Form 21-0960C-4 Diabetic Sensory-Motor Peripheral Neuropathy Disability Benefits Questionnaire

( OTHER SYMPTOMS (Describe symptoms location and severity):) ((For each instance of muscle atrophy provide measurements in cm between normal and atrophied side measured at maximum muscle bulk: cm )) ((If "Yes " describe) (Brief summary):) (10A PHYSICIAN'S SIGNATURE) (10B PHYSICIAN'S PRINTED NAME) (10C DATE SIGNED Enter 2 digit month 2 digit day and 4 digit year ) (10E PHYSICIAN'S MEDICAL LICENSE NUMBER) (10F PHYSICIAN'S ADDRESS) (1C IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO DIABETIC PERIPHERAL NEUROPATHY LIST USING ABOVE FORMAT:) (1C PROVIDE DIAGNOSES THAT PERTAIN TO DIABETIC PERIPHERAL NEUROPATHY DIAGNOSIS #1) (1C PROVIDE DIAGNOSES THAT PERTAIN TO DIABETIC PERIPHERAL NEUROPATHY DIAGNOSIS #2) (1C PROVIDE DIAGNOSES THAT PERTAIN TO DIABETIC PERIPHERAL NEUROPATHY DIAGNOSIS #3) (2B DESCRIBE THE HISTORY (including cause onset and course) OF THE VETERAN'S DIABETIC PERIPHERAL NEUROPATHY) (4G If muscle atrophy is present indicate location Line 1 of 3 ) (4G If muscle atrophy is present indicate location Line 2 of 3 ) (4G If muscle atrophy is present indicate location Line 3 of 3 ) (4H If "Yes " describe) (7B IF THERE ARE OTHER SIGNIFICANT FINDINGS OR DIAGNOSTIC TEST RESULTS PROVIDE DATES AND DESCRIBE) (9 REMARKS (If any)) (Date Enter 2 digit month 2 digit day and 4 digit year ) (Date Enter 2 digit month 2 digit day and 4 digit year ) (DATE OF DIAGNOSIS Enter 2 digit month 2 digit day and 4 digit year ) (DATE OF DIAGNOSIS Enter 2 digit month 2 digit day and 4 digit year ) (ICD CODE) (ICD CODE) (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?)) (If "Yes " complete Item 1B)NOYES1B PROVIDE DIAGNOSES THAT PERTAIN TO DIABETIC PERIPHERAL NEUROPATHY: (If "Yes " describe impact of the veteran's diabetic peripheral neuropathy providing one or more examples:) (If "Yes " describe):NOYES4H DOES THE VETERAN HAVE TROPHIC CHANGES (characterized by loss of extremity hair smooth shiny skin etc ) ATTRIBUTABLE TO DIABETIC PERIPHERAL (If "Yes " indicate nerve affected severity and side affected) (If abnormal describe Line 1 of 2 ) (If abnormal describe Line 2 of 2 ) (If abnormal describe): (If incomplete paralysis is checked indicate severity): (If incomplete paralysis is checked indicate severity): (If incomplete paralysis is checked indicate severity): (If muscle atrophy is present indicate location): (NAME OF PATIENT/VETERAN) (NOTE: Complete paralysis (hand and fingers drop wrist and fingers flexed; cannot extend hand at wrist extend proximal phalanges of fingers extend thumb or (PATIENT/VETERAN'S SOCIAL SECURITY NUMBER) (Physiciansphoneandfaxno ) (thumb to index finger)LEFT:1/50/52/5Knee ExtensionLEFT:1/50/52/54/53/55/5RIGHT:1/50/52/54/53/55/54/53/55/5RIGHT:1/50/52/54/53/55/5Ankle DorsiflexionLEFT:1/50/52/54/53/55/5RIGHT:1/50/52/54/53/55/5Wrist FlexionLEFT:1/50/52/54/53/55/5RIGHT:1/50/52/54/53/55/5Wrist ExtensionLEFT:1/50/52/54/53/55/5RIGHT:1/50/52/54/53/55/5GripLEFT:1/50/52/54/53/55/5RIGHT:1/50/52/54/53/55/5Ankle Plantar FlexionLEFT:1/50/52/54/53/55/5RIGHT:1/50/52/54/53/55/5Elbow FlexionLEFT:1/50/52/54/53/55/5RIGHT:1/50/52/54/53/55/5Elbow ExtensionLEFT:1/50/52/54/53/55/5RIGHT:1/50/52/54/53/55/5Knee FlexionLEFT:1/50/52/54/53/55/5RIGHT:1/50/52/54/53/55/5All normal0 Absent1+ Decreased2+ Normal3+ Increased without clonus4+ Increased with clonus4B DEEP TENDON REFLEXES (DTRs) RATE REFLEXES ACCORDING TO THE FOLLOWING SCALE: (VA Regional Office FAX No ) (VA Regional Office FAX Number) 1+2+02+01+3+4+ 1+2+03+4+ 1+2+04+ 1+2+0RIGHT: 10A PHYSICIAN'S SIGNATURE 10B PHYSICIAN'S PRINTED NAME 10C DATE SIGNED 10D PHYSICIAN'S PHONE AND FAX NUMBER 10E PHYSICIAN'S MEDICAL LICENSE NUMBER 10F PHYSICIAN'S ADDRESS 1C IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO DIABETIC PERIPHERAL NEUROPATHY LIST USING ABOVE FORMAT: 2+01+ 2+01+ 21 0960C 4 2B DESCRIBE THE HISTORY (including cause onset and course) OF THE VETERAN'S DIABETIC PERIPHERAL NEUROPATHY 3 DOES THE VETERAN HAVE ANY SYMPTOMS ATTRIBUTABLE TO DIABETIC PERIPHERAL NEUROPATHY? (Continued) 3+4+1+2+01+2+03+4+ 4A STRENGTH RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE: 4G DOES THE VETERAN HAVE MUSCLE ATROPHY? 5/5 Normal strength0/5 No muscle movement1/5 Visible muscle movement but no joint movement2/5 No movement against gravity3/5 No movement against resistance4/5 Less than normal strengthPinch 5A DOES THE VETERAN HAVE AN UPPER EXTREMITY DIABETIC PERIPHERAL NEUROPATHY? 5B DOES THE VETERAN HAVE A LOWER EXTREMITY DIABETIC PERIPHERAL NEUROPATHY? 6B DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS COMPLICATIONS CONDITIONS SIGNS AND/OR SYMPTOMS RELATED TO 7A HAVE EMG STUDIES BEEN PERFORMED? 7B IF THERE ARE OTHER SIGNIFICANT FINDINGS OR DIAGNOSTIC TEST RESULTS PROVIDE DATES AND DESCRIBE AbnormalDate: 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 All normal All Normal4D POSITION SENSE (grasp index finger/great toe on sides and ask patient to identify up and down movement) AMBIDEXTROUSRIGHTLEFT2C DOMINANT HANDSECTION III SYMPTOMS3 DOES THE VETERAN HAVE ANY SYMPTOMS ATTRIBUTABLE TO DIABETIC PERIPHERAL NEUROPATHY? and/or lost/decreased sensation to monofilament testing AnkleLEFT: ANY CONDITIONS LISTED IN SECTION I DIAGNOSIS? BEFORE COMPLETING FORM BicepsLEFT: BrachioradialisLEFT: cannot spread fingers cannot adduct the thumb; wrist flexion weakened ) 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 Complete paralysisIncomplete paralysisNormalMEDIAN NERVE(NOTE: Complete paralysis (hand inclined to the ulnar side index and middle fingers extended atrophy of thenar eminence cannot make fist defective Complete paralysisIncomplete paralysisNormalModerately SevereMildLEFT: Complete paralysisIncomplete paralysisNormalModerately SevereMildSevere with marked muscular atrophyLEFT: 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 CONSTANT PAIN (may be excruciating at times) 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 DATE OF DIAGNOSIS DATE OF DIAGNOSIS Date: DecreasedNormalDecreasedAbsentAbsentFoot/toesLEFT: Department of Veterans Affairs DIAGNOSIS # 1 DIAGNOSIS # 2 DIAGNOSIS # 3 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 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 For VA purposes when nerve impairment is wholly sensory the evaluation should be mild or at most moderate ICD CODE ICD CODE If "Yes " describe impact of the veteran's diabetic peripheral neuropathy providing one or more examples:NOYES IMPORTANT Physician please fax the completed form to IMPORTANT THEDEPARTMENTOFVETERANSAFFAIRS(VA)WILLNOTPAYORREIMBURSEANYEXPENSESORCOSTINCURREDINTHE IN SECTION I DIAGNOSIS? Inner/outer forearmLEFT: INTERMITTENT PAIN (usually dull) Knee/thighLEFT: KneeLEFT: LEFT LOWER EXTREMITY: LEFT LOWER EXTREMITY: LEFT LOWER EXTREMITYResults: LEFT UPPER EXTREMITY: LEFT UPPER EXTREMITYRIGHT UPPER EXTREMITY LEFT: make lateral movement of wrist; supination of hand elbow extension and flexion weak hand grip impaired ) MildSevere with marked muscular atrophyRIGHT: Moderate(NOTE: Complete paralysis (foot dangles and drops no active movement of muscles below the knee flexion of knee weakened or lost ) Moderate(NOTE: Complete paralysis (paralysis of quadriceps extensor muscles ) ModerateComplete paralysisIncomplete paralysisNormal(If incomplete paralysis is checked indicate severity): Moderately SevereMildRIGHT: Moderately SevereSCIATIC NERVEFEMORAL NERVE (anterior crural) NAME OF PATIENT/VETERAN nerve If the nerve is completely paralyzed check the box for "complete paralysis" If the nerve is not completely paralyzed check the box for "incomplete paralysis" and indicate severity NEUROPATHY? NO(If "Yes " describe) (Brief summary):YES NormalAbnormal NormalAbnormalRIGHT LOWER EXTREMITY NormalComplete paralysisIncomplete paralysisRADIAL NERVE (musculospiral nerve) NormalComplete paralysisIncomplete paralysisSevereModerateMild5A DOES THE VETERAN HAVE AN UPPER EXTREMITY DIABETIC PERIPHERAL NEUROPATHY? (Continued) NormalComplete paralysisIncomplete paralysisSevereModerateMildLEFT: NormalComplete paralysisIncomplete paralysisSevereModerateMildULNAR NERVE(NOTE: Complete paralysis ("griffin claw" deformity atrophy in dorsal interspaces thenar and hypothenar eminences; cannot extend ring and little finger NormalDate: NormalDecreased4C LIGHT TOUCH/MONOFILAMENT TESTING RESULTSNormalDecreasedAbsentNormalAnkle/lower legLEFT: NormalDecreasedAbsentLEFT UPPER EXTREMITYNormalDecreasedAbsentRIGHT UPPER EXTREMITY(For each instance of muscle atrophy provide measurements in cm between normal and atrophied side measured at maximum muscle bulk: NormalDecreasedNormalDecreasedAbsentAbsentAbsentNormalDecreasedAbsentShoulder areaLEFT: NormalDecreasedNormalDecreasedAbsentNormalDecreasedAbsentAbsentAbsentNormalDecreasedHand/fingersNormalDecreasedAbsentRIGHT: NormalResults: Not testedNormalDecreasedAbsentLEFT LOWER EXTREMITYNormalDecreasedAbsentRIGHT LOWER EXTREMITY4F COLD SENSATION (test distal extremities for cold sensation with side of tuning fork) Not testedNormalDecreasedAbsentNormalLEFT LOWER EXTREMITYDecreasedAbsentLEFT UPPER EXTREMITYNormalDecreasedAbsentRIGHT UPPER EXTREMITYNormalDecreasedAbsentRIGHT LOWER EXTREMITYNot testedNormalDecreasedAbsentNormalLEFT LOWER EXTREMITYDecreasedAbsentLEFT UPPER EXTREMITYNormalDecreasedAbsentRIGHT UPPER EXTREMITYNormalDecreasedAbsentRIGHT LOWER EXTREMITY4E VIBRATION SENSATION (place low pitched tuning fork over DIP joint of index finger/IP joint of great toe) 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 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 NOTE VA may request additional medical information including additional examinations if necessary to complete VA's review of the veteran's application NOTE: For VA purposes the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the description of complete paralysis that is given with each NOYES NOYES(Extremities tested): NOYES(If "Yes " ALSO complete VA Form 21 0960F 1 Scars/Disfigurement Disability Benefits Questionnaire) NOYES(If "Yes " indicate nerve affected severity and side affected) NOYES(If incomplete paralysis is checked indicate severity): NUMBNESSSevereNoneMildModerateRIGHT UPPER EXTREMITY: objective clinical findings which may include symmetrical lost/decreased reflexes decreased strength lost/decreased sensation for cold vibration and/or position sense OCT 2012WHICH WILL NOT BE USED OMB Control No 2900 0776 opposition of thumb cannot flex distal phalanx of thumb; wrist flexion weak ) OTHER SYMPTOMS (Describe symptoms location and severity): Page 2 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 PARESTHESIAS AND/OR DYSESTHESIASSevereNoneMildModerateRIGHT UPPER EXTREMITY: PATIENT/VETERAN'S SOCIAL SECURITY NUMBER peripheral neuropathy can be made in the appropriate clinical setting by a history of characteristic pain and/or sensory changes in a stocking/glove distribution and 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 PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION provide on this questionnaire as part of their evaluation in processing the veteran's claim 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 Respondent Burden: 30 minutes 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 Results: RIGHT LOWER EXTREMITY: RIGHT LOWER EXTREMITY: RIGHT UPPER EXTREMITY: RIGHT: RIGHT: RIGHT: RIGHT: RIGHT: RIGHT: SECTION I DIAGNOSIS1A DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH DIABETIC PERIPHERAL NEUROPATHY? SECTION II MEDICAL HISTORYNOYES2A DOES THE VETERAN HAVE DIABETES MELLITUS TYPE I OR TYPE II? SECTION III SYMPTOMS (Continued) SECTION IV NEUROLOGIC EXAM SECTION IV NEUROLOGIC EXAM (Continued) SECTION IX REMARKS9 REMARKS if any: SECTION V SEVERITY (Continued) SECTION V SEVERITYNOTE: Based on symptoms and findings from Sections III and IV complete Items 5a and 5b below to provide an evaluation of the severity of the veteran's diabetic peripheral neuropathy SECTION VI OTHER PERTINENT PHYSICAL FINDINGS COMPLICATIONS CONDITIONS SIGNS AND/OR SYMPTOMSNOYES6A DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED SECTION VII DIAGNOSTIC TESTINGNOTE:For purposes of this examination electromyography (EMG) studies are rarely required to diagnose diabetic peripheral neuropathy The diagnosis of diabetic SECTION VIII FUNCTIONAL IMPACT8 DOES THE VETERAN'S DIABETIC PERIPHERAL NEUROPATHY IMPACT HIS OR HER ABILITY TO WORK? SECTION X PHYSICIAN'S CERTIFICATION AND SIGNATURECERTIFICATION To the best of my knowledge the information contained herein is accurate complete and current SevereModerateMild SevereModerateMild(If incomplete paralysis is checked indicate severity): SevereModerateMildNoneSevereModerateMildNoneSevereModerateMildNone SevereModerateMildNoneSevereModerateMildNoneSevereModerateMildNoneLEFT UPPER EXTREMITY: SevereNoneMildModerateNOYES(If "Yes " indicate symptoms' location and severity) (Check all that apply): SevereNoneMildModerateRIGHT UPPER EXTREMITY: TricepsLEFT: 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 VA FORM 21 0960C 4 OCT 2012Page 3 VA FORM 21 0960C 4 OCT 2012Page 4 VA FORM 21 0960C 4 OCT 2012Page 5 VA FORM SUPERSEDES VA FORM 21 0960C 4 JAN 2011 Page 1 verification through computer matching programs with other agencies you will need an average of 30 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