VA Form 21-0960M-1 Osteomyelitis Disability Benefits Questionnaire

OMB Approved No. 2900-0778
Respondent Burden: 15 Minutes
Expiration Date: XX/XX/XXXX

OSTEOMYELITIS 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
BEFORE COMPLETING FORM.
NAME OF PATIENT/VETERAN

PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

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.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH OSTEOMYELITIS?
YES

NO

(If "No," complete Item 1B)

1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO OSTEOMYELITIS
DIAGNOSIS # 1 -

ICD CODE -

DATE OF DIAGNOSIS

DIAGNOSIS # 2 -

ICD CODE -

DATE OF DIAGNOSIS

DIAGNOSIS # 3 -

ICD CODE -

DATE OF DIAGNOSIS

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO OSTEOMYELITIS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S OSTEOMYELITIS (brief summary):

2B. INDICATE LOCATION OF INITIAL INFECTION (Check all that apply):
PELVIS
CERVICAL VERTEBRAE
THORACOLUMBAR VERTEBRAE
LONG BONES OF UPPER EXTREMITY

Side affected:

Right

Left

LONG BONES OF LOWER EXTREMITY

Side affected:

Right

Left

FINGER(S):

Right digit(s) affected:

Left digit(s) affected:

TOE(S):

Right digit(s) affected:

Left digit(s) affected:

OTHER, Specify:
EXTENSION INTO JOINTS
If checked, indicate joints affected:
Right:
Left:

Shoulder

Elbow

Wrist

Hip

Multiple hand joints

Multiple foot joints

Shoulder

Wrist

Elbow

Multiple hand joints

Hip

Knee

Ankle

Knee

Ankle

Multiple foot joints

OTHER, Specify:
2C. HAS THE VETERAN HAD MEDICAL TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING MEDICAL TREATMENT FOR OSTEOMYELITIS?
YES

NO

(If "Yes," describe treatment):
Date treatment started:
Date treatment completed or anticipated date of completion:

VA FORM
XXX XXXX

21-0960M-11

SUPERSEDES VA FORM 21-0960M-11, OCT 2012,
WHICH WILL NOT BE USED.

Page 1

SECTION II - MEDICAL HISTORY (continued)
2D. HAS THE VETERAN HAD SURGICAL TREATMENT FOR OSTEOMYELITIS?
YES

NO

(If "Yes," indicate surgical procedure and date (if multiple procedures, indicate below)):
Procedure #1:
Facility:

Date:
Procedure #2:

Facility:

Date:

If additional surgical procedures, list using above format:

2E. PROVIDE STATUS OF THE VETERAN'S CURRENT OSTEOMYELITIS CONDITION:
SUBACUTE

ACUTE

CHRONIC

INACTIVE

RESOLVED

OTHER describe:

SECTION III - RECURRENT INFECTIONS
3A. HAS THE VETERAN HAD ANY ADDITIONAL EPISODES OR RECURRING INFECTIONS OF OSTEOMYELITIS FOLLOWING THE INITIAL INFECTION?
NO (If "Yes," complete questions 3B and 3C) (If "No," skip to Section IV)

YES

(If "Yes," indicate number of additional episodes):
1

2

3

4

5 or more

3B. LOCATION OF RECURRENT INFECTIONS (check all that apply):
PELVIS
CERVICAL VERTEBRAE
THORACOLUMBAR VERTEBRAE
LONG BONES OF UPPER EXTREMITY

Side affected:

Right

Left

LONG BONES OF LOWER EXTREMITY

Side affected:

Right

Left

FINGER(S):

Right digit(s) affected:

TOE(S):

Left digit(s) affected:

Right digit(s) affected:

Left digit(s) affected:

OTHER, Specify:
EXTENSION INTO JOINTS

(If checked, indicate joints affected):
Right:

Shoulder

Elbow

Multiple hand joints
Left:

Shoulder

Elbow

Multiple hand joints

Wrist

Hip

Knee

Ankle

Knee

Ankle

Multiple foot joints
Wrist

Hip

Multiple foot joints

OTHER, Specify:
3C. DATES OF RECURRENT INFECTION
Indicate dates of recurrences:
Date of recurrence #1:

Site of recurrent infection:

Date of recurrence #2:

Site of recurrent infection:

Date of recurrence #3:

Site of recurrent infection:

If there are additional recurrences, list using above format:

SECTION IV - SIGNS, SYMPTOMS AND FINDINGS
4A. DOES THE VETERAN CURRENTLY HAVE ANY SIGNS OR FINDINGS ATTRIBUTABLE TO OSTEOMYELITIS OR TREATMENT FOR OSTEOMYELITIS?
NO (If "Yes," check all that apply):

YES

Involucrum
Sequestrum
Discharging sinus
Amyloidosis secondary to chronic infection
Anemia

(If checked, provide CBC results in diagnostic testing section).
Decreased joint function or range of motion due to osteomyelitis or residuals of treatment
If checked, indicate affected joints and ALSO complete appropriate Questionnaire for each affected joint and/or spinal segment.
Right:

Left:

Shoulder

Elbow

Wrist

Hip

Knee

Multiple hand joints

Multiple foot joints

Single hand joint

Shoulder

Wrist

Knee

Elbow

Multiple hand joints
Cervical vertebral joint(s)
VA FORM 21-0960M-11, XXX XXXX

Hip

Multiple foot joints

Ankle

Single foot joint

Ankle

Single foot joint

Single hand joint

Thoracolumbar vertebral joint(s) Specific vertebral joint(s) affected

Page 2

SECTION IV - SIGNS, SYMPTOMS AND FINDINGS (continued)
4B. DOES THE VETERAN CURRENTLY HAVE ANY SYMPTOMS ATTRIBUTABLE TO OSTEOMYELITIS OR TREATMENT FOR OSTEOMYELITIS?
YES

NO

(If "Yes," check all that apply):
Pain

(If checked, describe severity, duration and location):

Swelling

(If checked, describe severity, duration and location):

Tenderness

(If checked, describe severity, duration and location):

Erythema

(If checked, describe severity, duration and location):

Warmth

(If checked, describe severity, duration and location):

Malaise

(If checked, describe symptoms and duration):

Other Symptoms, describe:

SECTION V - AMPUTATION
5. HAS THE VETERAN HAD AN AMPUTATION DUE TO OSTEOMYELITIS?
NO

YES

(If "Yes," also complete VA Form 21-0960M-1 Amputations Disability Benefits Questionnaire)
SECTION VI - ASSISTIVE DEVICES
6A. DOES THE VETERAN USE ANY ASSISTIVE DEVICES AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS
MAY BE POSSIBLE?
YES

NO

(If "Yes," identify assistive devices used (check all that apply and indicate frequency):
Wheelchair

Frequency of use:

Occasional

Regular

Constant

Brace(s)

Frequency of use:

Occasional

Regular

Constant

Crutch(es)

Frequency of use:

Occasional

Regular

Constant

Cane(s)

Frequency of use:

Occasional

Regular

Constant

Walker

Frequency of use:

Occasional

Regular

Constant

Other:

Frequency of use:

Occasional

Regular

Constant

(If the veteran uses any assistive devices, specify the condition and identify the assitive device used for each condition):

SECTION VII - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
7. DUE TO THE VETERAN'S OSTEOMYELITIS OR RESIDUALS OF TREATMENTS, 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.)

YES, FUNCTIONING IS SO DIMINISHED THAT AMPUTATION WITH PROSTHESIS WOULD EQUALLY SERVE THE VETERAN
NO

(If "Yes," indicate extremities for which this applies):
Right upper

Left upper

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)

VA FORM 21-0960M-11, XXX XXXX

Page 3

SECTION VIII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
8A. 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?
YES

NO

(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 (If "Yes," also complete VA Form 21-0960F-1 Scars/Disfigurement Disability Benefits Questionnaire)

YES

8B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN SECTION I, DIAGNOSIS?
YES

NO

(If "Yes," describe (brief summary)):

SECTION IX - DIAGNOSTIC TESTING
9A. HAVE IMAGING OR LABORATORY STUDIES BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

(If "Yes," indicate tests performed, dates and results):
Bone scan

Date of test:

Results:

X-ray

Date of test:

Results:

MRI

Date of test:

Results:

Complete blood count (CBC)

Date of test:

Results:

C-reactive protein (CRP)

Date of test:

Results:

Erythrocyte sedimentation rate (ESR)

Date of test:

Results:

Blood culture

Date of test:

Results:

Bone biopsy and culture

Date of test:

Results:

Other, describe:

Date of test:

Results:

9B. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES

NO

(If "Yes," provide type of test or procedure, date and results - brief summary):

SECTION X - FUNCTIONAL IMPACT
10. DOES THE VETERAN'S OSTEOMYELITIS IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe the impact of the veteran's osteomyelitis or residuals of treatment, providing one or more examples):

SECTION XI - REMARKS

11. REMARKS (If any)

SECTION XII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
12A. PHYSICIAN'S SIGNATURE
12D. PHYSICIAN'S PHONE AND FAX NUMBER

12C. DATE SIGNED

12B. PHYSICIAN'S PRINTED NAME
12E. PHYSICIAN'S MEDICAL LICENSE NUMBER

12F. 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.benefits.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 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 15 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-11, XXX XXXX

Page 4