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FOOT CONDITIONS, INCLUDING FLATFOOT (PES PLANUS)

DISABILITY BENEFITS QUESTIONNAIRE

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

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:

OMB Approved No. 2900-0810

Respondent Burden: 30 minutes

Expiration Date: 04-30-2017

SECTION I - DIAGNOSIS

MEDICAL RECORD REVIEW

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.

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.

1A. LIST THE CLAIMED CONDITION(S) THAT PERTAIN TO THIS DBQ:

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.

WAS THE VETERAN'S VA CLAIMS FILE REVIEWED?

Side affected:

ICD Code: Date of diagnosis:LeftRight BothSide affected:

BothRight Left Date of diagnosis:ICD Code:

ICD Code: Date of diagnosis:LeftRight BothSide affected:

BothRight Left

Date of diagnosis:ICD Code:

ICD Code: Date of diagnosis:LeftRight BothSide affected:

BothRight Left

Date of diagnosis:ICD Code:

ICD Code: Date of diagnosis:LeftRight BothSide affected:

BothRight Left

Date of diagnosis:ICD Code:

ICD Code: Date of diagnosis:LeftRight BothSide affected:

BothRight Left

Date of diagnosis:ICD Code:

YES

PATIENT/VETERAN'S SOCIAL SECURITY NUMBERNAME OF PATIENT/VETERAN

Other:

No records were reviewed

Interviews with collateral witnesses

(family and others who have known the veteran before and after military service)

Civilian medical records

Veterans Health Administration medical records

(VA treatment records)

Department of Defense Form 214 Separation Documents

Military post-deployment questionnaire

Military separation examination

Military enlistment examination

Military service personnel records

Military service treatment records

The Veteran does not have a current diagnosis associated with any claimed condition listed above.

(Explain your findings and reasons in comments section.)

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.

Foot injury(ies) Specify:

Acquired pes cavus (claw foot)

Hallux rigidus

Hallux valgus

Hammer toes

Metatarsalgia

Morton's neuroma

Flat foot (pes planus)

Page 1

SUPERSEDES VA FORM 21-0960M-5, OCT 2012 AND

21-0960M-6, OCT 2012, WHICH WILL NOT BE USED.

21-0960M-6

VA FORM

MAY 2013

Malunion/nonunion of tarsal/

metatarsal bones

Plantar fasciitis

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

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

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

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

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

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

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

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

SECTION II - MEDICAL HISTORY

SECTION I - DIAGNOSIS

(Continued)

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

1C. COMMENTS (if any):

1D. WAS AN OPINION REQUESTED ABOUT THIS CONDITION (internal VA only)?

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

2D. DOES THE VETERAN REPORT HAVING ANY FUNCTIONAL LOSS OR FUNCTIONAL IMPAIRMENT OF THE FOOT BEING EVALUATED ON THIS DBQ (regardless

of repetitive use)?

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

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

YES NO

YES

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

IF YES, DOCUMENT THE VETERAN'S DESCRIPTION OF THE IMPACT OF FLARE-UPS IN HIS OR HER OWN WORDS:

YES

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.

VA FORM 21-0960M-6, MAY 2013 Page 2

N/A

NOYES

Side affected:

ICD Code: Date of diagnosis:LeftRight BothSide affected:

BothRight Left

Date of diagnosis:ICD Code:

ICD Code: Date of diagnosis:LeftRight BothSide affected:

Other diagnosis #3:

Other diagnosis #2:

Other diagnosis #1:

Other

(specify)

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

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

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

IF YES, INDICATE SIDE AFFECTED:

RIGHT LEFT

BOTH

YES

NOYESIF YES, IS THE PAIN ACCENTUATED ON MANIPULATION?

RIGHT LEFT BOTH

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

IF YES, INDICATE SIDE AFFECTED: RIGHT LEFT BOTH

NOYES

IF YES, INDICATE SIDE AFFECTED: RIGHT LEFT BOTH

NOYESIF YES, IS THE PAIN ACCENTUATED ON MANIPULATION?

Page 3VA FORM 21-0960M-6, MAY 2013

SECTION III - FLATFOOT (Continued)

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

NOYES

IF YES, INDICATE SIDE AFFECTED:

YES

3C. IS THERE INDICATION OF SWELLING ON USE?

NOYES

N/ANOYES

RIGHT LEFT BOTH

IS THE TENDERNESS IMPROVED BY ORTHOPEDIC SHOES OR APPLIANCES?

RIGHT

LEFT BOTH

3D. DOES THE VETERAN HAVE CHARACTERISTIC CALLUSES?

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

NOYES

YES

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

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

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?

NOYES

IF YES, INDICATE SIDE AFFECTED: RIGHT LEFT BOTH

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

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

NOYES

RIGHT LEFT BOTH

IF YES, INDICATE SIDE AFFECTED:

NOYES

RIGHT LEFT BOTHIF YES, INDICATE SIDE AFFECTED:

IF YES, INDICATE SIDE AFFECTED:

3H. IS THERE OBJECTIVE EVIDENCE OF MARKED DEFORMITY OF ONE OR BOTH FEET

(pronation, abduction etc.)?

NOYES

IF YES, INDICATE SIDE AFFECTED:

RIGHT LEFT BOTH

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?

NOYES

IF YES, INDICATE SIDE AFFECTED: RIGHT LEFT BOTH

N/A

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

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

NOYES

IF YES, INDICATE SIDE AFFECTED:

RIGHT LEFT

BOTH

Arch Supports

Effecting Relief of Symptoms Tried But Remains Symptomatic

Right Left Both

Orthotics Right Left Both

Built-up Shoes Right Left Both

Arch Supports Right Left Both

Orthotics Right Left Both

Built-up Shoes Right Left Both

Device Side Not RelievedDeviceSide Relieved

RIGHT

LEFT

NOYES

N/ANOYES

IS THE CONDITION IMPROVED BY ORTHOPEDIC SHOES OR APPLIANCES?

RIGHT

LEFT BOTH

IF YES, INDICATE SIDE AFFECTED:

N/A

RIGHT

LEFT

NOYES

N/ANOYES

RIGHT N/A

LEFT

3N. COMMENTS, IF ANY:

SECTION VI - HALLUX VALGUS

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

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

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

SIDE AFFECTED:

NOYES

IF YES, INDICATE SIDE AFFECTED:

4B. DOES THE VETERAN HAVE METATARSALGIA?

SEVERE SYMPTOMS, WITH FUNCTION EQUIVALENT TO AMPUTATION OF GREAT TOE

SECTION V - HAMMER TOE

SECTION IV - MORTON'S NEUROMA (

MORTON'S DISEASE) AND METATARSALGIA

RIGHT LEFT BOTH

NOYES

IF YES, INDICATE SIDE AFFECTED: RIGHT

LEFT

BOTH

MILD OR MODERATE SYMPTOMS

Fourth toe

None

Third toe

SIDE AFFECTED:

Great toe Second toe

Fourth toeNone Third toe

5A. WHICH TOES ARE AFFECTED ON EACH SIDE?

Great toe Second toe

LEFT:

RIGHT: Little toe

Little toe

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

4C. COMMENTS, IF ANY:

5B. COMMENTS, IF ANY:

COMPLETE THIS SECTION IF THE VETERAN HAS HAMMER TOE.

COMPLETE THIS SECTION IF THE VETERAN HAS HALLUX VALGUS.

SIDE AFFECTED:

OTHER SURGERY FOR HALLUX VALGUS, DESCRIBE:

DATE OF SURGERY:

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

NOYES

SIDE AFFECTED:

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

DATE OF SURGERY:

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

SIDE AFFECTED:

RESECTION OF METATARSAL HEAD

DATE OF SURGERY:

BOTHLEFTRIGHT

NOYES

RIGHT

BOTHLEFTRIGHT

LEFT BOTH

SECTION VII - HALLUX RIGIDUS

6C. COMMENTS, IF ANY:

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

COMPLETE THIS SECTION IF THE VETERAN HAS HALLUX RIGIDUS.

NOYES

SIDE AFFECTED:

SEVERE SYMPTOMS, WITH FUNCTION EQUIVALENT TO AMPUTATION OF GREAT TOE

MILD OR MODERATE SYMPTOMS:

SIDE AFFECTED:

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

BOTHLEFTRIGHT

7B. COMMENTS, IF ANY:

Page 4

VA FORM 21-0960M-6, MAY 2013

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

Limitation of dorsiflexion at ankle to right angle

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

SECTION VIII - ACQUIRED PES CAVUS (CLAW FOOT)

None

Marked contraction of plantar fascia with dropped forefoot

Shortened plantar fascia

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

All toes tending to dorsiflexion

None

Marked varus deformity

Some limitation of dorsiflexion at ankle

None

All toes hammer toes

Great toe dorsiflexed

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

Marked tenderness under metatarsal heads

None

Very painful callosities

Definite tenderness under metatarsal heads

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

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

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

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

COMPLETE THIS SECTION IF THE VETERAN HAS ACQUIRED PES CAVUS.

BothLeftRight

Right Left Both

Right

Left

Both

Right

BothLeftRight

Left Both

8E. COMMENTS, IF ANY:

SECTION IX - MALUNION OR NONUNION OF TARSAL OR METATARSAL BONES

Page 5

VA FORM 21-0960M-6, MAY 2013

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

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

MODERATELY SEVERE

MODERATE

SEVERE

BOTHLEFTRIGHT

SIDE AFFECTED:

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.

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

side affected).

YES

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

SECTION X - FOOT INJURES AND OTHER CONDITIONS (Continued)

Moderately severe

Moderate

Severe

BothLeftRight

Not Affected

BothLeftRight

Mild

BothLeftRight

10B. INDICATE SEVERITY AND SIDE AFFECTED.

YES

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

NOYES

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

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.

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

YES

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

YES

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

RIGHT FOOT PROCEDURE:

LEFT FOOT PROCEDURE:

DATE OF SURGERY:

IF YES, DESCRIBE RESIDUALS:

SECTION XII - PAIN

Is there pain

on physical

exam?

If yes (there is pain on physical

exam), does the pain contribute to

functional loss?

If no (the pain does not contribute to functional loss or additional

limitations), explain why the pain does not contribute:

LEFT

FOOT

Foot

Yes

(you will be asked to

further describe these

limitations in Section 13)

RIGHT

FOOT

Yes (you will be asked to

further describe these

limitations in Section 13)

Page 6

VA FORM 21-0960M-6, MAY 2013

If no, but the veteran reported pain in

his/her medical history, please provide

rationale below.

Page 7VA FORM 21-0960M-6, MAY 2013

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

Weakened movement (due to muscle injury, disease or injury of peripheral

nerves, divided or lengthened tendons, etc.)

Excess fatigability

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:

No functional loss for left lower extremity attributable to claimed condition

No functional loss for right lower extremity attributable to claimed condition

Both

LeftRight Both

Interference with standing

Interference with sitting

BothRight Left

LeftRight Both

Disturbance of locomotion

Instability of station

BothRight Left

LeftRight Both

Right Left

LeftRight Both

Right Left

LeftRight Both

Right Left

LeftRight Both

Right Left

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..)

LeftRight Both

Incoordination, impaired ability to execute skilled movements smoothly

Swelling

Atrophy of disuse

Other, describe:

Deformity

Pain on movement

BothRight Left

Pain on non weight-bearing

BothRight Left

Pain on weight-bearing

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?

YES

NOYES

IF YES, DESCRIBE:

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

LEFT FOOT

RIGHT FOOT

YES

NOYES

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:

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

RIGHT FOOT

Page 8VA FORM 21-0960M-6, MAY 2013

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?

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?

NO IF YES, COMPLETE QUESTIONS 14B-14D.

YES NO

IF YES, DESCRIBE

(brief summary):

YES NO

YES

14D. COMMENTS, IF ANY:

IF YES, ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT.

LOCATION:

MEASUREMENTS: Length cm X width cm.

IF NO, PROVIDE LOCATION AND MEASUREMENTS OF SCAR IN CENTIMETERS.

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.

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

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?

15A. DOES THE VETERAN USE ANY ASSISTIVE DEVICES AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS

MAY BE POSSIBLE?

15B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:

Crutches

Walker Frequency of use: Occasional Regular Constant

ConstantRegularOccasionalFrequency of use:Cane

Frequency of use: Occasional Regular Constant

Wheelchair Frequency of use: Occasional Regular Constant

Frequency of use: Occasional Regular Constant

YES NO

IF YES, IDENTIFY ASSISTIVE DEVICES USED

(check all that apply and indicate frequency):

SECTION XV - ASSISTIVE DEVICES

Other:

ConstantRegularOccasionalFrequency of use:Brace

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.)

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 XVI - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES

RIGHT LOWER

FOR EACH CHECKED EXTREMITY, IDENTIFY THE CONDITION CAUSING LOSS OF FUNCTION, DESCRIBE LOSS OF EFFECTIVE FUNCTION AND PROVIDE

SPECIFIC EXAMPLES

(brief summary):

LEFT LOWERIF YES, INDICATE EXTREMITIES FOR WHICH THIS APPLIES:

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

17A. HAVE IMAGING STUDIES OF THE FOOT BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?

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

17C. IF ANY TEST RESULTS ARE OTHER THAN NORMAL, INDICATE RELATIONSHIP OF ABNORMAL FINDINGS TO DIAGNOSED CONDITIONS:

IF YES, PROVIDE TYPE OF TEST OR PROCEDURE, DATE AND RESULTS

(brief summary):

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.

SECTION XVII - DIAGNOSTIC TESTING

YES

IF YES, IS DEGENERATIVE OR TRAUMATIC ARTHRITIS DOCUMENTED?

IF YES, INDICATE FOOT: RIGHT

BOTHLEFT

YES NO

VA FORM 21-0960M-6, MAY 2013 Page 9

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.)?

SECTION XVIII - FUNCTIONAL IMPACT

NO IF YES, DESCRIBE THE FUNCTIONAL IMPACT OF EACH CONDITION, PROVIDING ONE OR MORE EXAMPLES:YES

NOTE: Provide the impact of only the diagnosed condition(s), without consideration of the impact of other medical conditions or factors, such as age.

19. REMARKS, IF ANY:

SECTION XIX- REMARKS

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.

20C. DATE SIGNED

20E. PHYSICIAN'S MEDICAL LICENSE NUMBER 20F. PHYSICIAN'S ADDRESS

20B. PHYSICIAN'S PRINTED NAME

(VA Regional Office FAX No.)

20A. PHYSICIAN'S SIGNATURE

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

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.

SECTION XX - PHYSICIAN'S CERTIFICATION AND SIGNATURE

IMPORTANT - Physician please fax the completed form to

20D. PHYSICIAN'S PHONE NUMBER

NOTE: VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.