This form contains 532 fields organized into 147 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
Abnormal Findings Relationship to Diagnosed Conditions
12E Abnormal Findings Relationship	Text	Provide a detailed explanation of the relationship between any abnormal test results and the diagnosed conditions.
Achilles' Tendon Rupture Diagnosis
Achilles' Tendon Rupture Diagnosis	Checkbox	Select this option if the diagnosis for the claimed condition is Achilles' tendon rupture.
Achilles' Tendon Rupture - Right Side Affected	Radiobutton	Select this option if the Achilles' tendon rupture affects the right side.
Achilles' Tendon Rupture ICD Code	Text	Provide the ICD code for the Achilles' tendon rupture diagnosis.
Achilles' Tendon Rupture Right Date of Diagnosis	Date	Enter the date of diagnosis for Achilles' tendon rupture on the right side.
Achilles' Tendon Rupture Left Date of Diagnosis	Date	Enter the date of diagnosis for Achilles' tendon rupture on the left side.
Active Range of Motion 1
Plantar Flexion Endpoint 1	Number	Enter the measured active range of motion value for the 1st plantar flexion endpoint.
Dorsiflexion Endpoint 1	Number	Enter the measured active range of motion value for the 1st dorsiflexion endpoint.
1 Plantar Flexion	Checkbox	Check this box if plantar flexion exhibited pain during the examination.
1 Dorsiflexion	Checkbox	Check this box if dorsiflexion exhibited pain during the examination.
Active Range of Motion 2
Active Range of Motion 2 Plantar Flexion Endpoint	Number	Enter the active range of motion value for the plantar flexion endpoint in degrees.
Active Range of Motion 2 Dorsiflexion Endpoint	Number	Enter the active range of motion value for the dorsiflexion endpoint in degrees.
Active Range of Motion 2 Plantar flexion	Checkbox	Check this box if plantar flexion exhibited pain during the examination in the second ROM assessment.
Active Range of Motion 2 Dorsiflexion	Checkbox	Check this box if dorsiflexion exhibited pain during the examination in the second ROM assessment.
Additional Diagnoses List
Additional Ankle Diagnoses	Text	Enter any additional diagnoses that pertain to ankle conditions, formatted as described above.
Additional Factors Contributing to Disability (First Instance)
In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Right: None	CheckBox
In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Right: Interference with sitting	CheckBox
In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Right: Interference with standing	CheckBox
In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Right: Swelling	CheckBox
In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Right: Disturbance of locomotion	CheckBox
In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Right: Deformity	CheckBox
In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Right: Less movement than normal	CheckBox
In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Right: More movement than normal	CheckBox
In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Right: Weakened movement	CheckBox
In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Right: Atrophy of disuse	CheckBox
In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Right: Instability of station	CheckBox
In addition to those addressed above, are there additional contributing factors of disability? Please select all that apply and describe: Right: Other, describe	CheckBox
First Instance Other Contributing Factor	Text	Enter a description of any other additional factor contributing to the disability for the first instance.
First Instance Additional Contributing Factors Description	Text	Provide a detailed description of all additional factors contributing to the disability for the first instance.
Additional Factors Contributing to Disability (Second Instance)
Second Instance None	Checkbox	Check this box if there are no additional contributing factors to disability in the second instance.
Second Instance Interference with sitting	Checkbox	Check this box if interference with sitting is an additional contributing factor to disability in the second instance.
Second Instance Interference with standing	Checkbox	Check this box if interference with standing is an additional contributing factor to disability in the second instance.
Second Instance Swelling	Checkbox	Check this box if swelling is an additional contributing factor to disability in the second instance.
Second Instance Disturbance of locomotion	Checkbox	Check this box if disturbance of locomotion is an additional contributing factor to disability in the second instance.
Second Instance Deformity	Checkbox	Check this box if deformity is an additional contributing factor to disability in the second instance.
Second Instance Less movement than normal	Checkbox	Check this box if less movement than normal is an additional contributing factor to disability in the second instance.
Second Instance More movement than normal	Checkbox	Check this box if more movement than normal is an additional contributing factor to disability in the second instance.
Second Instance Weakened movement	Checkbox	Check this box if weakened movement is an additional contributing factor to disability in the second instance.
Second Instance Atrophy of disuse	Checkbox	Check this box if atrophy of disuse is an additional contributing factor to disability in the second instance.
Second Instance Instability of station	Checkbox	Check this box if instability of station is an additional contributing factor to disability in the second instance.
Second Instance Other (Additional Factors)	Checkbox	Check this box if there are other additional contributing factors to disability not listed, and provide a description in the accompanying text field for the second instance.
Second Instance Other Contributing Factor	Text	Enter a description for the 'Other' additional contributing factor to disability for the second instance.
Second Instance Additional Factors Description	Text	Provide a detailed description of additional contributing factors to disability for the second instance.
Additional Loss of Function Question 1
Question 1 Yes	Radiobutton	Check this box if there is additional loss of function or range of motion after three repetitions as per Question 1.
Question 1 Plantar Flexion Endpoint	Number	Enter the plantar flexion endpoint.
Question 1 Dorsiflexion Endpoint	Number	Enter the dorsiflexion endpoint.
Additional Loss of Function Question 2
Additional Loss of Function Question 2 Yes	Radiobutton	Check this box if there is additional loss of function or range of motion after three repetitions.
Question 2 Plantar Flexion Endpoint	Number	Provide the plantar flexion endpoint in degrees.
Question 2 Dorsiflexion Endpoint	Number	Provide the dorsiflexion endpoint in degrees.
Ankle Flare-ups
Yes	Radiobutton	Check this box if the Veteran reports flare-ups of the ankle.
Ankle Flare-ups Description	Text	Document the Veteran's description of the ankle flare-ups, including the frequency, duration, characteristics, precipitating and alleviating factors, severity, and/or extent of functional impairment experienced during a flare-up of symptoms.
Ankle Joint Replacement Diagnosis
Ankle Joint Replacement Diagnosis	Checkbox	Check this box if the diagnosis is ankle joint replacement.
RG_AnkleJoint	RadioButton
Ankle Joint Replacement ICD Code	Text	Enter the ICD code for the An Ankle joint replacement diagnosis.
Ankle Joint Replacement Date of Diagnosis Right Ankle	Date	Provide the date of diagnosis for the right ankle joint replacement.
Ankle Joint Replacement Date of Diagnosis Left Ankle	Date	Provide the date of diagnosis for the left ankle joint replacement.
Ankylosis of Ankle Diagnosis
Ankylosis of ankle, subtalar or tarsal joint	Checkbox	Check this box if the diagnosis is ankylosis of the ankle, subtalar, or tarsal joint.
RG_Ankylosis	RadioButton
Ankylosis of Ankle Diagnosis ICD Code	Text	Please provide the ICD code for the ankylosis of the ankle, subtalar, or tarsal joint diagnosis.
Ankylosis of Ankle Diagnosis Right Date of Diagnosis	Date	Please enter the date of diagnosis for the right ankylosis of the ankle, subtalar, or tarsal joint.
Ankylosis of Ankle Diagnosis Left Date of Diagnosis	Date	Please enter the date of diagnosis for the left ankylosis of the ankle, subtalar, or tarsal joint.
Assistive Device - Brace(s)
Brace(s)	Checkbox	Check this box if the veteran uses brace(s) as an assistive device.
Brace(s) - Occasional Use	Radiobutton	Check this box if the veteran uses brace(s) occasionally.
Assistive Device - Cane(s)
Cane(s)	Checkbox	Check this box if the Veteran uses one or more canes as an assistive device.
Cane(s) - Occasional frequency of use	Radiobutton	Check this box if the Veteran uses cane(s) occasionally.
Assistive Device - Crutch(es)
Crutch(es)	Checkbox	Check this box if crutches are an assistive device used.
Crutch(es) Frequency of use: Occasional	Radiobutton	Check this box if crutches are used occasionally.
Assistive Device - Other
Other Assistive Device	Checkbox	Check this box if the veteran uses an assistive device other than those listed (Wheelchair, Brace(s), Crutch(es), Cane(s), Walker).
Assistive Device Other Type	Text	Specify the type of assistive device used if it is not listed in the common options.
Other Device - Occasional Frequency of Use	Radiobutton	Check this box if the veteran uses the specified 'Other' assistive device occasionally.
Assistive Device - Walker
Walker	Checkbox	Check this box if the Veteran uses a walker as an assistive device.
Walker - Occasional	Radiobutton	Check this box if the Veteran uses a walker occasionally.
Assistive Device - Wheelchair
Wheelchair	Checkbox	Check this box if the veteran uses a wheelchair as an assistive device.
Occasional	Radiobutton	Check this box if the veteran uses the wheelchair occasionally.
Assistive Device Specification
Assistive Device Specification	Text	Specify the condition, indicate the side, and identify the assistive device used for each condition.
Avascular Necrosis Diagnosis
Avascular Necrosis, Talus Diagnosis	Checkbox	Check this box if the diagnosis is Avascular necrosis affecting the talus.
Avascular Necrosis, Talus - Side Affected: Right	Radiobutton	Check this box if the Avascular necrosis, talus diagnosis affects the right side.
Avascular Necrosis Talus ICD Code	Text	Enter the International Classification of Diseases (ICD) code for Avascular necrosis, talus.
Avascular Necrosis Talus Right Side Diagnosis Date	Date	Enter the date of diagnosis for Avascular necrosis, talus affecting the right side.
Avascular Necrosis Talus Left Side Diagnosis Date	Date	Enter the date of diagnosis for Avascular necrosis, talus affecting the left side.
Benign Bone Neoplasm Diagnosis
Benign Bone Neoplasm Diagnosis	Checkbox	Check this box if the diagnosis is benign bone neoplasm.
Benign Bone Neoplasm Diagnosis - Right Side Affected	Radiobutton	Check this box if the benign bone neoplasm affects the right side.
Benign Bone Neoplasm ICD Code	Text	Enter the International Classification of Diseases (ICD) code for the benign bone neoplasm diagnosis.
Benign Bone Neoplasm Right Side Diagnosis Date	Date	Enter the date of diagnosis for the benign bone neoplasm affecting the right side.
Benign Bone Neoplasm Left Side Diagnosis Date	Date	Enter the date of diagnosis for the benign bone neoplasm affecting the left side.
Bursitis Diagnosis
Bursitis	Checkbox	Check this box if the patient has been diagnosed with Bursitis.
Bursitis - Right Side Affected	Radiobutton	Check this box if the Bursitis diagnosis affects the right side.
Bursitis: ICD code	Text
Bursitis Date of diagnosis: Right	Text
Bursitis Date of diagnosis: Left	Text
Claimed Conditions
Claimed Conditions 1	Text	Provide the claimed condition(s) that pertain to this questionnaire.
Degenerative Arthritis Diagnosis
Degenerative arthritis, other than post-traumatic	Checkbox	Check this box if the diagnosis is degenerative arthritis, other than post-traumatic.
RG_Degenerative	RadioButton
Degenerative Arthritis ICD Code	Text	Enter the International Classification of Diseases (ICD) code for degenerative arthritis, other than post-traumatic.
Degenerative Arthritis Right Side Diagnosis Date	Date	Enter the date of diagnosis for degenerative arthritis affecting the right side.
Degenerative Arthritis Left Side Diagnosis Date	Date	Enter the date of diagnosis for degenerative arthritis affecting the left side.
Deltoid Ligament Sprain Diagnosis
Deltoid Ligament Sprain (Chronic/Recurrent)	Checkbox	Check this box if the veteran has a current diagnosis of deltoid ligament sprain, which is chronic or recurrent.
Deltoid Ligament Sprain - Side Affected: Right	Radiobutton	Check this box if the deltoid ligament sprain affects the right side.
Deltoid Ligament Sprain ICD Code	Text	Provide the ICD code for the deltoid ligament sprain diagnosis.
Deltoid Ligament Sprain Right Side Date of Diagnosis	Date	Enter the date of diagnosis for the deltoid ligament sprain on the right side.
Deltoid Ligament Sprain Left Side Date of Diagnosis	Date	Enter the date of diagnosis for the deltoid ligament sprain on the left side.
Diagnostic Imaging and Arthritis Documentation
12A. Diagnostic Imaging Studies Performed	Radiobutton	Check this box if clinically relevant diagnostic imaging studies or other diagnostic procedures have been performed or reviewed in conjunction with this examination.
12B. Degenerative/Post-Traumatic Arthritis Documented	Radiobutton	Check this box if degenerative or post-traumatic arthritis is documented, provided the previous question (12A) was answered 'Yes'.
12B. Arthritis Side: Right	Radiobutton	Check this box if the documented degenerative or post-traumatic arthritis affects the right side.
12C Diagnostic Test Summary	Text	Enter the type of diagnostic test or procedure performed, its date, and a brief summary of the results.
Evidence for Repeated Use Estimate 1
Evidence for Repeated Use Estimate 1 Discussion	Text	Please cite and discuss evidence that is specific to the case and based on all procurable evidence.
Evidence for Repeated Use Estimate 2
Repeated Use Estimate 2 Evidence	Text	Provide specific evidence for the Repeated Use Estimate 2, ensuring it is specific to the case and based on all procurable evidence.
Evidence of Pain
RG_3A_YN_RIGHT_EVIDENCE_PAIN	RadioButton
Is there evidence of pain? If yes, check all that apply. Right: Weight-bearing	CheckBox
Is there evidence of pain? If yes, check all that apply. Right: Nonweight-bearing	CheckBox
Is there evidence of pain? If yes, check all that apply. Right: Active motion	CheckBox
Is there evidence of pain? If yes, check all that apply. Right: Passive motion	CheckBox
Is there evidence of pain? If yes, check all that apply. Right: On rest/non-movement	CheckBox
Is there evidence of pain? If yes, check all that apply. Right: Causes functional loss (if checked describe in the comments box below)	CheckBox
Is there evidence of pain? If yes, check all that apply. Right: Does not result in/cause functional loss	CheckBox
Evidence of Pain Comments	Text	Provide any additional comments or details regarding the evidence of pain.
Evidence Review
No records were reviewed	Radiobutton	Check this box if no records were reviewed for the veteran's condition.
Evidence Reviewed Description	Text	Provide details about the evidence reviewed, such as service treatment records, VA treatment records, private treatment records, and their date ranges.
Examiner's Certification and Signature
Examiner's Signature	Text	Enter the examiner's signature.
Examiner's Printed Name and Title	Text	Enter the examiner's printed name and professional title, such as MD, DO, DDS, DMD, Ph.D, Psy.D, NP, or PA-C.
Examiner's Area of Practice/Specialty	Text	Enter the examiner's area of practice or specialty, for example, Cardiology, Orthopedics, Psychology/Psychiatry, or General Practice.
Date Signed	Date	Enter the date the certification was signed.
Examiner's Phone/Fax Numbers	Text	Enter the examiner's phone and/or fax numbers.
National Provider Identifier (NPI)	Text	Enter the examiner's National Provider Identifier (NPI) number.
Medical License Number and State	Text	Enter the examiner's medical license number and the state where it was issued.
Examiner's Address	Text	Enter the examiner's complete mailing address.
Factors for Additional Functional Loss 1
Functional Loss 1: Pain	Checkbox	Check this box if pain is a factor causing the functional loss after three repetitions.
Functional Loss 1: Fatigability	Checkbox	Check this box if fatigability is a factor causing the functional loss after three repetitions.
Functional Loss 1: Weakness	Checkbox	Check this box if weakness is a factor causing the functional loss after three repetitions.
Functional Loss 1: Lack of Endurance	Checkbox	Check this box if lack of endurance is a factor causing the functional loss after three repetitions.
Functional Loss 1: Incoordination	Checkbox	Check this box if incoordination is a factor causing the functional loss after three repetitions.
Functional Loss 1: Other	Checkbox	Check this box if another factor, not listed, is causing the functional loss after three repetitions.
Functional Loss Factor 1 Other	Text	Provide details for the other factor causing additional functional loss.
Functional Loss 1: N/A	Checkbox	Check this box if none of the listed factors or other factors are causing the functional loss after three repetitions.
Factors for Additional Functional Loss 2
Pain 2	Checkbox	Check this box if pain is a factor causing the additional functional loss.
Fatigability 2	Checkbox	Check this box if fatigability is a factor causing the additional functional loss.
Weakness 2	Checkbox	Check this box if weakness is a factor causing the additional functional loss.
Lack of Endurance 2	Checkbox	Check this box if lack of endurance is a factor causing the additional functional loss.
Incoordination 2	Checkbox	Check this box if incoordination is a factor causing the additional functional loss.
Other Factor 2	Checkbox	Check this box if an unlisted factor is contributing to the additional functional loss and should be specified in the adjacent text field.
Other Functional Loss Factor 2	Text	Enter any additional factor not listed that contributes to this functional loss for the second set of factors.
Not Applicable 2	Checkbox	Check this box if none of the provided factors are applicable to the additional functional loss.
Factors for Flare-up Functional Loss 1
Flare-up 1 Pain	Checkbox	Check this box if pain is a factor causing functional loss during a flare-up.
Flare-up 1 Fatigability	Checkbox	Check this box if fatigability is a factor causing functional loss during a flare-up.
Flare-up 1 Weakness	Checkbox	Check this box if weakness is a factor causing functional loss during a flare-up.
Flare-up 1 Lack of endurance	Checkbox	Check this box if lack of endurance is a factor causing functional loss during a flare-up.
Flare-up 1 Incoordination	Checkbox	Check this box if incoordination is a factor causing functional loss during a flare-up.
Flare-up 1 Other Factor	Checkbox	Check this box if another factor, not listed, causes functional loss during a flare-up, and specify it in the adjacent text field.
Flare-up Functional Loss 1 Other Factor	Text	Provide details for the 'Other' factor causing functional loss due to flare-ups.
Flare-up 1 N/A	Checkbox	Check this box if none of the listed factors cause functional loss during a flare-up.
Factors for Flare-up Functional Loss 2
Flare-up Functional Loss 2 Pain	Checkbox	Check this box if pain is a factor causing functional loss during flare-ups in this second assessment.
Flare-up Functional Loss 2 Fatigability	Checkbox	Check this box if fatigability is a factor causing functional loss during flare-ups in this second assessment.
Flare-up Functional Loss 2 Weakness	Checkbox	Check this box if weakness is a factor causing functional loss during flare-ups in this second assessment.
Flare-up Functional Loss 2 Lack of endurance	Checkbox	Check this box if lack of endurance is a factor causing functional loss during flare-ups in this second assessment.
Flare-up Functional Loss 2 Incoordination	Checkbox	Check this box if incoordination is a factor causing functional loss during flare-ups in this second assessment.
Flare-up Functional Loss 2 Other	Checkbox	Check this box if other factors not listed cause functional loss during flare-ups in this second assessment.
Flare-up Functional Loss 2 Other Factor	Text	Enter any other factor that causes functional loss during flare-ups.
Flare-up Functional Loss 2 N/A	Checkbox	Check this box if no factors cause functional loss during flare-ups in this second assessment.
Factors for Functional Loss from Repeated Use 1
Functional Loss Factor 1 - Pain	Checkbox	Check this box if pain is a factor causing functional loss from repeated use.
Functional Loss Factor 1 - Fatigability	Checkbox	Check this box if fatigability is a factor causing functional loss from repeated use.
Functional Loss Factor 1 - Weakness	Checkbox	Check this box if weakness is a factor causing functional loss from repeated use.
Functional Loss Factor 1 - Lack of Endurance	Checkbox	Check this box if lack of endurance is a factor causing functional loss from repeated use.
Functional Loss Factor 1 - Incoordination	Checkbox	Check this box if incoordination is a factor causing functional loss from repeated use.
Functional Loss Factor 1 - Other	Checkbox	Check this box if there are other factors, not listed, causing functional loss from repeated use.
Repeated Use Other Factor 1	Text	Provide details for any other factor, not listed, that causes functional loss due to repeated use over time.
Functional Loss Factor 1 - N/A	Checkbox	Check this box if none of the listed or other factors cause functional loss from repeated use.
Factors for Functional Loss from Repeated Use 2
Pain 2	Checkbox	Check this box if procured evidence indicates pain significantly limits functional ability with repeated use over time.
Fatigability 2	Checkbox	Check this box if procured evidence indicates fatigability significantly limits functional ability with repeated use over time.
Weakness 2	Checkbox	Check this box if procured evidence indicates weakness significantly limits functional ability with repeated use over time.
Lack of endurance 2	Checkbox	Check this box if procured evidence indicates lack of endurance significantly limits functional ability with repeated use over time.
Incoordination 2	Checkbox	Check this box if procured evidence indicates incoordination significantly limits functional ability with repeated use over time.
Other 2	Checkbox	Check this box if procured evidence indicates another factor, not listed, significantly limits functional ability with repeated use over time.
Other Factor 2	Text	Enter any other factor contributing to functional loss from repeated use that is not listed.
N/A 2	Checkbox	Check this box if procured evidence does not indicate any of these factors significantly limit functional ability with repeated use over time.
First "Shin Splints" Details
First Shin Splints (Medial Tibial Stress Syndrome - MTSS)	Checkbox	Check this box if the Veteran has or has had Shin Splints (medial tibial stress syndrome - MTSS).
First Shin Splints - No Treatment Received	Radiobutton	Check this box if no treatment has been received for the Shin Splints condition.
First Achilles Tendonitis Details
First Achilles Tendonitis or Achilles Tendon Rupture	Checkbox	Check this box if the veteran has or has ever had Achilles tendonitis or an Achilles tendon rupture.
First Achilles Tendonitis Symptoms	Text	Provide a description of the current symptoms related to the first instance of Achilles tendonitis or Achilles tendon rupture.
First Ankle Condition History
First Ankle Condition History Yes	Radiobutton	Check this box if the Veteran now has or has ever had shin splints, stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus or talus, or a talectomy (astragalectomy).
First Ankle Instability
First Ankle Instability Suspected - Yes	Radiobutton	Check this box if ankle instability is suspected when the Talar Tilt Test cannot be performed.
First Ankle Instability Description	Text	Provide a description if first ankle instability is suspected.
First Malunion of Calcaneus Details
First Malunion of Calcaneus (os calcis) or Talus (astragalus)	Checkbox	Check this box if the veteran has a malunion of the calcaneus (os calcis) or talus (astragalus).
First Malunion of Calcaneus: Moderate Deformity	Radiobutton	Check this box if the malunion of the calcaneus or talus presents with a moderate deformity.
First Range of Motion During Flare-ups and Evidence
First Plantar Flexion Endpoint	Number	Enter the estimated plantar flexion endpoint in degrees.
First Dorsiflexion Endpoint	Number	Enter the estimated dorsiflexion endpoint in degrees.
First Range of Motion Evidence	Text	Provide a detailed discussion and citation of the evidence used to estimate the range of motion for this joint during flare-ups, specific to the case and based on all procurable evidence.
First Stress Fracture Details
First Stress fracture of the lower leg	Checkbox	Check this box if the veteran has a stress fracture of the lower leg.
First Stress Fracture Lower Leg Symptoms	Text	Enter a description of the veteran's current symptoms related to the first stress fracture of the lower leg.
First Talar Tilt Test
First Talar Tilt Test Yes	Radiobutton	Check this box if the First Talar Tilt Test shows asymmetric or excessive motion.
First Talar Tilt Test Explanation	Text	Provide a detailed explanation if the first Talar Tilt Test was unable to be performed.
Flare-up Questions 1
Flare-up 1: Examination during flare-up	Radiobutton	Check this box if the examination is currently being conducted during a flare-up.
Flare-up 1: Evidence suggests limits during flare-up	Radiobutton	Check this box if procured evidence suggests pain, fatigability, weakness, lack of endurance, or incoordination significantly limits functional ability during flare-ups.
Flare-up Questions 2
Flare-up 2 Yes - Examination during flare-up	Radiobutton	Check this box if the examination for Flare-up 2 is being conducted while the Veteran is experiencing a flare-up.
Flare-up 2 Yes - Evidence of functional limitation due to flare-ups	Radiobutton	Check this box if procured evidence suggests that pain, fatigability, weakness, lack of endurance, or incoordination significantly limits functional ability during flare-ups for Flare-up 2.
Functional Impact
13A Yes	Radiobutton	Check this box if the diagnosed conditions impact the Veteran's ability to perform any type of occupational task.
Functional Impact Description	Text	Describe the functional impact of each condition, providing one or more examples of how it affects occupational tasks.
Functional Loss Explanation 1
Functional Loss Explanation 1: Yes	Radiobutton	Check this box if, for the first functional loss explanation, an abnormal range of motion contributes to a functional loss.
Functional Loss Explanation 1	Text	Provide an explanation if the range of motion contributes to a functional loss.
Functional Loss Explanation 2
2 Yes	Radiobutton	Check this box if, for the second functional loss explanation, the abnormal range of motion itself contributes to a functional loss.
Functional Loss Explanation 2	Text	Provide an explanation if the abnormal range of motion contributes to a functional loss.
Gonorrheal Arthritis Diagnosis
Arthritis, gonorrheal	Checkbox	Check this box if the diagnosis is gonorrheal arthritis.
Gonorrheal Arthritis - Right Side	Radiobutton	Check this box if the gonorrheal arthritis affects the right side.
Gonorrheal Arthritis ICD Code	Text	Enter the ICD code for the gonorrheal arthritis diagnosis.
Right Gonorrheal Arthritis Diagnosis Date	Date	Enter the date of diagnosis for gonorrheal arthritis affecting the right side.
Left Gonorrheal Arthritis Diagnosis Date	Date	Enter the date of diagnosis for gonorrheal arthritis affecting the left side.
Gout Diagnosis
Gout	Checkbox	Check this box if the diagnosis is Gout.
RG_Gout	RadioButton
Gout ICD Code	Text	Enter the International Classification of Diseases (ICD) code for the gout diagnosis.
Gout Right Side Diagnosis Date	Date	Provide the date of diagnosis for gout affecting the right side.
Gout Left Side Diagnosis Date	Date	Provide the date of diagnosis for gout affecting the left side.
Heterotopic Ossification
Heterotopic Ossification	Checkbox	Check this box if the patient has heterotopic ossification.
Heterotopic Ossification Right	Radiobutton	Check this box if heterotopic ossification affects the right side.
Heterotopic Ossification Details	Text	Enter any additional details or values related to the heterotopic ossification.
Heterotopic Ossification Right Side	Text	Enter details or values specific to heterotopic ossification on the right side.
Heterotopic Ossification Left Side	Text	Enter details or values specific to heterotopic ossification on the left side.
Impingement Diagnosis
Impingement (anterior/posterior (or trigonum syndrome)/anterolateral)	Checkbox	Check this box if the diagnosis is Impingement (anterior/posterior (or trigonum syndrome)/anterolateral).
RG_Impingement	RadioButton
Impingement ICD Code	Text	Enter the International Classification of Diseases code for the impingement diagnosis.
Impingement Date of Diagnosis Right	Date	Enter the date of diagnosis for impingement affecting the right side.
Impingement Date of Diagnosis Left	Date	Enter the date of diagnosis for impingement affecting the left side.
Lateral Collateral Ligament Sprain Diagnosis
Lateral collateral ligament sprain (chronic/recurrent)	Checkbox	Check this box if the veteran has a diagnosis of lateral collateral ligament sprain (chronic/recurrent).
Side affected: Right	Radiobutton	Check this box if the lateral collateral ligament sprain affects the right side.
Lateral Collateral Ligament Sprain ICD Code	Text	Enter the ICD code for the lateral collateral ligament sprain diagnosis.
Lateral Collateral Ligament Sprain Right Side Diagnosis Date	Date	Enter the date of diagnosis for the lateral collateral ligament sprain on the right side.
Lateral Collateral Ligament Sprain Left Side Diagnosis Date	Date	Enter the date of diagnosis for the lateral collateral ligament sprain on the left side.
Left Ankle - Arthroscopic Surgery Details
Left Ankle Arthroscopic Surgery Type	Text	Provide the specific type of arthroscopic or other ankle surgery performed on the left ankle.
Left Ankle Arthroscopic Surgery Date	Date	Enter the date when the arthroscopic or other ankle surgery was performed on the left ankle.
Left Ankle - Surgical Procedure Types
Left Ankle - No surgery	Checkbox	Check this box if the veteran has not undergone any surgical procedures related to the left ankle.
Left Ankle - Total ankle joint replacement	Checkbox	Check this box if the veteran has undergone a total ankle joint replacement procedure on the left ankle.
Left Ankle - Arthroscopic or other ankle surgery	Checkbox	Check this box if the veteran has undergone an arthroscopic or any other type of ankle surgery on the left ankle.
Left Ankle - Total Joint Replacement Details
Left Ankle Total Joint Replacement Date of Surgery	Date	Enter the date when the Left Ankle Total Joint Replacement surgery was performed.
Left Ankle Total Joint Replacement Residuals - None	Checkbox	Check this box if there are no residuals from the left ankle total joint replacement.
Left Ankle Total Joint Replacement Residuals - Intermediate degrees of residual weakness, pain or limitation of motion	Checkbox	Check this box if the veteran experiences intermediate degrees of residual weakness, pain, or limitation of motion following the left ankle total joint replacement.
Left Ankle Total Joint Replacement Residuals - Chronic residuals consisting of severe painful motion or weakness	Checkbox	Check this box if the veteran experiences chronic residuals consisting of severe painful motion or weakness following the left ankle total joint replacement.
Left Ankle Total Joint Replacement Residuals - Other	Checkbox	Check this box if there are other residuals from the left ankle total joint replacement not listed, and then provide a specific description.
Left Ankle Total Joint Replacement Other Residuals Description	Text	Provide a detailed description of any other residuals from the Left Ankle Total Joint Replacement surgery not covered by the listed options.
Left Ankle Ankylosis Angle
Left N/A no ankle ankylosis of joint	Checkbox	Check this box if there is no ankylosis of the left ankle joint, indicating that the angle of ankylosis is not applicable.
Left Ankle Ankylosis Plantar Flexion Angle	Number	Enter the angle of left ankle ankylosis for plantar flexion in degrees.
Left Ankle Ankylosis Dorsiflexion Angle	Number	Enter the angle of left ankle ankylosis for dorsiflexion in degrees.
Left Ankle Ankylosis Severity
Left Ankle Ankylosis Yes	Radiobutton	Check this box if there is ankylosis of the left ankle.
Left Ankle Plantar Flexion Less Than 30 Degrees	Checkbox	Check this box if the left ankle ankylosis is in plantar flexion, less than 30 degrees.
Left Ankle Plantar Flexion Between 30 and 40 Degrees	Checkbox	Check this box if the left ankle ankylosis is in plantar flexion, between 30 degrees and 40 degrees.
Left Ankle Plantar Flexion More Than 40 Degrees	Checkbox	Check this box if the left ankle ankylosis is in plantar flexion, at more than 40 degrees.
Left Ankle Dorsiflexion Between 0 and 10 Degrees	Checkbox	Check this box if the left ankle ankylosis is in dorsiflexion, between 0 degrees and 10 degrees.
Left Ankle Dorsiflexion More Than 10 Degrees	Checkbox	Check this box if the left ankle ankylosis is in dorsiflexion, at more than 10 degrees.
Left Ankle With Abduction Deformity	Checkbox	Check this box if the left ankle ankylosis presents with an abduction deformity.
Left Ankle With Adduction Deformity	Checkbox	Check this box if the left ankle ankylosis presents with an adduction deformity.
Left Ankle With Inversion Deformity	Checkbox	Check this box if the left ankle ankylosis presents with an inversion deformity.
Left Ankle With Eversion Deformity	Checkbox	Check this box if the left ankle ankylosis presents with an eversion deformity.
Left Ankle Initial ROM Measurements
All Normal	Radiobutton	Check this box if the initial range of motion measurements for the left ankle are all normal.
Left Ankle Initial ROM - Unable to Test/Not Indicated Explanation	Text	Provide an explanation if the left ankle initial Range of Motion (ROM) measurements were unable to be tested or not indicated.
Left Ankle Initial ROM - Normal for Veteran Explanation	Text	Describe why the left ankle Range of Motion (ROM) is considered normal for the Veteran, even if it is outside the general normal range, due to factors such as age, body habitus, or neurologic disease.
Left Anterior Drawer Test
Left Anterior Drawer Test Yes	Radiobutton	Check this box if, during the Left Anterior Drawer Test, there is an absence of a firm end point with asymmetric or excessive motion.
Left Condition - Response to Treatment and Symptoms
Left Condition - Responsive to Surgery/Treatment	Radiobutton	Check this box if the veteran's left condition was responsive to surgery and/or other treatment.
Left Condition - Affects ROM of Knee (Yes)	Radiobutton	Check this box if the veteran's left condition affects the range of motion (ROM) of their knee.
Left Condition Symptoms Description	Text	Provide a detailed description of the current symptoms for the left condition.
Left Condition - Talectomy
Left Talectomy	Checkbox	Check this box if the Veteran's left condition involves a talectomy.
Left Talectomy Current Symptoms Description	Text	Provide a detailed description of the veteran's current symptoms related to the left talectomy.
Left Lower Extremity Muscle Atrophy
Left Lower Extremity	Checkbox	Check this box if the muscle atrophy is located in the left lower extremity.
Left Lower Extremity Measurement Location	Text	Specify the location on the left lower extremity where the muscle atrophy measurement was taken, such as '1cm above or below ankle'.
Left Lower Extremity Normal Side Circumference	Number	Enter the circumference of the more normal side of the left lower extremity in centimeters.
Left Lower Extremity Atrophied Side Circumference	Number	Enter the circumference of the atrophied side of the left lower extremity in centimeters.
Left Subastragalar or Tarsal Joint Ankylosis
Left Subastragalar or Tarsal Joint Ankylosis: Yes	Radiobutton	Check this box if there is ankylosis of the subastragalar or tarsal joint on the left side.
Left Subastragalar or Tarsal Joint Ankylosis: In good weight-bearing position	Radiobutton	Check this box if the ankylosis of the left subastragalar or tarsal joint is in a good weight-bearing position.
Limitation of Motion Description
Plantar Flexion Degree Endpoint	Text	Enter the plantar flexion degree endpoint if it is different from a previously stated value.
Dorsiflexion Degree Endpoint	Text	Enter the dorsiflexion degree endpoint if it is different from a previously stated value.
Limitation of Motion Description	Text	Provide a detailed description of how the limitation of motion is specifically attributable to the identified factors such as pain, weakness, fatigability, or incoordination.
Limitation of Motion Description 1
Limitation 1: Plantar Flexion Degree Endpoint	Number	Provide the plantar flexion degree endpoint if it is different from the active range of motion value.
Limitation 1: Dorsiflexion Degree Endpoint	Number	Provide the dorsiflexion degree endpoint if it is different from the active range of motion value.
Limitation 1: Attributable Factors Description	Text	Describe the degree(s) and factors to which any limitation of motion is specifically attributable.
Limitation of Motion Description 2
2nd Plantar Flexion Degree Endpoint	Number	Enter the plantar flexion degree endpoint if it is different from the active range of motion value.
2nd Dorsiflexion Degree Endpoint	Number	Enter the dorsiflexion degree endpoint if it is different from the active range of motion value.
2nd Limitation of Motion Description	Text	Provide details if any limitation of motion is specifically attributable to pain, weakness, fatigability, incoordination, or other factors, noting the degree(s) and describing the attribution.
Malignant Bone Neoplasm Diagnosis
Malignant Bone Neoplasm, Primary or Secondary	Checkbox	Check this box if the diagnosis is malignant bone neoplasm, either primary or secondary.
RG_BonesMalignant	RadioButton
Malignant Bone Neoplasm ICD Code	Text	Enter the International Classification of Diseases (ICD) code for the malignant bone neoplasm.
Malignant Bone Neoplasm Right Side Diagnosis Date	Date	Enter the date of diagnosis for the malignant bone neoplasm on the right side.
Malignant Bone Neoplasm Left Side Diagnosis Date	Date	Enter the date of diagnosis for the malignant bone neoplasm on the left side.
Muscle Atrophy Questions (First Instance)
1st Instance: Muscle Atrophy Present	Radiobutton	Check this box if the Veteran has muscle atrophy.
1st Instance: Atrophy Due to Claimed Condition	Radiobutton	Check this box if the first instance of muscle atrophy is due to the claimed condition in the diagnosis section.
First Muscle Atrophy Rationale	Text	Provide a detailed rationale if the muscle atrophy is not due to the claimed condition in the diagnosis section.
Muscle Atrophy Questions (Second Instance)
Second Instance 4A Muscle Atrophy Yes	Radiobutton	Check this box if the Veteran has muscle atrophy.
Second Instance 4B Atrophy Due to Claimed Condition Yes	Radiobutton	Check this box if the muscle atrophy identified in 4A is due to the claimed condition in the diagnosis section.
Second Instance 4B Rationale	Text	Explain why, for the second instance, the muscle atrophy is not due to the claimed condition in the diagnosis section.
Myositis
Myositis	Checkbox	Check this box if Myositis is present.
Myositis Right	Radiobutton	Check this box if Myositis affects the right side.
Myositis General Comments	Text	Enter any general comments or additional information regarding Myositis.
Myositis Right Side	Text	Provide specific details about Myositis affecting the right side.
Myositis Left Side	Text	Provide specific details about Myositis affecting the left side.
No Diagnosis Checkbox
1B. No Current Diagnosis	Checkbox	Check this box if the Veteran does not have a current diagnosis associated with any claimed condition(s) listed above.
Objective Evidence of Crepitus
Objective Evidence of Crepitus Yes	Radiobutton	Check this box if there is objective evidence of crepitus.
Objective Evidence of Localized Tenderness or Pain
Objective Evidence of Localized Tenderness or Pain - Yes	Radiobutton	Check this box if there is objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue.
Explanation of Localized Tenderness or Pain	Text	Provide a detailed explanation, including the location, severity, and relationship to the condition(s), regarding objective evidence of localized tenderness or pain.
Observed Repetitive Use ROM
3B. Observed Repetitive Use ROM: Yes	Radiobutton	Check this box if the Veteran is able to perform repetitive-use testing with at least three repetitions.
3B. Observed Repetitive Use ROM Explanation	Text	Provide an explanation if the Veteran is unable to perform repetitive-use testing with at least three repetitions.
Osteitis Deformans Diagnosis
Osteitis deformans	Checkbox	Check this box if the diagnosis is Osteitis deformans.
Osteitis deformans - Right Side Affected	Radiobutton	Check this box if the Osteitis deformans affects the right side.
Osteitis Deformans ICD Code	Text	Provide the ICD code for the Osteitis Deformans diagnosis.
Osteitis Deformans Right Date of Diagnosis	Date	Enter the date of diagnosis for Osteitis Deformans affecting the right side.
Osteitis Deformans Left Date of Diagnosis	Date	Enter the date of diagnosis for Osteitis Deformans affecting the left side.
Osteochondritis Dissecans Diagnosis
Osteochondritis Dissecans (includes osteochondral fracture)	Checkbox	Check this box if the diagnosis is Osteochondritis Dissecans, which includes osteochondral fracture.
RG_OsteochondritisDissecans	RadioButton
Osteochondritis Dissecans ICD Code	Text	Enter the ICD (International Classification of Diseases) code for the osteochondritis dissecans diagnosis.
Osteochondritis Dissecans Diagnosis Date (Right)	Date	Provide the date of diagnosis for osteochondritis dissecans affecting the right side.
Osteochondritis Dissecans Diagnosis Date (Left)	Date	Provide the date of diagnosis for osteochondritis dissecans affecting the left side.
Osteomalacia Diagnosis
1B. Select diagnoses associated with the claimed condition(s) (check all that apply):: Osteomalacia, residuals of	CheckBox
Osteomalacia Residuals - Right	Radiobutton	Check this box if the osteomalacia residuals affect the right side.
Osteomalacia ICD Code	Text	Enter the International Classification of Diseases (ICD) code for osteomalacia.
Osteomalacia Diagnosis Date (Right)	Date	Enter the date of diagnosis for osteomalacia affecting the right side.
Osteomalacia Diagnosis Date (Left)	Date	Enter the date of diagnosis for osteomalacia affecting the left side.
Osteoporosis Diagnosis
Osteoporosis, residuals of	Checkbox	Check this box if the diagnosis is Osteoporosis, residuals of.
Osteoporosis, residuals of - Side affected: Right	Radiobutton	Check this box if Osteoporosis, residuals of affects the right side.
Osteoporosis ICD Code	Text	Enter the International Classification of Diseases (ICD) code for the osteoporosis diagnosis.
Osteoporosis Right Side Diagnosis Date	Date	Enter the date of diagnosis for osteoporosis affecting the right side.
Osteoporosis Left Side Diagnosis Date	Date	Enter the date of diagnosis for osteoporosis affecting the left side.
Other Arthropathy Diagnosis
Other Specified Forms of Arthropathy (Excluding Gout)	Checkbox	Check this box if the diagnosis is an other specified form of arthropathy, excluding gout.
Specific Arthropathy Diagnosis	Text	Enter the specific form of arthropathy diagnosis, excluding gout.
Other Arthropathy Diagnosis Side Affected: Right	Radiobutton	Check this box if the other specified form of arthropathy (excluding gout) affects the right side.
ICD Code	Text	Enter the ICD code for this other specified form of arthropathy diagnosis.
Right Side Diagnosis Date	Date	Enter the date when the arthropathy diagnosis was made for the right side.
Left Side Diagnosis Date	Date	Enter the date when the arthropathy diagnosis was made for the left side.
Other Diagnosis 1
Other Diagnosis 1 Name	Text	Enter the name or description for the first other diagnosis.
Other Diagnosis 1 Right	Radiobutton	Check this box if the first other diagnosis affects the right side.
Other Diagnosis 1 General Details	Text	Provide any general details or additional information for the first other diagnosis.
Other Diagnosis 1 Right Details	Text	Provide specific details for the first other diagnosis pertaining to the right side.
Other Diagnosis 1 Left Details	Text	Provide specific details for the first other diagnosis pertaining to the left side.
Other Diagnosis 2
Other Diagnosis 2 Description	Text	Enter the detailed description for the second other diagnosis.
Other Diagnosis 2 Right	Radiobutton	Check this box if the second other diagnosis affects the right side.
Other Diagnosis 2 Detail	Text	Provide any additional detail for the second other diagnosis.
Other Diagnosis 2 Right Detail	Text	Provide details specific to the right side for the second other diagnosis.
Other Diagnosis 2 Left Detail	Text	Provide details specific to the left side for the second other diagnosis.
Other Diagnosis 3
Other Diagnosis 3 Name	Text	Please enter the name of the third other diagnosis.
Other Diagnosis 3 Right	Radiobutton	Check this box if the third other diagnosis affects the right side.
Other Diagnosis 3 Additional Detail	Text	Please provide any additional detail for the third other diagnosis.
Other Diagnosis 3 Right Side Details	Text	Please provide details pertaining to the right side for the third other diagnosis.
Other Diagnosis 3 Left Side Details	Text	Please provide details pertaining to the left side for the third other diagnosis.
Other Diagnosis Checkbox
Other Diagnosis #1	Checkbox	Check this box if you need to specify a first diagnosis that is not listed in the options above.
Other Diagnostic Test Findings
Yes	Radiobutton	Check this box if there are other clinically relevant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es) that were reviewed in conjunction with this examination.
Other Diagnostic Test Findings Summary	Text	Provide the type of test or procedure, date, and a brief summary of the results for any other clinically relevant diagnostic test findings or results.
Other Pertinent Physical Findings
Yes	Radiobutton	Check this box if the Veteran has any other pertinent physical findings, complications, conditions, signs, or symptoms related to any conditions listed in the diagnosis section.
Other Pertinent Physical Findings Summary	Text	Provide a brief summary of any other pertinent physical findings, complications, conditions, signs, or symptoms.
Passive Range of Motion 1
Passive ROM 1 Plantar Flexion Endpoint	Number	Enter the measured passive range of motion for plantar flexion in degrees.
Passive ROM 1 - Plantar Flexion Endpoint Same as Active ROM	Checkbox	Check this box if the passive range of motion for the plantar flexion endpoint is the same as the active range of motion.
Passive ROM 1 Dorsiflexion Endpoint	Number	Enter the measured passive range of motion for dorsiflexion in degrees.
Passive ROM 1 - Dorsiflexion Endpoint Same as Active ROM	Checkbox	Check this box if the passive range of motion for the dorsiflexion endpoint is the same as the active range of motion.
Passive ROM 1 - Pain During Plantar Flexion	Checkbox	Check this box if pain was noted during plantar flexion during the passive range of motion examination.
Passive ROM 1 - Pain During Dorsiflexion	Checkbox	Check this box if pain was noted during dorsiflexion during the passive range of motion examination.
Passive Range of Motion 2
2nd Passive Range of Motion Plantar Flexion Endpoint	Number	Enter the second passive range of motion plantar flexion endpoint in degrees.
Passive ROM 2 - Plantar Flexion - Same as Active ROM	Checkbox	Check this box if the passive range of motion for plantar flexion in the second assessment is the same as the active range of motion for plantar flexion.
2nd Passive Range of Motion Dorsiflexion Endpoint	Number	Enter the second passive range of motion dorsiflexion endpoint in degrees.
Passive ROM 2 - Dorsiflexion - Same as Active ROM	Checkbox	Check this box if the passive range of motion for dorsiflexion in the second assessment is the same as the active range of motion for dorsiflexion.
Passive ROM 2 - Pain - Plantar Flexion	Checkbox	Check this box if passive plantar flexion range of motion exhibited pain during the second assessment.
Passive ROM 2 - Pain - Dorsiflexion	Checkbox	Check this box if passive dorsiflexion range of motion exhibited pain during the second assessment.
Patient/Veteran Information
Patient/Veteran Name	Text	Please enter the full name of the patient or veteran.
Patient/Veteran Social Security Number	Text	Please enter the Social Security Number of the patient or veteran.
Date of Examination	Date	Please enter the date when the examination was conducted.
Pneumococcic Arthritis Diagnosis
Pneumococcic Arthritis Diagnosis	Checkbox	Check this box if pneumococcic arthritis is diagnosed as a claimed condition.
Pneumococcic Arthritis - Right Side	Radiobutton	Check this box if the pneumococcic arthritis affects the right side.
Pneumococcic Arthritis ICD Code	Text	Enter the ICD code for pneumococcic arthritis.
Pneumococcic Arthritis Right Diagnosis Date	Date	Provide the diagnosis date for pneumococcic arthritis affecting the right side.
Pneumococcic Arthritis Left Diagnosis Date	Date	Provide the diagnosis date for pneumococcic arthritis affecting the left side.
Post-Traumatic Arthritis Diagnosis
Arthritis, post-traumatic	Checkbox	Check this box if the patient has a post-traumatic arthritis diagnosis.
Post-Traumatic Arthritis Right Side Affected	Radiobutton	Check this box if the post-traumatic arthritis diagnosis affects the right side.
Post-Traumatic Arthritis ICD Code	Text	Enter the International Classification of Diseases (ICD) code for the post-traumatic arthritis diagnosis.
Post-Traumatic Arthritis Date of Right Diagnosis	Date	Enter the date of diagnosis for post-traumatic arthritis affecting the right side.
Post-Traumatic Arthritis Date of Left Diagnosis	Date	Enter the date of diagnosis for post-traumatic arthritis affecting the left side.
Provider and Examination Information
VA Healthcare Provider Yes	Radiobutton	Check this box if you are a VA Healthcare provider.
Veteran Regularly Seen Yes	Radiobutton	Check this box if the Veteran is regularly seen as a patient in your clinic.
Veteran Examined In Person Yes	Radiobutton	Check this box if the Veteran was examined in person.
Examination Conducted Method	Text	Enter how the examination was conducted if it was not done in person.
Questionnaire Requester Information
Veteran/Claimant	Checkbox	Check this box if you are completing the Disability Benefits Questionnaire at the request of the Veteran or Claimant themselves.
Third Party	Checkbox	Check this box if you are completing the Disability Benefits Questionnaire at the request of a third party, such as an organization or individual.
Third Party Requester Name(s)	Text	Enter the name(s) of the organization(s) or individual(s) requesting the questionnaire on behalf of a third party.
Other	Checkbox	Check this box if you are completing the Disability Benefits Questionnaire at the request of someone other than the Veteran/Claimant or a specified third party, and then describe who requested it.
Other Requester Description	Text	Provide a description of the other party requesting the questionnaire.
Range of Motion After Repeated Use 1
Range of Motion After Repeated Use 1 Plantar Flexion Endpoint	Number	Enter the estimated plantar flexion endpoint in degrees for this joint after repeated use over time.
Range of Motion After Repeated Use 1 Dorsiflexion Endpoint	Number	Enter the estimated dorsiflexion endpoint in degrees for this joint after repeated use over time.
Range of Motion After Repeated Use 2
Plantar Flexion Endpoint 2	Number	Enter the estimated plantar flexion endpoint in degrees after repeated use for the second assessment.
Dorsiflexion Endpoint 2	Number	Enter the estimated dorsiflexion endpoint in degrees after repeated use for the second assessment.
Remaining Effective Function of Extremities
11A Yes, diminished functioning	Radiobutton	Check this box if the Veteran's functional impairment in an extremity is so severe that no effective function remains, and an amputation with prosthesis would serve the Veteran equally well.
Right lower extremity	Checkbox	Check this box if the functional impairment described in 11A applies to the Veteran's right lower extremity.
Left lower extremity	Checkbox	Check this box if the functional impairment described in 11A applies to the Veteran's left lower extremity.
11B. Extremity Loss of Function Summary	Text	Provide a brief summary identifying the condition causing loss of function, describing the loss of effective function, and giving specific examples for each checked extremity.
Remarks
14A Remarks	Text	Enter any additional remarks, identifying the section to which each remark pertains when appropriate.
Repeated Use Over Time Questions 1
Question 1: Examined Immediately After Repeated Use - Yes	Radiobutton	Check this box if the Veteran is being examined immediately after repeated use over time.
Question 2: Procured Evidence Suggests Functional Limits - Yes	Radiobutton	Check this box if procured evidence suggests pain, fatigability, weakness, lack of endurance, or incoordination significantly limits functional ability with repeated use over time.
Repeated Use Over Time Questions 2
2. Is Veteran Examined Immediately (Yes)	Radiobutton	Check this box if the Veteran is being examined immediately after repeated use over time.
2. Evidence Suggests Functional Limits (Yes)	Radiobutton	Check this box if procured evidence suggests pain, fatigability, weakness, lack of endurance, or incoordination significantly limits functional ability with repeated use over time.
Residuals of Ankle Surgery Description 1
1. Residuals of arthroscopic or other ankle surgery	Checkbox	Check this box if there are any residuals resulting from arthroscopic or other types of ankle surgery.
Residuals of Ankle Surgery Description 1	Text	Provide a detailed description of the residuals from the arthroscopic or other ankle surgery.
Residuals of Ankle Surgery Description 2
Residuals of arthroscopic or other ankle surgery 2	Checkbox	Check this box if there are residuals from arthroscopic or other ankle surgery.
Ankle Surgery Residuals Description 2	Text	Provide a detailed description of the residuals from arthroscopic or other ankle surgery.
Retrocalcaneal Bursitis Diagnosis
Retrocalcaneal Bursitis	Checkbox	Check this box if the veteran has been diagnosed with retrocalcaneal bursitis.
Retrocalcaneal Bursitis - Right Side Affected	Radiobutton	Check this box if the retrocalcaneal bursitis affects the right side.
Retrocalcaneal Bursitis ICD Code	Text	Provide the ICD code for the retrocalcaneal bursitis diagnosis.
Retrocalcaneal Bursitis Right Date of Diagnosis	Date	Enter the date of diagnosis for retrocalcaneal bursitis affecting the right side.
Retrocalcaneal Bursitis Left Date of Diagnosis	Date	Enter the date of diagnosis for retrocalcaneal bursitis affecting the left side.
Rheumatoid Arthritis Diagnosis
Arthritis, rheumatoid (multi-joints)	Checkbox	Check this box if the veteran has a diagnosis of rheumatoid arthritis affecting multiple joints.
RG_ArthritisRheumatoid	RadioButton
Rheumatoid Arthritis ICD Code	Text	Please provide the ICD (International Classification of Diseases) code for Rheumatoid Arthritis (multi-joints).
Rheumatoid Arthritis Diagnosis Date (Right)	Date	Please enter the date of diagnosis for Rheumatoid Arthritis affecting the right side.
Rheumatoid Arthritis Diagnosis Date (Left)	Date	Please enter the date of diagnosis for Rheumatoid Arthritis affecting the left side.
Right Ankle - Arthroscopic Surgery Details
Right Ankle Arthroscopic Surgery Type	Text	Provide the type of arthroscopic surgery performed on the right ankle.
Right Ankle Arthroscopic Surgery Date	Date	Enter the date the arthroscopic surgery was performed on the right ankle.
Right Ankle - Surgical Procedure Types
No surgery	Checkbox	Check this box if the veteran has not had any surgical procedures related to their right ankle.
Total ankle joint replacement	Checkbox	Check this box if the veteran has undergone a total ankle joint replacement for their right ankle.
Arthroscopic or other ankle surgery	Checkbox	Check this box if the veteran has undergone an arthroscopic procedure or any other type of surgery on their right ankle.
Right Ankle - Total Joint Replacement Details
Surgery Date	Date	Enter the date the right ankle total joint replacement surgery was performed.
Right Ankle Total Joint Replacement Residuals - None	Checkbox	Check this box if there are no residuals from the right ankle total joint replacement.
Right Ankle Total Joint Replacement Residuals - Intermediate Weakness, Pain, or Limitation of Motion	Checkbox	Check this box if the right ankle total joint replacement resulted in intermediate degrees of residual weakness, pain, or limitation of motion.
Right Ankle Total Joint Replacement Residuals - Chronic Severe Painful Motion or Weakness	Checkbox	Check this box if the right ankle total joint replacement resulted in chronic residuals consisting of severe painful motion or weakness.
Right Ankle Total Joint Replacement Residuals - Other	Checkbox	Check this box if there are other residuals from the right ankle total joint replacement not listed, and provide a description.
Other Residuals Description	Text	Provide a description of any other residuals from the right ankle total joint replacement surgery.
Right Ankle Ankylosis Angle
N/A No Right Ankle Ankylosis	Checkbox	Check this box if there is no ankylosis of the right ankle joint.
Right Ankle Plantar Flexion Angle	Number	Enter the angle of plantar flexion for the right ankle ankylosis in degrees.
Right Ankle Dorsiflexion Angle	Number	Enter the angle of dorsiflexion for the right ankle ankylosis in degrees.
Right Ankle Ankylosis Severity
Right Ankle Ankylosis Yes	Radiobutton	Check this box if there is ankylosis present in the right ankle.
Right Ankle Plantar Flexion Less Than 30 Degrees	Checkbox	Check this box if the ankylosis in the right ankle is in plantar flexion, less than 30 degrees.
Right Ankle Plantar Flexion Between 30 and 40 Degrees	Checkbox	Check this box if the ankylosis in the right ankle is in plantar flexion, between 30 degrees and 40 degrees.
Right Ankle Plantar Flexion More Than 40 Degrees	Checkbox	Check this box if the ankylosis in the right ankle is in plantar flexion, more than 40 degrees.
Right Ankle Dorsiflexion Between 0 and 10 Degrees	Checkbox	Check this box if the ankylosis in the right ankle is in dorsiflexion, between 0 degrees and 10 degrees.
Right Ankle Dorsiflexion More Than 10 Degrees	Checkbox	Check this box if the ankylosis in the right ankle is in dorsiflexion, more than 10 degrees.
Right Ankle With Abduction Deformity	Checkbox	Check this box if the ankylosis in the right ankle presents with an abduction deformity.
Right Ankle With Adduction Deformity	Checkbox	Check this box if the ankylosis in the right ankle presents with an adduction deformity.
Right Ankle With Inversion Deformity	Checkbox	Check this box if the ankylosis in the right ankle presents with an inversion deformity.
Right Ankle With Eversion Deformity	Checkbox	Check this box if the ankylosis in the right ankle presents with an eversion deformity.
Right Ankle Initial ROM Measurements
Right Ankle All Normal Initial ROM	Radiobutton	Check this box if the initial range of motion measurements for the right ankle are all normal.
Right Ankle Initial ROM Measurement Explanation	Text	Provide an explanation if the initial range of motion (ROM) measurements for the right ankle were 'Unable to test' or 'Not indicated'.
Right Ankle ROM Normal for Veteran Explanation	Text	Describe if the right ankle's range of motion (ROM) is outside the 'normal' range but is considered normal for the Veteran due to reasons other than an ankle condition, such as age, body habitus, or neurologic disease.
Right Anterior Drawer Test
Right Anterior Drawer Test Yes	Radiobutton	Check this box if the Right Anterior Drawer Test indicates an absence of a firm end point with asymmetric or excessive motion.
Right Condition - Response to Treatment and Symptoms
Right Condition Response - Responsive to Surgery/Treatment	Radiobutton	Check this box if the Veteran's right condition was responsive to surgery or other treatment.
Right Condition Symptoms - Affects ROM of Knee (Yes)	Radiobutton	Check this box if the Veteran's right condition affects the range of motion (ROM) of the knee.
Right Condition Current Symptoms	Text	Provide a detailed description of the veteran's current symptoms for the right condition.
Right Condition - Talectomy
Right Talectomy	Checkbox	Check this box if the veteran has undergone a talectomy on the right side.
Right Talectomy Current Symptoms Description	Text	Provide a detailed description of the current symptoms for the right talectomy condition.
Right Lower Extremity Muscle Atrophy
Right Lower Extremity	Checkbox	Check this box if muscle atrophy is present in the right lower extremity, requiring you to specify its location and provide measurements.
Right Lower Extremity Atrophy Location	Text	Provide the specific location of muscle atrophy in the right lower extremity, for example, '1cm above or below ankle'.
Right Lower Extremity Normal Side Circumference	Number	Enter the circumference of the more normal right lower extremity side.
Right Lower Extremity Atrophied Side Circumference	Number	Enter the circumference of the atrophied right lower extremity side.
Right Subastragalar or Tarsal Joint Ankylosis
Right Subastragalar or Tarsal Joint Ankylosis: Yes	Radiobutton	Check this box if there is ankylosis of the right subastragalar or tarsal joint.
Right Subastragalar or Tarsal Joint Ankylosis: In good weight-bearing position	Radiobutton	Check this box if the ankylosis of the right subastragalar or tarsal joint is in a good weight-bearing position.
Scars or Disfigurement Presence
Scars or Disfigurement Presence - Yes	Radiobutton	Check this box if the veteran has any scars or other disfigurement related to conditions or their treatment.
Second "Shin Splints" Details
Second Shin Splints (MTSS)	Checkbox	Check this box if the Veteran has or has had 'Shin Splints' (medial tibial stress syndrome - MTSS).
Second Shin Splints - No treatment received	Radiobutton	Check this box if no treatment has been received for the second instance of 'Shin Splints'.
Second Achilles Tendonitis Details
Second Achilles Tendonitis or Achilles Tendon Rupture	Checkbox	Check this box if the Veteran has Achilles tendonitis or Achilles tendon rupture, specifically for the second instance being detailed.
Second Achilles Tendonitis Symptoms	Text	Provide a detailed description of the current symptoms related to Achilles tendonitis or Achilles tendon rupture for the second instance.
Second Ankle Condition History
Second Ankle Condition 7A Yes	Radiobutton	Check this box if the Veteran has or has ever had shin splints, stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus or talus, or a talectomy related to the second ankle condition.
Second Ankle Instability
Second Ankle Instability Suspected - Yes	Radiobutton	Check this box if ankle instability is suspected for the second assessment, given that the Talar Tilt Test was unable to be performed.
Second Ankle Instability Description	Text	Provide a detailed description of the suspected second ankle instability if unable to test.
Second Evidence of Pain
Second Evidence of Pain - Yes	Radiobutton	Check this box if there is evidence of pain in the second assessment.
Second Evidence of Pain - Weight-bearing	Checkbox	Check this box if the pain occurs during weight-bearing activities in the second assessment.
Second Evidence of Pain - Nonweight-bearing	Checkbox	Check this box if the pain occurs during nonweight-bearing activities in the second assessment.
Second Evidence of Pain - Active Motion	Checkbox	Check this box if the pain occurs during active motion in the second assessment.
Second Evidence of Pain - Passive Motion	Checkbox	Check this box if the pain occurs during passive motion in the second assessment.
Second Evidence of Pain - On Rest/Non-Movement	Checkbox	Check this box if the pain occurs while at rest or during non-movement in the second assessment.
Second Evidence of Pain - Causes Functional Loss	Checkbox	Check this box if the pain causes functional loss in the second assessment, and provide a description in the comments.
Second Evidence of Pain - Does Not Cause Functional Loss	Checkbox	Check this box if the pain does not result in or cause functional loss in the second assessment.
Second Evidence of Pain Comments	Text	Provide any additional comments or detailed explanations regarding the second evidence of pain, especially if functional loss is caused.
Second Limitation of Motion Description
Second Plantar Flexion Degree Endpoint	Number	Enter the second plantar flexion degree endpoint if it is different from the previously noted endpoint.
Second Dorsiflexion Degree Endpoint	Number	Enter the second dorsiflexion degree endpoint if it is different from the previously noted endpoint.
Second Limitation of Motion Description	Text	Provide a detailed description of the second limitation of motion, including the degree(s) and factors identified such as pain, weakness, fatigability, or incoordination.
Second Malunion of Calcaneus Details
Second Malunion of Calcaneus or Talus (Astragalus)	Checkbox	Check this box if the Veteran has a malunion of the calcaneus (os calcis) or talus (astragalus) on the second side being evaluated.
Second Malunion Moderate Deformity	Radiobutton	Check this box if the second malunion of calcaneus or talus presents with moderate deformity.
Second Objective Evidence of Crepitus
Second Objective Evidence of Crepitus Yes	Radiobutton	Check this box if there is objective evidence of crepitus for the second instance of evaluation.
Second Objective Evidence of Localized Tenderness or Pain
Second Objective Evidence of Localized Tenderness or Pain - Yes	Radiobutton	Check this box if there is objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue.
Second Localized Tenderness or Pain Explanation	Text	Provide a detailed explanation of the location, severity, and relationship to the condition(s) for the second instance of objective evidence of localized tenderness or pain.
Second Observed Repetitive Use ROM
Second Observed Repetitive Use ROM Yes	Radiobutton	Check this box if, for the second observed instance, the Veteran is able to perform repetitive-use testing with at least three repetitions.
Second Observed Repetitive Use ROM Inability Explanation	Text	Provide an explanation if the Veteran is unable to perform repetitive-use testing with at least three repetitions.
Second Range of Motion During Flare-ups and Evidence
Second Plantar Flexion Endpoint	Number	Enter the estimated plantar flexion endpoint in degrees during flare-ups.
Second Dorsiflexion Endpoint	Number	Enter the estimated dorsiflexion endpoint in degrees during flare-ups.
Second Flare-up Evidence Discussion	Text	Provide specific evidence to support the estimated range of motion during flare-ups, based on all procurable evidence.
Second Stress Fracture Details
Second Stress Fracture of the Lower Leg	Checkbox	Check this box if the veteran has a second stress fracture of the lower leg that affects the Range of Motion (ROM) of the knee, and requires the completion of the musculoskeletal questionnaire and ROM section.
Second Stress Fracture Current Symptoms	Text	Provide a detailed description of the current symptoms related to the second stress fracture of the lower leg.
Second Talar Tilt Test
Second Talar Tilt Test: Yes	Radiobutton	Check this box if the second Talar Tilt Test indicates asymmetric or excessive motion.
Second Talar Tilt Test Unable to Test Explanation	Text	Provide a detailed explanation if the second Talar Tilt Test was unable to be performed.
Shin Splints Diagnosis
Shin Splints/Medial Tibial Stress Syndrome (MTSS)	Checkbox	Check this box if the veteran has been diagnosed with Shin splints/medial tibial stress syndrome (MTSS), including conditions post-surgery or treatment.
Shin Splints - Side Affected: Right	Radiobutton	Check this box if the Shin splints/medial tibial stress syndrome affects the right side.
Shin Splints Diagnosis ICD Code	Text	Enter the ICD code for the shin splints diagnosis.
Shin Splints Diagnosis Date (Right)	Date	Enter the date of diagnosis for shin splints affecting the right side.
Shin Splints Diagnosis Date (Left)	Date	Enter the date of diagnosis for shin splints affecting the left side.
Streptococcic Arthritis Diagnosis
Streptococcic Arthritis Diagnosis	Checkbox	Check this box if streptococcic arthritis is diagnosed.
Streptococcic Arthritis - Right Side	Radiobutton	Check this box if streptococcic arthritis affects the right side.
Streptococcic Arthritis ICD Code	Text	Provide the International Classification of Diseases (ICD) code for streptococcic arthritis.
Streptococcic Arthritis Right Diagnosis Date	Date	Provide the date of diagnosis for streptococcic arthritis affecting the right side.
Streptococcic Arthritis Left Diagnosis Date	Date	Provide the date of diagnosis for streptococcic arthritis affecting the left side.
Syphilitic Arthritis Diagnosis
Syphilitic Arthritis	Checkbox	Check this box if the diagnosed condition is Syphilitic Arthritis.
Syphilitic Arthritis Right Side Affected	Radiobutton	Check this box if Syphilitic Arthritis affects the right side.
Syphilitic Arthritis ICD Code	Text	Enter the ICD code for the syphilitic arthritis diagnosis.
Syphilitic Arthritis Right Date of Diagnosis	Date	Provide the date of diagnosis for syphilitic arthritis affecting the right side.
Syphilitic Arthritis Left Date of Diagnosis	Date	Provide the date of diagnosis for syphilitic arthritis affecting the left side.
Tendinitis
Tendinitis	Checkbox	Check this box if the patient has tendinitis.
Tendinitis - Right	Radiobutton	Check this box if the tendinitis affects the right side.
Tendinitis General Details	Text	Provide any additional details or specific information about the Tendinitis condition.
Tendinitis Right Side Details	Text	Enter specific details or comments related to Tendinitis on the right side.
Tendinitis Left Side Details	Text	Enter specific details or comments related to Tendinitis on the left side.
Tendinosis
Tendinosis	Checkbox	Check this box if the patient has Tendinosis.
Tendinosis Right	Radiobutton	Check this box if Tendinosis affects the right side.
Tendinosis General Details	Text	Please provide any additional details or specific information about the tendinosis condition.
Tendinosis Right Side Details	Text	Please provide specific details regarding the tendinosis on the right side.
Tendinosis Left Side Details	Text	Please provide specific details regarding the tendinosis on the left side.
Tendipathy
Tendipathy	Checkbox	Check this box if Tendipathy is present and you want to select a specific type or side.
Tendipathy Right	Radiobutton	Check this box if the Tendipathy affects the right side.
Tendinopathy Details	Text	Provide specific details about the Tendinopathy.
Tendinopathy Right Side	Text	Enter specific details regarding the tendinopathy on the right side.
Tendinopathy Left Side	Text	Enter specific details regarding the tendinopathy on the left side.
Tendonitis Diagnosis
Tendonitis (Achilles/peroneal/posterior tibial)	Checkbox	Check this box if the veteran has a diagnosis of Tendonitis (Achilles/peroneal/posterior tibial).
RG_TENDONITIS_ACHILLES_RLB	RadioButton
Tendonitis Diagnosis ICD Code	Text	Enter the International Classification of Diseases (ICD) code for the Tendonitis diagnosis.
Tendonitis Right Side Diagnosis Date	Date	Provide the date when the Tendonitis diagnosis was made for the right side.
Tendonitis Left Side Diagnosis Date	Date	Provide the date when the Tendonitis diagnosis was made for the left side.
Tenosynovitis
Tenosynovitis	Checkbox	Check this box if the patient has tenosynovitis.
RG_Tenosynovitis	RadioButton
Tenosynovitis Details	Text	Provide general additional details regarding the Tenosynovitis diagnosis.
Tenosynovitis Right Side Details	Text	Provide specific details for Tenosynovitis affecting the right side.
Tenosynovitis Left Side Details	Text	Provide specific details for Tenosynovitis affecting the left side.
Testing Performance Explanation 1
Testing Performance 1 Yes	Radiobutton	Check this box if testing can be performed for the first explanation.
Testing Performance Explanation 1	Text	Provide an explanation if testing cannot be performed.
Testing Performance Explanation 2
Testing Performance 2 Yes	Radiobutton	Check this box if testing can be performed for the second instance of the testing performance explanation.
Testing Performance Explanation 2	Text	Provide an explanation if testing cannot be performed, or if there are medical contraindications.
Typhoid Arthritis Diagnosis
Arthritis, typhoid	Checkbox	Check this box if the diagnosis is Typhoid Arthritis.
Typhoid Arthritis - Side affected: Right	Radiobutton	Check this box if Typhoid Arthritis affects the right side.
Typhoid Arthritis Diagnosis ICD Code	Text	Enter the International Classification of Diseases (ICD) code for the typhoid arthritis diagnosis.
Typhoid Arthritis Diagnosis Right Side Date	Date	Provide the date of diagnosis for typhoid arthritis affecting the right side.
Typhoid Arthritis Diagnosis Left Side Date	Date	Provide the date of diagnosis for typhoid arthritis affecting the left side.
Unclaimed Joint Status 1
Unclaimed Joint 1 Damaged	Radiobutton	Check this box if the first unclaimed joint is determined to be damaged.
Unclaimed Joint Status 2
Unclaimed Joint 2 Damaged	Radiobutton	Check this box if the second unclaimed joint is considered damaged.
Use of Assistive Devices
10A. Yes	Radiobutton	Check this box if the Veteran uses any assistive devices as a normal mode of locomotion, even if occasional locomotion by other methods is possible.
Veteran's Ankle Condition History
2A. Ankle Condition Brief Summary	Text	Provide a brief summary detailing the history, including the onset and course, of the Veteran's ankle condition(s).
Veteran's Report of Ankle Instability
2D Yes, Veteran reports ankle instability	Radiobutton	Check this box if the veteran reports having or has a history of instability of the ankle.
2D Ankle Instability Description	Text	Provide a detailed description of the Veteran's reported ankle instability in their own words.
Veteran's Report of Functional Loss
Veteran Reports Functional Loss - Yes	Radiobutton	Check this box if the veteran reports any functional loss or functional impairment of the joint or extremity being evaluated on this questionnaire, including after repeated use over time.
Functional Loss Description	Text	Enter the Veteran's own words describing their functional loss or functional impairment.

Ankle Conditions Disability Benefits Questionnaire (DBQ) Instructions