFT

YES

N/A

3N. COMMENTS, IF ANY:

VA FORM 21-0960M-6, MAY 2013

Page 3

SECTION IV - MORTON'S NEUROMA (MORTON'S DISEASE) AND METATARSALGIA

COMPLETE THIS SECTION IF THE VETERAN HAS MORTON'S NEUROMA OR METATARSALGIA.

4A. DOES THE VETERAN HAVE MORTON'S NEUROMA?

YES

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

4B. DOES THE VETERAN HAVE METATARSALGIA?

YES

IF YES, INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

4C. COMMENTS, IF ANY:

SECTION V - HAMMER TOE

COMPLETE THIS SECTION IF THE VETERAN HAS HAMMER TOE.

5A. WHICH TOES ARE AFFECTED ON EACH SIDE?

RIGHT:

None

Great toe

Second toe

Third toe

Fourth toe

Little toe

LEFT:

None

Great toe

Second toe

Third toe

Fourth toe

Little toe

5B. COMMENTS, IF ANY:

SECTION VI - HALLUX VALGUS

COMPLETE THIS SECTION IF THE VETERAN HAS HALLUX VALGUS.

6A. DOES THE VETERAN HAVE SYMPTOMS DUE TO A HALLUX VALGUS CONDITION?

YES

IF YES, INDICATE SEVERITY (check all that apply):

MILD OR MODERATE SYMPTOMS

SIDE AFFECTED:

RIGHT

LEFT

BOTH

SEVERE SYMPTOMS, WITH FUNCTION EQUIVALENT TO AMPUTATION OF GREAT TOE

SIDE AFFECTED:

RIGHT

LEFT

BOTH

6B. HAS THE VETERAN HAD SURGERY FOR HALLUX VALGUS?

YES

IF YES, INDICATE TYPE AND DATE OF SURGERY AND SIDE AFFECTED:

RESECTION OF METATARSAL HEAD

DATE OF SURGERY:

SIDE AFFECTED:

RIGHT

LEFT

BOTH

METATARSAL OSTEOTOMY/METATARSAL HEAD OSTEOTOMY (equivalent to metatarsal head resection)

DATE OF SURGERY:

SIDE AFFECTED:

RIGHT

LEFT

BOTH

OTHER SURGERY FOR HALLUX VALGUS, DESCRIBE:

DATE OF SURGERY:

SIDE AFFECTED:

RIGHT

LEFT

BOTH

6C. COMMENTS, IF ANY:

SECTION VII - HALLUX RIGIDUS

COMPLETE THIS SECTION IF THE VETERAN HAS HALLUX RIGIDUS.

7A. DOES THE VETERAN HAVE SYMPTOMS DUE TO HALLUX RIGIDUS?

YES

IF YES, INDICATE SEVERITY (check all that apply):

MILD OR MODERATE SYMPTOMS:

SIDE AFFECTED:

RIGHT

LEFT

BOTH

SEVERE SYMPTOMS, WITH FUNCTION EQUIVALENT TO AMPUTATION OF GREAT TOE

SIDE AFFECTED:

RIGHT

LEFT

BOTH

7B. COMMENTS, IF ANY:

VA FORM 21-0960M-6, MAY 2013

Page 4

SECTION VIII - ACQUIRED PES CAVUS (CLAW FOOT)

COMPLETE THIS SECTION IF THE VETERAN HAS ACQUIRED PES CAVUS.

8A. EFFECT ON TOES DUE TO PES CAVUS (check all that apply):

None

Right

Left

Both

Great toe dorsiflexed

Right

Left

Both

All toes tending to dorsiflexion

Right

Left

Both

All toes hammer toes

Right

Left

Both

Other, describe (if there is an effect on toes due to other etiology than pes cavus, indicate other etiology):

8B. PAIN AND TENDERNESS DUE TO PES CAVUS (check all that apply):

None

Right

Left

Both

Definite tenderness under metatarsal heads

Right

Left

Both

Marked tenderness under metatarsal heads

Right

Left

Both

Very painful callosities

Right

Left

Both

Other, describe (if the veteran has pain and tenderness due to other etiology than pes cavus, indicate other etiology):

8C. EFFECT ON PLANTAR FASCIA DUE TO PES CAVUS (check all that apply):

None

Right

Left

Both

Shortened plantar fascia

Right

Left

Both

Marked contraction of plantar fascia with dropped forefoot

Right

Left

Both

Other, describe (if there is an effect on plantar fascia due to other etiology than pes cavus, indicate other etiology):

8D. DORSIFLEXION AND VARGUS DEFORMITY DUE TO PES CAVUS (check all that apply):

None

Right

Left

Both

Some limitation of dorsiflexion at ankle

Right

Left

Both

Limitation of dorsiflexion at ankle to right angle

Right

Left

Both

Marked varus deformity

Right

Left

Both

Other, describe (if the veteran has dorsiflexion and varus deformity due to other etiology than pes cavus, indicate other etiology):

8E. COMMENTS, IF ANY:

SECTION IX - MALUNION OR NONUNION OF TARSAL OR METATARSAL BONES

COMPLETE THIS SECTION IF THE VETERAN HAS MALUNION OR NONUNION OF TARSAL OR METATARSAL BONES.

9A. INDICATE SEVERITY AND SIDE AFFECTED FOR MALUNION OR NONUNION OF TARSAL OR METATARSAL BONES:

MODERATE

SIDE AFFECTED:	RIGHT	LEFT	BOTH
MODERATELY SEVERE
MODERATELY SEVERE
	RIGHT	LEFT	BOTH
SIDE AFFECTED:	RIGHT	LEFT	BOTH
SEVERE
SEVERE
	RIGHT	LEFT	BOTH
SIDE AFFECTED:	RIGHT	LEFT	BOTH

9B. COMMENTS, IF ANY:

SECTION X - FOOT INJURES AND OTHER CONDITIONS

COMPLETE THIS SECTION IF THE VETERAN HAS ANY FOOT INJURIES OR OTHER FOOT CONDITIONS (SUCH AS PLANTAR FASCIITIS OR "BILATERAL WEAK FOOT"} NOT ALREADY DESCRIBED.

NOTE: For VA purposes "bilateral weak foot" describes a symptomatic condition secondary to many constitutional conditions, and is characterized by atrophy of the musculature, disturbed circulation and weakness.

10A. DOES THE VETERAN HAVE ANY FOOT INJURIES OR OTHER FOOT CONDITIONS NOT ALREADY DESCRIBED?

YES

IF YES, DESCRIBE THE FOOT INJURY OR OTHER FOOT CONDITIONS (including frequency and physical exam findings) AND COMPLETE QUESTION B (severity and side affected).

VA FORM 21-0960M-6, MAY 2013

Page 5

SECTION X - FOOT INJURES AND OTHER CONDITIONS (Continued)

10B. INDICATE SEVERITY AND SIDE AFFECTED.

Not Affected	Right	Left	Both

Mild	Right	Left	Both
Moderate	Right	Left	Both
Moderate	Right	Left	Both
Moderately severe	Right	Left	Both
Moderately severe	Right	Left	Both
Severe	Right	Left	Both
Severe	Right	Left	Both

10C. DOES THE FOOT CONDITION CHRONICALLY COMPROMISE WEIGHT BEARING?

YES

10D. DOES THE FOOT CONDITION REQUIRE ARCH SUPPORTS, CUSTOM ORTHOTIC INSERTS OR SHOE MODIFICATIONS?

YES

10E. COMMENTS, IF ANY:

SECTION XI - SURGICAL PROCEDURES

COMPLETE THIS SECTION IF THE VETERAN HAS HAD ANY SURGICAL PROCEDURES FOR THE CLAIMED CONDITION THAT HAVE NOT ALREADY BEEN DESCRIBED.

11A. HAS THE VETERAN HAD FOOT SURGERY (arthroscopic or open)?

YES

IF YES, INDICATE SIDE AFFECTED, TYPE OF PROCEDURE AND DATE OF SURGERY.

RIGHT FOOT PROCEDURE:

DATE OF SURGERY:

LEFT FOOT PROCEDURE:

DATE OF SURGERY:

11B. DOES THE VETERAN HAVE ANY RESIDUAL SIGNS OR SYMPTOMS DUE TO ARTHROSCOPIC OR OTHER FOOT SURGERY?

YES

IF YES, DESCRIBE RESIDUALS:

							SECTION XII - PAIN

	Is there pain			If no, but the veteran reported pain in		If yes (there is pain on physical		If no (the pain does not contribute to functional loss or additional
Foot		on physical		his/her medical history, please provide	exam), does the pain contribute to
Foot		on physical		his/her medical history, please provide	exam), does the pain contribute to			limitations), explain why the pain does not contribute:
		exam?		rationale below.			functional loss?	limitations), explain why the pain does not contribute:
		exam?		rationale below.			functional loss?

			Yes				Yes (you will be asked to
			Yes				Yes (you will be asked to
RIGHT							further describe these
							further describe these
							limitations in Section 13)
FOOT							limitations in Section 13)
FOOT
			No				No

			Yes				Yes (you will be asked to
			Yes				Yes (you will be asked to
LEFT							further describe these
							further describe these
							limitations in Section 13)
FOOT							limitations in Section 13)
FOOT
			No				No

VA FORM 21-0960M-6, MAY 2013

Page 6

SECTION XIII - FUNCTIONAL LOSS AND LIMITATION OF MOTION

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:

13A. CONTRIBUTING FACTORS OF DISABILITY (check all that apply and indicate side affected):

No functional loss for left lower extremity attributable to claimed condition

No functional loss for right lower extremity attributable to claimed condition

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..)

Weakened movement (due to muscle injury, disease or injury of peripheral nerves, divided or lengthened tendons, etc.)

Right

Left

Both

Excess fatigability

Right

Left

Both

Incoordination, impaired ability to execute skilled movements smoothly

Right

Left

Both

Pain on movement

Right

Left

Both

Pain on weight-bearing

Right

Left

Both

Pain on non weight-bearing

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:

CONTRIBUTING FACTORS OF DISABILITY ASSOCIATED WITH LIMITATION OF MOTION

13B. IS THERE PAIN, WEAKNESS, FATIGABILITY, OR IN COORDINATION THAT SIGNIFICANTLY LIMITS FUNCTIONAL ABILITY DURING FLARE-UPS OR WHEN THE FOOT IS USED REPEATEDLY OVER A PERIOD OF TIME OR OTHERWISE?

RIGHT FOOT

YES

IF YES, (there is a functional loss due to pain, during flare-ups and/or when the joint is used repeatedly over a period of time) PLEASE DESCRIBE THE FUNCTIONAL LOSS:

LEFT FOOT

YES

IF YES, (there is a functional loss due to pain, during flare-ups and/or when the joint is used repeatedly over a period of time) PLEASE DESCRIBE THE FUNCTIONAL LOSS:

13C. IS THERE ANY OTHER FUNCTIONAL LOSS DURING FLARE-UPS OR WHEN THE FOOT IS USED REPEATEDLY OVER A PERIOD OF TIME?

RIGHT FOOT

YES

NO IF YES, DESCRIBE:

LEFT FOOT

YES

NO IF YES, DESCRIBE:

VA FORM 21-0960M-6, 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 AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS MAY BE POSSIBLE?

YES

IF YES, IDENTIFY ASSISTIVE DEVICES USED (check all that apply and indicate frequency):

Wheelchair

Frequency of use:

Occasional

Regular

Constant

Brace

Frequency of use:

Occasional

Regular

Constant

Crutches

Frequency of use:

Occasional

Regular

Constant

Cane

Frequency of use:

Occasional

Regular

Constant

Walker

Frequency of use:

Occasional

Regular

Constant

Other:

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 FOOT 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 LOWER

LEFT LOWER

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.

VA FORM 21-0960M-6, MAY 2013

Page 8

SECTION XVII - DIAGNOSTIC TESTING

NOTE: Testing listed below is not indicated for every condition. Plain or weight-bearing foot x-rays are not required to make the diagnosis of flatfoot. 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 FOOT BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?

YES NO

IF YES, IS DEGENERATIVE OR TRAUMATIC ARTHRITIS DOCUMENTED?
YES	NO	IF YES, INDICATE FOOT:	RIGHT	LEFT

BOTH

17B. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS OR RESULTS?

YES

IF YES, PROVIDE TYPE OF TEST OR PROCEDURE, DATE AND RESULTS (brief summary):

17C. 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-6, MAY 2013

Page 9

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