Fillable Printable Vba 21 0960C 10 Are
Fillable Printable Vba 21 0960C 10 Are
Vba 21 0960C 10 Are
1A. DOES THE VETERAN HAVE A PERIPHERAL NERVE CONDITION OR PERIPHERAL NEUROPATHY?
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO A PERIPHERAL NERVE CONDITION AND/OR PERIPHERAL NEUROPATHY, LIST USING ABOVE
FORMAT:
VA FORM
FEB 2015
21-0960C-10
Peripheral Nerves Conditions (Not Including Diabetic Sensory- Motor Peripheral
Neuropathy) Disability Benefits Questionnaire
NAME OF PATIENT/VETERAN PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
DEFINITIONS: For VA purposes, neuralgia indicates a condition characterized by a dull and intermittent pain of typical distribution so as to identify
the nerve, while neuritis is characterized by loss of reflexes, muscle atrophy, sensory disturbances and constant pain, at times excruciating.
OMB Control No. 2900-0779
Respondent Burden: 45 Minutes
Expiration Date: 01/31/2018
3A. Does the veteran have any symptoms attributable to any peripheral nerve conditions?
(If "Yes," complete Item 1B)
AmbidextrousRight
Intermittent pain
(usually dull)
Left upper extremity:
Constant pain
(may be excruciating at times)
Paresthesias and/or dysesthesias
None
SECTION III - SYMPTOMS
Left lower extremity:
Right lower extremity:
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 FORM.
Right upper extremity:
Mild Moderate
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S PERIPHERAL NERVE CONDITION (brief summary):
Left
SECTION II - MEDICAL HISTORY
2B. DOMINANT HAND
Severe
Mild Moderate None Severe
If yes, indicate symptoms' location and severity
(check all that apply):
SECTION I - DIAGNOSIS
NoYes
Page 1
No
None Mild Moderate Severe
Yes
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. VA reserves the right to confirm the authenticity of ALL DBQs completed by
private health care providers.
Mild Moderate None Severe
Left upper extremity:
Left upper extremity:
None
Left lower extremity:
Right lower extremity:
Right upper extremity:
Mild Moderate Severe
Mild Moderate None Severe
None Mild Moderate Severe
Mild Moderate None Severe
None
Left lower extremity:
Right lower extremity:
Right upper extremity:
Mild Moderate
Severe
Mild Moderate None Severe
None Mild Moderate Severe
Mild Moderate None Severe
Date of diagnosis:
Date of diagnosis:
Date of diagnosis:
ICD Code:
ICD Code:
ICD Code:
Diagnosis # 3:
Diagnosis # 2:
Diagnosis # 1:
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO A PERIPHERAL NERVE CONDITION AND/OR PERIPHERAL NEUROPATHY:
SUPERSEDES VA FORM 21-0960C-10, OCT 2012,
WHICH WILL NOT BE USED.
SECTION IV - MUSCLE STRENGTH TESTING
5. Rate deep tendon reflexes (DTRs) 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
5/5 Normal strength
4A. Rate strength according to the following scale:
Ankle dorsiflexion:
Grip:
Knee extension:
Ankle plantar flexion:
Brachioradialis
Left:
Right:
Ankle
Left:
Right:
Knee
Left:
Right:
3+ 4+1+ 2+0
1+ 2+0 3+ 4+
Biceps
Left:
3+ 4+
3+ 4+
2+
Page 2
0 1+
Right:
Triceps
Left:
3+ 4+
3+
1+ 2+0
Right:
4+
1+ 2+0
2+0 1+ 3+ 4+
3+
1+ 2+0
4+
1+ 2+0 3+ 4+
2+0 1+
3+ 4+
2+0 1+
Left: 1/5 0/52/5
Left:
Left: 1/5 0/52/54/5 3/55/5
Right: 1/5 0/52/5
4/5 3/55/5
4/5 3/55/5
Right: 1/5 0/52/54/5 3/55/5
Wrist extension:
Left: 1/5 0/52/54/5 3/55/5
Right: 1/5 0/52/54/5 3/55/5
Pinch
(thumb to index finger):
Elbow extension:
Elbow flexion:
Wrist flexion:
1/5 0/5
Left upper extremity:
None
Left lower extremity:
Right lower extremity:
2/5
Left: 1/5
0/52/54/5 3/55/5
Right: 1/5 0/52/54/5 3/55/5
4/5
Left: 1/5 0/52/54/5 3/55/5
Right: 1/5 0/52/54/5 3/55/5
Mild Moderate Severe
Mild Moderate None Severe
Mild Moderate None Severe
3/55/5
Right: 1/5 0/52/54/5 3/55/5
3B. Other symptoms
(describe symptoms, location and severity):
Numbness
Right upper extremity: None Mild Moderate Severe
Left: 1/5 0/52/54/5 3/55/5
Right: 1/5 0/52/54/5 3/55/5
Left: 1/5 0/52/54/5 3/55/5
Right: 1/5 0/52/54/5
SECTION III - SYMPTOMS (Continued)
4B. Does the veteran have muscle atrophy?
4/5 Active movement against some resistance
3/55/5
0 - Absent
1+ Hypoactive
2+ Normal
3+ Hyperactive without clonus
4+ Hyperactive with clonus
Left: 1/5 0/52/54/5 3/55/5
Right: 1/5 0/52/54/5 3/55/5
SECTION V - REFLEX EXAM
NoYes
If muscle atrophy is present, indicate location:
For each instance of muscle atrophy, provide measurements in centimeters of normal side and atrophied side, measured at maximum muscle bulk:
Normal side:
cm
cm
Atrophied side:
All normal
All normal
3A. Does the veteran have any symptoms attributable to any peripheral nerve conditions? (Continued)
VA FORM 21-0960C-10, FEB 2015
SECTION VIII - GAIT
Page 3
7. DOES THE VETERAN HAVE TROPHIC CHANGES (characterized by loss of extremity hair, smooth, shiny skin, etc.) ATTRIBUTABLE TO PERIPHERAL NEUROPATHY?
Provide etiology of abnormal gait:
If yes, describe:
SECTION IX - SPECIAL TESTS FOR MEDIAN NERVE
Foot/toes (L5):
Normal Decreased Absent
Normal
Left:
Decreased AbsentLeft:
Normal Decreased AbsentRight:
Normal Decreased AbsentRight:
8. IS THE VETERAN'S GAIT NORMAL?
SECTION VI - SENSORY EXAM
6. Indicate results for sensation testing for light touch:
NoYes
9. WERE SPECIAL TESTS INDICATED AND PERFORMED FOR MEDIAN NERVE EVALUATION?
Positive Negative
Inner/outer forearm (C6/T1):
Shoulder area (C5):
Hand/fingers (C6-8):
Thigh/knee (L3/4):
Lower leg/ankle (L4/L5/S1):
Normal Decreased AbsentLeft:
Normal Decreased AbsentRight:
Normal Decreased AbsentLeft:
Normal Decreased AbsentRight:
Normal Decreased AbsentLeft:
Normal Decreased AbsentRight:
Normal Decreased AbsentLeft:
Normal Decreased AbsentRight:
If no, describe abnormal gait:
NoYes
Left: Normal Decreased Absent
Absent
DecreasedNormalRight:
Upper anterior thigh (L2):
Other sensory findings, if any:
SECTION VII - TROPHIC CHANGES
If yes, indicate results:
NoYes
Positive
Negative
Phalen's sign:
Left:
Right:
Negative
Negative
Positive
Positive
Left:
Right:
Tinel's sign:
SECTION X - NERVES AFFECTED: Severity Evaluation for Upper Extremity Nerves and Radicular Groups
Based on symptoms and findings from this exam, complete the following section to provide an estimation of the severity of the veteran's
peripheral neuropathy. This summary provides useful information for VA purposes.
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 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. For VA purposes, when nerve impairment is wholly sensory, the evaluation should be mild,
or at most, moderate.
All normal
VA FORM 21-0960C-10, FEB 2015
10B. Median nerve
Page 4
10A. Radial nerve (musculospiral nerve)
Note: Complete paralysis (hand inclined to the ulnar side, index and middle fingers extended, atrophy of thenar eminence, cannot make fist, defective opposition
of thumb, cannot flex distal phalanx of thumb; wrist flexion weak)
Note: Complete paralysis (hand and fingers drop, wrist and fingers flexed; cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb or
make lateral movement of wrist; supination of hand, elbow extension and flexion weak, hand grip impaired)
10C. Ulnar nerve
10D. Musculocutaneous nerve
Note: Complete paralysis
("griffin claw" deformity, atrophy in dorsal interspaces, thenar and hypothenar eminences; cannot extend ring and little finger, cannot
spread fingers, cannot adduct the thumb; wrist flexion weakened)
10F. Long thoracic nerve
Note: Complete paralysis
(weakened flexion of elbow and supination of forearm)
10E. Circumflex nerve
Severe
ModerateMild
If Incomplete paralysis is checked, indicate severity:
Normal Incomplete paralysis
Complete paralysis
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Complete paralysis
Incomplete paralysisNormal
Left:
Right:
Note: Complete paralysis
(innervates deltoid and teres minor; cannot abduct arm, outward rotation is weakened)
Note: Complete paralysis (inability to raise arm above shoulder level, winged scapula deformity)
SECTION X - NERVES AFFECTED: Severity Evaluation for Upper Extremity Nerves and Radicular Groups (Continued)
NOTE: INDICATE THE AFFECTED NERVES, SIDE AFFECTED AND SEVERITY OF CONDITION.
VA FORM 21-0960C-10, FEB 2015
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Normal Incomplete paralysis
Complete paralysis
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Complete paralysis
Incomplete paralysisNormal
Left:
Right:
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Normal Incomplete paralysis
Complete paralysis
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Complete paralysis
Incomplete paralysisNormal
Left:
Right:
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Normal Incomplete paralysis
Complete paralysis
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Complete paralysis
Incomplete paralysisNormal
Left:
Right:
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Normal Incomplete paralysis
Complete paralysis
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Complete paralysis
Incomplete paralysisNormal
Left:
Right:
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Normal Incomplete paralysis
Complete paralysis
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Complete paralysis
Incomplete paralysisNormal
Left:
Right:
SECTION XI - NERVES AFFECTED: Severity Evaluation for Lower Extremity Nerves
11A. Sciatic nerve
Normal
Note: Complete paralysis
(foot dangles and drops, no active movement of muscles below the knee, flexion of knee weakened or lost)
Mild
If incomplete paralysis is checked, indicate severity:
Moderate Moderately Severe
Right:
Left:
Incomplete paralysis
Severe, with marked muscular atrophy
11B. External popliteal
(common peroneal) nerve
11C. Musculocutaneous
(superficial peroneal) nerve
Based on symptoms and findings from this exam, complete the following section to provide an estimation of the severity of the veteran's peripheral
neuropathy. This summary provides useful information for VA purposes.
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 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. For VA purposes, when nerve impairment is wholly sensory, the evaluation should be mild, or at most, moderate.
10G. Upper radicular group (5
th
& 6
th
cervicals)
10H. Middle radicular group
10I. Lower radicular group
Page 5
Complete paralysis
Severe, with marked muscular atrophyModerately SevereModerateMild
If incomplete paralysis is checked, indicate severity:
Complete paralysis
Incomplete paralysisNormal
Note: Complete paralysis (all shoulder and elbow movements lost; hand and wrist movements not affected)
Note: Complete paralysis
(adduction, abduction, rotation of arm, flexion of elbow and extension of wrist lost)
Note: Complete paralysis (intrinsic hand muscles, wrist and finger flexors paralyzed; substantial loss of use of hand)
Note: Complete paralysis (foot drop, cannot dorsiflex foot or extend toes; dorsum of foot and toes are numb)
Note: Complete paralysis (eversion of foot weakened)
SECTION X - NERVES AFFECTED: Severity Evaluation for Upper Extremity Nerves and Radicular Groups (Continued)
NOTE: INDICATE AFFECTED NERVES, SIDE AFFECTED AND SEVERITY OF CONDITION.
VA FORM 21-0960C-10, FEB 2015
Severe
ModerateMild
If Incomplete paralysis is checked, indicate severity:
Normal Incomplete paralysis
Complete paralysis
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Complete paralysis
Incomplete paralysisNormal
Left:
Right:
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Normal Incomplete paralysis
Complete paralysis
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Complete paralysis
Incomplete paralysisNormal
Left:
Right:
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Normal Incomplete paralysis
Complete paralysis
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Complete paralysis
Incomplete paralysisNormal
Left:
Right:
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Normal Incomplete paralysis
Complete paralysis
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Complete paralysis
Incomplete paralysisNormal
Left:
Right:
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Complete paralysis
Incomplete paralysisNormal
Right:
Page 6
11I. Obturator nerve
11H. Internal saphenous nerve
11G. Anterior crural
(femoral) nerve
11F. Posterior tibial nerve
11E. Internal popliteal (tibial) nerve
Note: Complete paralysis
(plantar flexion lost, frank adduction of foot impossible, flexion and separation of toes abolished; no muscle in sole can move; in lesions
of the nerve high in popliteal fossa, plantar flexion of foot is lost)
Note: Complete paralysis (paralysis of all muscles of sole of foot, frequently with painful paralysis of a causalgic nature; loss of toe flexion; adduction weakened;
plantar flexion impaired)
Note: Complete paralysis (paralysis of quadriceps extensor muscles)
11D. Anterior tibial (deep peroneal) nerve
Note: Complete paralysis (dorsiflexion of foot lost)
11C. Musculocutaneous (superficial peroneal) nerve (continued)
SECTION XI - NERVES AFFECTED: Severity Evaluation for Lower Extremity Nerves (Continued)
VA FORM 21-0960C-10, FEB 2015
Severe
ModerateMild
If Incomplete paralysis is checked, indicate severity:
Normal Incomplete paralysis
Complete paralysis
Left:
Severe
ModerateMild
If Incomplete paralysis is checked, indicate severity:
Normal Incomplete paralysis
Complete paralysis
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Complete paralysis
Incomplete paralysisNormal
Left:
Right:
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Normal Incomplete paralysis
Complete paralysis
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Complete paralysis
Incomplete paralysisNormal
Left:
Right:
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Normal Incomplete paralysis
Complete paralysis
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Complete paralysis
Incomplete paralysisNormal
Left:
Right:
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Normal Incomplete paralysis
Complete paralysis
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Complete paralysis
Incomplete paralysisNormal
Left:
Right:
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Normal Incomplete paralysis
Complete paralysis
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Complete paralysis
Incomplete paralysisNormal
Left:
Right:
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Normal Incomplete paralysis
Complete paralysis
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Complete paralysis
Incomplete paralysisNormal
Left:
Right:
If yes, indicate extremity(ies) (check all extremities for which this applies):
No
Yes, functioning is so diminished that amputation with prosthesis would equally serve the veteran
SECTION XII - ASSISTIVE DEVICES
NOYES
12A. DOES THE VETERAN USE ANY ASSISTIVE DEVICES AS A NORMAL MODE OF LOCOMOTION ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS
MAY BE POSSIBLE?
13. Due to peripheral nerve conditions, 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., while functions for
the lower extremity include balance and propulsion, etc.)
12B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:
Right upper Left upper Right lower Left lower
(If yes, describe (brief summary):
SECTION XIV - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS
14B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS?
If yes, identify assistive device(s) used (check all that apply and indicate frequency):
NoYes
Other:
Constant
Crutch(es)
Occasional
Constant
Occasional
ConstantOccasionalFrequency of use:
Frequency of use:
Frequency of use:Brace(s)
Wheelchair
Occasional
Constant
Frequency of use:
Frequency of use:
Frequency of use:
Occasional
OccasionalWalker
Cane(s) Constant
Regular
Constant
Regular
Regular
Regular
Regular
Regular
Page 7
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)?
No
Yes
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?
No
Yes
If "Yes, also complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire.
SECTION XIII - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
For each checked extremity, describe loss of effective function, identify the condition causing loss of function, and provide specific examples (brief summary):
11K. Illio-inguinal nerve
11J. External cutaneous nerve of the thigh
SECTION XI - NERVES AFFECTED: Severity Evaluation for Lower Extremity Nerves (Continued)
VA FORM 21-0960C-10, FEB 2015
Severe
ModerateMild
If Incomplete paralysis is checked, indicate severity:
Normal Incomplete paralysis
Complete paralysis
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Complete paralysis
Incomplete paralysisNormal
Left:
Right:
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Normal Incomplete paralysis
Complete paralysis
SevereModerateMild
If Incomplete paralysis is checked, indicate severity:
Complete paralysis
Incomplete paralysisNormal
Left:
Right:
SECTION XVIII - PHYSICIAN'S CERTIFICATION AND SIGNATURE
SECTION XV - DIAGNOSTIC TESTING
18C. DATE SIGNED
18E. PHYSICIAN'S MEDICAL LICENSE NUMBER 18F. PHYSICIAN'S ADDRESS
18B. PHYSICIAN'S PRINTED NAME
(VA Regional Office FAX No.)
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
16. DOES THE VETERAN'S PERIPHERAL NERVE CONDITION AND/OR PERIPHERAL NEUROPATHY IMPACT HIS OR HER ABILITY TO WORK?
IMPORTANT - Physician please fax the completed form to
SECTION XVI - FUNCTIONAL IMPACT
18D. PHYSICIAN'S PHONE AND FAX NUMBER
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.
If yes, describe impact of each of the veteran's peripheral nerve and/or peripheral neuropathy condition(s), providing one or more examples:
NoYes
18A. PHYSICIAN'S SIGNATURE
NOTE - VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.
Page 8
15B. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
If abnormal, describe:
Right lower extremity
Normal
If yes, provide type of test or procedure, date and results
(brief summary):
Normal
Date:
Date:
Date:Results:
Results:Left upper extremity
Right upper extremity
NormalResults:
Results: Normal
Date:
Left lower extremity
Abnormal
15A. HAVE EMG STUDIES BEEN PERFORMED?
Abnormal
Extremities tested:
Abnormal
Abnormal
NoYes
NoYes
NOTE: For the purpose of this examination, electromyography (EMG) studies are usually rarely required to diagnose specific peripheral nerve conditions in the
appropriate clinical setting. If EMG studies are in the medical record and reflect the veteran's current condition, repeat studies are not indicated.
17. REMARKS (If any)
SECTION XVII - REMARKS
VA FORM 21-0960C-10, FEB 2015
or obtained by calling 1-800-827-1000.www.benefits.va.gov/disabilityexams
NOTE - A list of VA Regional Office FAX Numbers can be found at
