Ankle Conditions Disability Benefits Questionnaire Completed Form Examples and Samples
View a detailed example of a completed Ankle Conditions Disability Benefits Questionnaire (VA Form 21-0960M-2). This sample DBQ for veterans shows how to document diagnoses like arthritis, range of motion limitations, and functional loss for a successful VA disability claim.
Ankle Conditions Disability Benefits Questionnaire Example
How this form was filled:
This example shows a filled Ankle Conditions DBQ for a veteran with left ankle chronic instability and post-traumatic arthritis. It details a specific diagnosis, documents significant limitations in range of motion, and describes the functional impact on daily life, including painful motion and the need for an assistive device (ankle brace).
Information used to fill out the document:
- Veteran's Name: John R. Smith
- Condition Diagnosed: Left Ankle Chronic Instability with Post-Traumatic Degenerative Arthritis
- Date of Examination: 01/15/2026
- Ankle Affected: Left
- History: Injury sustained during military training exercise in 2015.
- Range of Motion - Dorsiflexion (Left): 5 degrees (Limitation)
- Range of Motion - Plantar Flexion (Left): 30 degrees (Limitation)
- Painful Motion: Yes, with weight-bearing and at end of range of motion.
- Functional Loss: Difficulty walking on uneven surfaces, inability to run, pain after walking more than 1/4 mile.
- Flare-ups: Yes, occurring 3-4 times per month, lasting 2-3 days, causing significant pain and inability to bear weight.
- Assistive Devices: Yes, requires ankle brace for stability during prolonged standing or walking.
- Physician's Remarks: The veteran's left ankle condition results in significant functional loss and chronic pain, which is consistent with the objective findings of reduced range of motion and clinical history. The condition limits ambulation and weight-bearing activities.
What this filled form sample shows:
- Clear identification of the diagnosed condition and its history.
- Precise range of motion measurements demonstrating significant limitation compared to normal values.
- Detailed description of functional loss and how it impacts daily activities like walking and standing.
- Documentation of painful motion, frequent flare-ups, and the medical necessity for an assistive device.
Form specifications and details:
| Use Case: | Veteran with a service-connected chronic ankle injury leading to instability and arthritis. |
| Form Name: | Ankle Conditions Disability Benefits Questionnaire |
| Form Number: | VA Form 21-0960F-2 |
| Purpose: | To collect medical information to help VA adjudicate a disability claim for ankle conditions. |
Created: January 22, 2026 09:53 PM
