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OMB Approved No. 2900-0811

Respondent Burden: 30 minutes

Expiration Date: 04-30-2017

HIP AND THIGH 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.)

Osteoarthritis, hip

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Hip joint replacement

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Trochanteris pain syndrome

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

(includes trochanteric bursitis)

Femoral acetabular impingement Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

syndrome (includes labral tears)

Iliopsoas tendinitis

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Femoral neck stress fracture

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

Side affected:

ICD Code:

Date of diagnosis:

Avascular necrosis, hip

Right

Left

Both

Ankylosis of hip joint

Side affected:

Right

Left

Both

ICD Code:

Date of diagnosis:

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):

VA FORM	21-0960M-8	SUPERSEDES VA FORM 21-0960M-8, OCT 2012,	Page 1
MAY 2013	21-0960M-8	WHICH WILL NOT BE USED.

SECTION I - DIAGNOSIS (Continued)

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 HIP OR THIGH CONDITION (brief summary):

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

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

Hip	Joint Movement		ROM Measurement		If ROM testing is not indicated for the veteran's condition or not able to be performed,
Hip	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
	= 125 degrees)			Not able to perform
	= 125 degrees)


	Extension/
	Hyperextension			Not indicated
	Hyperextension
	(normal endpoint
				Not able to perform

	= 30 degrees)
	= 30 degrees)

	Abduction
				Not indicated

RIGHT	(normal endpoint
	= 45 degrees)			Not able to perform

HIP



	Adduction
				Not indicated

	(normal endpoint
				Not able to perform

	= 25 degrees)
	= 25 degrees)

		Is adduction limited such that the Veteran cannot cross legs				Yes	No

	External Rotation
				Not indicated

	(normal endpoint
	= 60 degrees)			Not able to perform
	= 60 degrees)


	Internal Rotation
				Not indicated

	(normal endpoint
	= 40 degrees)			Not able to perform
	= 40 degrees)

VA FORM 21-0960M-8, MAY 2013

Page 2

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

3A. INITIAL ROM MEASUREMENTS (Continued)

Hip

Joint Movement

ROM Measurement

If ROM testing is not indicated for the veteran's condition or not able to be performed,

please explain why, and then proceed to Section 5:

Flexion

Not indicated

(normal endpoint

= 125 degrees)

Not able to perform

Extension/

Hyperextension

Not indicated

(normal endpoint

Not able to perform

= 30 degrees)

Abduction

Not indicated

LEFT

(normal endpoint

= 45 degrees)

Not able to perform

HIP

Adduction

Not indicated

(normal endpoint

Not able to perform

= 25 degrees)

Is adduction limited such that the Veteran cannot cross legs

Yes

External Rotation

Not indicated

(normal endpoint

= 60 degrees)

Not able to perform

Internal Rotation

Not indicated

(normal endpoint

= 40 degrees)

Not able to perform

3B. DO ANY ABNORMAL ROMs NOTED ABOVE CONTRIBUTE TO FUNCTIONAL LOSS?

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

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 an ankle

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

SECTION IV - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING

4A. POST-TEST ROM MEASUREMENTS

Hip

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

Extension

If no, provide reason below, then proceed to Section 6

If yes, report ROM after a minimum

of 3 repetitions.

Abduction

If no, documentation of ROM after

RIGHT

repetitive-use testing is not required.

Adduction

HIP

Is post-test adduction limited such that the

Veteran cannot cross legs?

Yes

External Rotation

Internal Rotation

VA FORM 21-0960M-8, MAY 2013

Page 3

SECTION IV - ROM MEASUREMENTS AFTER REPETITIVE USE TESTING (Continued)

4A. POST-TEST ROM MEASUREMENTS (Continued)

Hip

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

If yes, perform repetitive-use testing

Yes

Flexion

If no, provide reason below, then proceed to

No, there is no change in ROM

Extension

Section 6

after repetitive testing

If yes, report ROM after a minimum

Abduction

LEFT

of 3 repetitions.

Adduction

If no, documentation of ROM after

HIP

repetitive-use testing is not required.

Is post-test adduction limited such that the

Veteran cannot cross legs?

Yes

External Rotation

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:

					SECTION V - PAIN

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

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

RIGHT		Yes			Yes (you will be asked to further describe
		Yes			Yes (you will be asked to further describe
					these limitations in Section 6 below)
HIP					these limitations in Section 6 below)
HIP		No			No
		No			No

LEFT		Yes			Yes (you will be asked to further describe
		Yes			Yes (you will be asked to further describe
					these limitations in Section 6 below)
HIP					these limitations in Section 6 below)
HIP		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 weight-bearing or non			If yes (there is pain when used in weight-bearing
weight-bearing?			If yes (there is pain when used in weight-bearing			If no (the pain does not contribute to functional loss or additional
weight-bearing?			or non weight-bearing), does the pain contribute
Hip			or non weight-bearing), does the pain contribute			limitation of ROM), explain why the pain does not contribute:
(If yes, identify whether weight-			to functional loss or additional limitation of ROM?
(If yes, identify whether weight-			to functional loss or additional limitation of ROM?
bearing or non weight-bearing
in question 5D)

RIGHT		Yes			Yes (you will be asked to further describe
		Yes			Yes (you will be asked to further describe
					these limitations in Section 6 below)
HIP					these limitations in Section 6 below)
HIP		No			No
		No			No

LEFT		Yes			Yes (you will be asked to further describe
		Yes			Yes (you will be asked to further describe
					these limitations in Section 6 below)
HIP					these limitations in Section 6 below)
HIP		No			No
		No			No

5C. LOCALIZED TENDERNESS OR PAIN ON PALPATION

Hip

Does the Veteran have localized tenderness 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 HIP

Yes

LEFT HIP

Yes

5D. COMMENTS, IF ANY:

VA FORM 21-0960M-8, MAY 2013

Page 4

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 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.)

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

Right

Left

Both

Other, describe:

NOTE: If any of the above factors is/are associated with limitation of motion, the examiner must give an opinion on whether pain, weakness, fatigability, or incoordination could significantly limit functional ability during flare-ups or when the joint is used repeatedly over a period of time and that opinion, if feasible, should be expressed in terms of the degree of additional ROM loss due to pain on use or during flare-ups. The following section will assist you in providing this required opinion.

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

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

incoordination significantly limit functional

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

Hip

functional loss during flare-ups or when the

ability during flare-ups or when the joint is

limitation of ROM cannot be estimated, please describe

joint is used repeatedly over a period of time:

used repeatedly over a period of time?

the functional loss:

Flexion

Est. ROM is

not feasible

Extension

Est. ROM is

not feasible

Abduction

Est. ROM is

not feasible

RIGHT

Yes

HIP

Adduction

Est. ROM is

not feasible

External

Est. ROM is

Rotation

not feasible

Internal

Est. ROM is

Rotation

not feasible

VA FORM 21-0960M-8, MAY 2013

Page 5

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

6C. CONTRIBUTING FACTORS OF DISABILITY ASSOCIATED WITH LIMITATION OF MOTION (Continued)

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

incoordination significantly limit functional

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

Hip

functional loss during flare-ups or when the

ability during flare-ups or when the joint is

limitation of ROM cannot be estimated, please describe

joint is used repeatedly over a period of time:

used repeatedly over a period of time?

the functional loss:

Flexion

Est. ROM is

not feasible

Extension

Est. ROM is

not feasible

Abduction

Est. ROM is

LEFT

Yes

not feasible

HIP

Est. ROM is

Adduction

not feasible

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 HIP	Yes	No	If yes, describe:
LEFT HIP	Yes	No	If yes, describe:
LEFT HIP	Yes	No	If yes, describe:

SECTION VII - MUSCLE STRENGTH TESTING

7A. MUSCLE STRENGTH - RATE STRENTH 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

Hip

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

Extension

Strength

muscle strength?

claimed condition in the Diagnosis section?

claimed condition), provide rationale:

RIGHT HIP

Flexion

Yes

Extension

Abduction

LEFT HIP

Flexion

Yes

Extension

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:

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

CIRCUMFERENCE OF MORE NORMAL SIDE:

CM CIRCUMFERENCE OF ATROPHIED SIDE:

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

CIRCUMFERENCE OF MORE NORMAL SIDE:

CM CIRCUMFERENCE OF ATROPHIED SIDE:

VA FORM 21-0960M-8, MAY 2013

Page 6

LEFT

RIGHT

LEFT

RIGHT

BOTH

BOTH BOTH BOTH BOTH BOTH

SECTION VII - MUSCLE STRENGTH TESTING (Continued)

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 THE KNEE AND/OR LOWER LEG.
8A. INDICATE SEVERITY OF ANKYLOSIS AND SIDE AFFECTED (check all that apply):
RIGHT SIDE:		LEFT SIDE:
	Favorable, in flexion at an angle between 20 and 40 degrees,		Favorable, in flexion at an angle between 20 and 40 degrees,

	and slight abduction or adduction		and slight abduction or adduction
	Intermediate, between favorable and unfavorable		Intermediate, between favorable and unfavorable
	Intermediate, between favorable and unfavorable		Intermediate, between favorable and unfavorable
	Unfavorable, extremely unfavorable ankylosis, foot not		Unfavorable, extremely unfavorable ankylosis, foot not
	Unfavorable, extremely unfavorable ankylosis, foot not		Unfavorable, extremely unfavorable ankylosis, foot not
	reaching ground, crutches needed		reaching ground, crutches needed
	No ankylosis		No ankylosis
	No ankylosis		No ankylosis

8B. COMMENTS, IF ANY:

SECTION IX - ADDITIONAL COMMENTS

9A. DOES THE VETERAN HAVE MALUNION OR NONUNION OF FEMUR, FLAIL HIP JOINT OR LEG LENGTH DISCREPENCY?

YES

IF YES, INDICATE CONDITION AND COMPLETE THE APPROPRIATE SECTIONS BELOW:

MALUNION OR NONUNION OF THE FEMUR

MALUNION WITH SLIGHT HIP DISABILITY

MALUNION WITH MODERATE HIP DISABILITY

MALUNION WITH MARKED HIP DISABILITY

FRACTURE OF SURGICAL NECK WITH FALSE JOINT

FRACTURE OF SHAFT OR NECK (anatomical),

RESULTING IN NONUNION WITHOUT LOOSE

MOTION; WEIGHT-BEARING PRESERVED WITH AID

OF A BRACE

FRACTURE OF SHAFT OR NECK (anatomical), WITH

NONUNION WITH LOOSE MOTION (spiral or oblique

fracture)

NOTE: If impairment of the femur causes any knee disability, also complete the VA Form 21-0960M-9 Knee and Lower Leg Conditions DBQ.

FLAIL HIP JOINT

INDICATE SIDE AFFECTED:

RIGHT

LEFT

BOTH

LEG LENGTH DISCREPANCY (shortening of any bones of the lower extremity)

IF CHECKED, PROVIDE LENGTH OF EACH LOWER EXTREMITY IN INCHES (to the nearest 1/4 inch) OR CENTIMETERS, MEASURING FROM THE ANTERIOR SUPERIOR ILIAC SPINE TO THE INTERNAL MALLEOLUS OF THE TIBIA.

RIGHT LEG:

	IN	LEFT LEG:

FOR ANY LEG LENGTH DISCREPANCY, PLEASE DESCRIBE THE RELATIONSHIP TO THE CONDITONS LISTED IN THE DIAGNOSIS SECTION ABOVE:

9B. COMMENTS, IF ANY:

VA FORM 21-0960M-8, MAY 2013

Page 7

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

SECTION X - SURGICAL PROCEDURES

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

(check all that apply):

RIGHT SIDE:

LEFT SIDE:

TOTAL HIP JOINT REPLACEMENT

DATE OF SURGERY:

RESIDUALS:

None

Moderately severe residuals of weakness, pain or limitation of motion

Markedly severe residual weakness, pain or limitation of motion

following implantation of prosthesis

Following implantation of prosthesis with painful motion or weakness

such as to require the use of crutches

Other, describe:

ARTHROSCOPIC OR OTHER HIP SURGERY

TYPE OF SURGERY:

DATE OF SURGERY:

RESIDUALS OF ARTHROSCOPIC OR OTHER HIP SURGERY

DESCRIBE RESIDUALS:

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

11A. 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 11B-11D.

11B. 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):

11C. 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.

11D. COMMENTS, IF ANY:

SECTION XII - ASSISTIVE DEVICES

12A. DOES THE VETERAN USE ANY ASSISTIVE DEVICES AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS MAY BE POSSIBLE?

YES NO

	Wheelchair		Frequency of use:
	Brace		Frequency of use:
	Brace		Frequency of use:

	Crutches		Frequency of use:
	Cane		Frequency of use:
	Cane		Frequency of use:
	Walker		Frequency of use:
	Walker		Frequency of use:

	Other:		Frequency of use:

Occasional

Regular

Constant

12B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:

VA FORM 21-0960M-8, MAY 2013

Page 8

SECTION XIII - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES

13.DUE TO THE VETERAN'S HIP OR THIGH 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.

SECTION XIV - 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.

14A. HAVE IMAGING STUDIES OF THE HIP OR THIGH BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?

YES NO

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

BOTH

14B. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS OR RESULTS?

YES

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

14C. IS THERE OBJECTIVE EVIDENCE OF CREPITUS?
YES	NO	IF YES, INDICATE HIP:	RIGHT

LEFT

BOTH

14D. IF ANY TEST RESULTS ARE OTHER THAN NORMAL, INDICATE RELATIONSHIP OF ABNORMAL FINDINGS TO DIAGNOSED CONDITIONS:

SECTION XV - 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.

15.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:

VA FORM 21-0960M-8, MAY 2013

Page 9

SECTION XVI - REMARKS

16. REMARKS, IF ANY:

SECTION XVII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

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

17A. PHYSICIAN'S SIGNATURE

17B. PHYSICIAN'S PRINTED NAME

17C. DATE SIGNED

17D. PHYSICIAN'S PHONE NUMBER

17E. PHYSICIAN'S MEDICAL LICENSE NUMBER

17F. 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-8, MAY 2013

Page 10

Question	Answer
Form Name	Va Form 21 0960M 8
Form Length	10 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 30 sec
Other names	21-0960M-9, ICD, 21-0960M-8, MALUNION

Va Form 21 0960M 8 – Fill Out and Use This PDF

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