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3A. INITIAL ROM MEASUREMENTS BACK All Normal Joint Movement ROM Measurement Forward Flexion normal endpoint 90 degrees Not indicated Extension Right Lateral Flexion Left Lateral Rotation VA FORM 21-0960M-14 MAY 2013 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 Not able to perform Page 2 3B. Explain your findings and reasons in comments section. Mechanical back pain syndrome ICD Code Date of diagnosis Lumbosacral sprain/strain Facet joint arthropathy Degenerative disc disease Foraminal/lateral recess/ central stenosis Spondylolysis/isthmic spondylolisthesis degenerative joint disease of lumbosacral spine Intervertebral disc syndrome Radiculopathy Ankylosis of thoracolumbar spine Ankylosing spondylitis of the thoracolumbar spine back NOTE If there are systemic or other constitutional manifestations of ankylosing spondylitis ALSO complete the Non-degenerative Arthritis DBQ and the appropriate DBQ for each affected system. Vertebral fracture vertebrae of the back Other specify Other diagnosis 1 VA FORM MAY 2013 21-0960M-14 SUPERSEDES VA FORM 21-0960M-14 OCT 2012 WHICH WILL NOT BE USED. OMB Approved No. 2900-0808 Respondent Burden 45 minutes Expiration Date 04-30-2017 BACK THORACOLUMBAR SPINE 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. SPECIFY NERVE ROOTS INVOLVED check all that apply INVOLVEMENT OF L2/L3/L4 NERVE ROOTS femoral nerve If checked indicate side affected Right Left Both OTHER NERVES specify nerve root involved 13J. DOMINANT HAND AMBIDEXTROUS SECTION XIV - OTHER NEUROLOGIC ABNORMALITIES ASSOCIATED WITH A THORACOLUMBAR SPINE back CONDITION Disability Benefits Questionnaire for each condition identified. SECTION XV - INTERVERTEBRAL DISC SYNDROME IVDS AND INCAPACITATING EPISODES NOTE For VA purposes IVDS is a group of signs and symptoms due to nerve root irritation that commonly includes back pain and sciatica pain along the course of the sciatic nerve in the case of lumbar disc disease and neck and arm or hand pain in the case of cervical disc disease. 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 NO 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 Department of Defense Form 214 Separation Documents Veterans Health Administration medical records VA treatment records Military enlistment examination Civilian medical records Military separation examination Interviews with collateral witnesses family and others who have known the veteran before and after military service Military post-deployment questionnaire 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.
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