Ankle Conditions Disability Benefits Questionnaire Instructions

Check this box if the functional impairment described in 11A applies to the Veteran’s right lower extremity. Fill only if 'Yes' is selected.

Check this box if the functional impairment described in 11A applies to the Veteran’s left lower extremity. Fill only if 'Yes' is selected.

Check this box if the Veteran’s ankle condition causes functional impairment so severe that amputation with a prosthesis would serve the Veteran equally well.

Check this box if the Veteran’s ankle condition does not cause functional impairment equivalent to amputation with a prosthesis.

Provide a brief summary identifying the condition(s) causing loss of effective function for each affected extremity and describe the functional loss with specific examples. Fill only if 'Right lower', 'Left lower' is 'Yes' for any fields selection.

Check this box if clinically relevant diagnostic imaging studies or other diagnostic procedures have been performed or reviewed in conjunction with this examination.

Check this box if no clinically relevant diagnostic imaging studies or other diagnostic procedures have been performed or reviewed in conjunction with this examination.

Check this box if degenerative or post-traumatic arthritis is documented (based on relevant diagnostic imaging/procedures). Fill only if 'Yes' is 'Yes'.

Check this box if degenerative or post-traumatic arthritis is not documented. Fill only if 'Yes' is 'Yes'.

Check this box if the documented degenerative or post-traumatic arthritis affects the right side only. Fill only if 'Arthritis documented: Yes' is 'Yes'.

Check this box if the documented degenerative or post-traumatic arthritis affects the left side only. Fill only if 'Arthritis documented: Yes' is 'Yes'.

Check this box if the documented degenerative or post-traumatic arthritis affects both the right and left sides. Fill only if 'Arthritis documented: Yes' is 'Yes'.

Enter the type of diagnostic test or procedure performed, the date it was performed or reviewed, and a brief summary of the results. Fill only if 'Yes' is 'Yes'.

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 with this examination.

Check this box if there are no other clinically relevant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es) that were reviewed with this examination.

Provide the type of other relevant diagnostic test or procedure, the date it was performed or reviewed, and a brief summary of the results. Fill only if 'Yes' is 'Yes'.

Describe how any abnormal diagnostic test findings relate to the diagnosed condition(s), including which diagnosis each abnormal result supports or is associated with.

Check this box if the Veteran reports any functional loss or functional impairment of the joint or extremity being evaluated (including after repeated use over time).

Check this box if the Veteran does not report any functional loss or functional impairment of the joint or extremity being evaluated.

Enter the Veteran's own words describing any functional loss or functional impairment of the joint or extremity being evaluated, including after repeated use over time. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran reports or has a history of ankle instability.

Check this box if the Veteran does not report and has no history of ankle instability.

Enter the Veteran's description, in their own words, of any ankle instability history (e.g., giving way, rolling, or feeling unstable). Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran’s initial left ankle range of motion (ROM) measurements are all within normal limits.

Check this box if any initial left ankle ROM measurement is abnormal or outside the normal range.

Check this box if you cannot perform initial left ankle ROM testing and will provide an explanation.

Check this box if initial left ankle ROM measurements are not indicated for this evaluation and you will provide an explanation.

Provide an explanation for why the left ankle initial range of motion (ROM) measurements were marked as “Unable to test” or “Not indicated.” Fill only if 'Unable to test', 'Not indicated' is 'Yes' (any).

Describe why the left ankle ROM is outside the normal range but is considered normal for the Veteran for reasons other than an ankle condition (e.g., age, body habitus, neurologic disease). Fill only if 'Abnormal or outside of normal range' is 'Yes'.

Check this box if the Veteran’s right ankle initial range of motion (ROM) measurements are within normal limits.

Check this box if the Veteran’s right ankle initial ROM measurements are abnormal or fall outside the normal range.

Check this box if you cannot perform the initial ROM testing for the Veteran’s right ankle (and provide an explanation in the space below).

Check this box if initial right ankle ROM measurements are not indicated for this evaluation (and provide an explanation in the space below).

Explain why the right ankle initial range of motion (ROM) measurements were marked as "Unable to test" or "Not indicated." Fill only if 'Unable to test', 'Not indicated' is 'Yes' (any).

Describe why the right ankle ROM is outside the normal range but is considered normal for the Veteran due to reasons other than an ankle condition (e.g., age, body habitus, neurologic disease). Fill only if 'Abnormal or outside of normal range' is 'Yes'.

Check this box if the Veteran has a current diagnosis of an Achilles tendon rupture associated with the claimed condition(s).

Select this option if the Achilles' tendon rupture affects the right side only. Fill only if 'Achilles' tendon rupture' is checked.

Select this option if the Achilles' tendon rupture affects the left side only. Fill only if 'Achilles' tendon rupture' is checked.

Select this option if the Achilles' tendon rupture affects both the right and left sides. Fill only if 'Achilles' tendon rupture' is checked.

Enter the ICD diagnosis code for the Achilles tendon rupture. Fill only if 'Achilles' tendon rupture' is checked.

Enter the date the Achilles tendon rupture was diagnosed for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Enter the date the Achilles tendon rupture was diagnosed for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Enter any additional diagnoses related to the Veteran's ankle condition(s) using the same right/left/bilateral detail format shown above.

Check this box if there is additional loss of function or range of motion after three repetitions. Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions?' is 'Yes'.

Check this box if there is no additional loss of function or range of motion after three repetitions. Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions?' is 'Yes'.

Enter the plantar flexion endpoint measurement after three repetitions. Fill only if 'Yes' is 'Yes'.

Enter the dorsiflexion endpoint measurement after three repetitions. Fill only if 'Yes' is 'Yes'.

Check this box if pain is a factor causing the additional functional loss after three repetitions. Fill only if 'Yes' is 'Yes'.

Check this box if fatigability is a factor causing the additional functional loss after three repetitions. Fill only if 'Yes' is 'Yes'.

Check this box if weakness is a factor causing the additional functional loss after three repetitions. Fill only if 'Yes' is 'Yes'.

Check this box if lack of endurance is a factor causing the additional functional loss after three repetitions. Fill only if 'Yes' is 'Yes'.

Check this box if incoordination is a factor causing the additional functional loss after three repetitions. Fill only if 'Yes' is 'Yes'.

Check this box if another factor (not listed) caused the additional functional loss after three repetitions, and provide details in the line provided. Fill only if 'Yes' is 'Yes'.

Provide a description of any other factor that causes additional functional loss after three repetitions. Fill only if 'Other' is 'Yes'.

Check this box if selecting factors that cause functional loss does not apply. Fill only if 'Yes' is 'Yes'.

Check this box if there is additional loss of function or range of motion after three repetitions. Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions?' is 'Yes'.

Check this box if there is no additional loss of function or range of motion after three repetitions. Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions?' is 'Yes'.

Enter the plantar flexion endpoint measurement after completing three repetitions. Fill only if 'Yes' is 'Yes'.

Enter the dorsiflexion endpoint measurement after completing three repetitions. Fill only if 'Yes' is 'Yes'.

Check this box if pain causes the additional functional loss after three repetitions. Fill only if 'Yes' is 'Yes'.

Check this box if fatigability (easy tiring) causes the additional functional loss after three repetitions. Fill only if 'Yes' is 'Yes'.

Check this box if weakness causes the additional functional loss after three repetitions. Fill only if 'Yes' is 'Yes'.

Check this box if lack of endurance causes the additional functional loss after three repetitions. Fill only if 'Yes' is 'Yes'.

Check this box if incoordination causes the additional functional loss after three repetitions. Fill only if 'Yes' is 'Yes'.

Check this box if another factor not listed causes the additional functional loss after three repetitions, and specify the factor on the provided line. Fill only if 'Yes' is 'Yes'.

Specify any other factor causing the additional functional loss after three repetitions. Fill only if 'Other' is 'Yes'.

Check this box if the listed factors do not apply or no factor selection is applicable for the additional functional loss after three repetitions. Fill only if 'Yes' is 'Yes'.

Check this box if, because you were unable to perform the test, ankle instability is suspected for the left ankle. Fill only if 'Unable to test' is 'Unable to test'.

Check this box if, despite being unable to perform the test, ankle instability is not suspected for the left ankle. Fill only if 'Unable to test' is 'Unable to test'.

Describe why ankle instability is suspected for the left ankle when the test could not be performed. Fill only if 'Yes' is 'Yes'.

Check this box if you were unable to test and ankle instability is suspected (right ankle). Fill only if 'Unable to test' is 'Unable to test'.

Check this box if you were unable to test and ankle instability is not suspected (right ankle). Fill only if 'Unable to test' is 'Unable to test'.

Describe the suspected right ankle instability and the reasons for suspecting it when the test could not be performed. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran has a diagnosis/history of ankle joint replacement associated with the claimed condition.

Select this option if the ankle joint replacement involves the right ankle. Fill only if 'Ankle joint replacement' is checked.

Select this option if the ankle joint replacement involves the left ankle. Fill only if 'Ankle joint replacement' is checked.

Select this option if the ankle joint replacement involves both ankles. Fill only if 'Ankle joint replacement' is checked.

Enter the ICD diagnosis code for the ankle joint replacement condition. Fill only if 'Ankle joint replacement' is checked.

Enter the date of diagnosis for ankle joint replacement on the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Enter the date of diagnosis for ankle joint replacement on the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Check this box if the Veteran has a diagnosis of ankylosis (joint fusion/stiffness) involving the ankle, subtalar, or tarsal joint.

Check this box if the ankylosis affects the right ankle/subtalar/tarsal joint only. Fill only if 'Ankylosis of ankle, subtalar or tarsal joint' is checked.

Check this box if the ankylosis affects the left ankle/subtalar/tarsal joint only. Fill only if 'Ankylosis of ankle, subtalar or tarsal joint' is checked.

Check this box if the ankylosis affects both the right and left ankle/subtalar/tarsal joints. Fill only if 'Ankylosis of ankle, subtalar or tarsal joint' is checked.

Enter the ICD diagnosis code for ankylosis of the ankle, subtalar, or tarsal joint. Fill only if 'Ankylosis of ankle, subtalar or tarsal joint' is checked.

Provide the date when ankylosis of the ankle, subtalar, or tarsal joint was diagnosed for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Provide the date when ankylosis of the ankle, subtalar, or tarsal joint was diagnosed for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Check this box if the Veteran has a current diagnosis of gonorrheal arthritis associated with the claimed condition(s).

Select this option if the gonorrheal arthritis affects the right side only. Fill only if 'Arthritis, gonorrheal' is checked.

Select this option if the gonorrheal arthritis affects the left side only. Fill only if 'Arthritis, gonorrheal' is checked.

Select this option if the gonorrheal arthritis affects both the right and left sides. Fill only if 'Arthritis, gonorrheal' is checked.

Enter the ICD diagnosis code for gonorrheal arthritis. Fill only if 'Arthritis, gonorrheal' is checked.

Enter the date gonorrheal arthritis was diagnosed for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Enter the date gonorrheal arthritis was diagnosed for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Check this box if the claimed condition includes a diagnosis of pneumococcal arthritis.

Check this box if pneumococcal arthritis affects the right side only. Fill only if 'Arthritis, pneumococcic' is checked.

Check this box if pneumococcal arthritis affects the left side only. Fill only if 'Arthritis, pneumococcic' is checked.

Check this box if pneumococcal arthritis affects both the right and left sides. Fill only if 'Arthritis, pneumococcic' is checked.

Enter the ICD diagnosis code for pneumococcic arthritis. Fill only if 'Arthritis, pneumococcic' is checked.

Enter the date pneumococcic arthritis was diagnosed for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Enter the date pneumococcic arthritis was diagnosed for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Check this box if the Veteran has a diagnosis of post-traumatic arthritis associated with the claimed condition(s).

Check this box if the post-traumatic arthritis affects the right side/ankle. Fill only if 'Arthritis, post-traumatic' is checked.

Check this box if the post-traumatic arthritis affects the left side/ankle. Fill only if 'Arthritis, post-traumatic' is checked.

Check this box if the post-traumatic arthritis affects both the right and left sides/ankles. Fill only if 'Arthritis, post-traumatic' is checked.

Enter the ICD diagnosis code for the Veteran’s post-traumatic arthritis. Fill only if 'Arthritis, post-traumatic' is checked.

Enter the date of diagnosis for post-traumatic arthritis affecting the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Enter the date of diagnosis for post-traumatic arthritis affecting the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Check this box if the Veteran has a diagnosis of rheumatoid arthritis affecting multiple joints associated with the claimed condition(s).

Check this box if the rheumatoid arthritis (multi-joints) affects the right side. Fill only if 'Arthritis, rheumatoid (multi-joints)' is checked.

Check this box if the rheumatoid arthritis (multi-joints) affects the left side. Fill only if 'Arthritis, rheumatoid (multi-joints)' is checked.

Check this box if the rheumatoid arthritis (multi-joints) affects both the right and left sides. Fill only if 'Arthritis, rheumatoid (multi-joints)' is checked.

Enter the ICD diagnosis code for rheumatoid arthritis (multi-joints). Fill only if 'Arthritis, rheumatoid (multi-joints)' is checked.

Provide the date the right side was diagnosed with rheumatoid arthritis (multi-joints). Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Provide the date the left side was diagnosed with rheumatoid arthritis (multi-joints). Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Check this box if the Veteran’s current diagnosis includes streptococcal (streptococcic) arthritis associated with the claimed condition(s).

Check this box if streptococcal arthritis affects the right side/ankle only. Fill only if 'Arthritis, streptococcic' is checked.

Check this box if streptococcal arthritis affects the left side/ankle only. Fill only if 'Arthritis, streptococcic' is checked.

Check this box if streptococcal arthritis affects both the right and left sides/ankles. Fill only if 'Arthritis, streptococcic' is checked.

Enter the ICD diagnosis code for streptococcic arthritis. Fill only if 'Arthritis, streptococcic' is checked.

Enter the date streptococcic arthritis was diagnosed for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Enter the date streptococcic arthritis was diagnosed for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Check this box if the Veteran has a current diagnosis of syphilitic arthritis associated with the claimed condition(s).

Check this box if syphilitic arthritis affects the right side/ankle only. Fill only if 'Arthritis, syphilitic' is checked.

Check this box if syphilitic arthritis affects the left side/ankle only. Fill only if 'Arthritis, syphilitic' is checked.

Check this box if syphilitic arthritis affects both the right and left sides/ankles. Fill only if 'Arthritis, syphilitic' is checked.

Enter the ICD diagnosis code for syphilitic arthritis. Fill only if 'Arthritis, syphilitic' is checked.

Provide the date syphilitic arthritis was diagnosed for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Provide the date syphilitic arthritis was diagnosed for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Check this box if the Veteran has a current diagnosis of typhoid arthritis associated with the claimed condition(s).

Select this option if the typhoid arthritis affects the right side only. Fill only if 'Arthritis, typhoid' is checked.

Select this option if the typhoid arthritis affects the left side only. Fill only if 'Arthritis, typhoid' is checked.

Select this option if the typhoid arthritis affects both the right and left sides. Fill only if 'Arthritis, typhoid' is checked.

Enter the ICD diagnosis code for typhoid arthritis. Fill only if 'Arthritis, typhoid' is checked.

Enter the date the typhoid arthritis diagnosis was made for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Enter the date the typhoid arthritis diagnosis was made for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Check this box if the Veteran has had arthroscopic surgery or another type of ankle surgery on the left ankle.

Enter the specific type of arthroscopic or other ankle surgery performed on the left ankle. Fill only if 'Arthroscopic or other ankle surgery' is 'Yes'.

Enter the date the arthroscopic or other left ankle surgery was performed. Fill only if 'Arthroscopic or other ankle surgery' is 'Yes'.

Check this box if the Veteran has had arthroscopic or any other type of ankle surgery on the right ankle.

Enter the type of arthroscopic or other ankle surgery performed on the right ankle (e.g., debridement, ligament repair, fusion). Fill only if 'Arthroscopic or other ankle surgery' is 'Yes'.

Enter the date the arthroscopic or other right ankle surgery was performed. Fill only if 'Arthroscopic or other ankle surgery' is 'Yes'.

Check this box if the Veteran uses a brace or braces as an assistive device for normal locomotion. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran uses brace(s) occasionally. Fill only if 'Brace(s)' is 'Yes'.

Check this box if the Veteran uses brace(s) on a regular basis. Fill only if 'Brace(s)' is 'Yes'.

Check this box if the Veteran uses brace(s) constantly. Fill only if 'Brace(s)' is 'Yes'.

Check this box if the Veteran uses a cane (or canes) as an assistive device for normal locomotion. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran uses a cane occasionally. Fill only if 'Cane(s)' is 'Yes'.

Check this box if the Veteran uses a cane regularly. Fill only if 'Cane(s)' is 'Yes'.

Check this box if the Veteran uses a cane constantly. Fill only if 'Cane(s)' is 'Yes'.

Check this box if the Veteran uses crutches as an assistive device for normal locomotion. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran uses crutches occasionally. Fill only if 'Crutch(es)' is 'Yes'.

Check this box if the Veteran uses crutches regularly. Fill only if 'Crutch(es)' is 'Yes'.

Check this box if the Veteran uses crutches constantly. Fill only if 'Crutch(es)' is 'Yes'.

Check this box if the Veteran uses an assistive device not listed above and you will specify what it is on the line provided. Fill only if 'Yes' is 'Yes'.

Enter the name or description of the other assistive device the Veteran uses. Fill only if 'Other (assistive device)' is 'Yes'.

Select this option if the Veteran uses the specified “Other” assistive device only occasionally. Fill only if 'Other (assistive device)' is 'Yes'.

Select this option if the Veteran uses the specified “Other” assistive device on a regular basis but not constantly. Fill only if 'Other (assistive device)' is 'Yes'.

Select this option if the Veteran uses the specified “Other” assistive device constantly. Fill only if 'Other (assistive device)' is 'Yes'.

Check this box if the Veteran uses a walker as an assistive device for normal locomotion. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran uses a walker occasionally. Fill only if 'Walker' is 'Yes'.

Check this box if the Veteran uses a walker on a regular basis. Fill only if 'Walker' is 'Yes'.

Check this box if the Veteran uses a walker constantly. Fill only if 'Walker' is 'Yes'.

Check this box if the Veteran uses a wheelchair as an assistive device for locomotion. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran uses a wheelchair occasionally. Fill only if 'Wheelchair' is 'Yes'.

Check this box if the Veteran uses a wheelchair on a regular basis. Fill only if 'Wheelchair' is 'Yes'.

Check this box if the Veteran uses a wheelchair constantly. Fill only if 'Wheelchair' is 'Yes'.

For each condition requiring an assistive device, describe the condition, indicate the affected side (left/right/bilateral), and identify the assistive device used. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran is diagnosed with avascular necrosis of the talus as part of the claimed ankle/foot conditions.

Check this box if the avascular necrosis of the talus affects the right side only. Fill only if 'Avascular necrosis, talus' is checked.

Check this box if the avascular necrosis of the talus affects the left side only. Fill only if 'Avascular necrosis, talus' is checked.

Check this box if the avascular necrosis of the talus affects both the right and left sides. Fill only if 'Avascular necrosis, talus' is checked.

Enter the ICD diagnosis code for avascular necrosis of the talus. Fill only if 'Avascular necrosis, talus' is checked.

Enter the date when avascular necrosis of the right talus was diagnosed. Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Enter the date when avascular necrosis of the left talus was diagnosed. Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Check this box if the Veteran has a current diagnosis of a benign bone neoplasm related to the claimed condition(s).

Check this box if the benign bone neoplasm affects the right side only. Fill only if 'Bones, neoplasm, benign' is checked.

Check this box if the benign bone neoplasm affects the left side only. Fill only if 'Bones, neoplasm, benign' is checked.

Check this box if the benign bone neoplasm affects both the right and left sides. Fill only if 'Bones, neoplasm, benign' is checked.

Enter the ICD diagnostic code for the benign bone neoplasm diagnosis. Fill only if 'Bones, neoplasm, benign' is checked.

Enter the date the benign bone neoplasm was diagnosed on the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Enter the date the benign bone neoplasm was diagnosed on the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Check this box if the Veteran has a diagnosis of a malignant bone neoplasm, whether primary or secondary.

Check this box if the malignant bone neoplasm affects the right side. Fill only if 'Bones, neoplasm, malignant (primary or secondary)' is checked.

Check this box if the malignant bone neoplasm affects the left side. Fill only if 'Bones, neoplasm, malignant (primary or secondary)' is checked.

Check this box if the malignant bone neoplasm affects both the right and left sides. Fill only if 'Bones, neoplasm, malignant (primary or secondary)' is checked.

Enter the ICD diagnostic code for the veteran’s malignant bone neoplasm (primary or secondary). Fill only if 'Bones, neoplasm, malignant (primary or secondary)' is checked.

Enter the date the malignant bone neoplasm (primary or secondary) was diagnosed on the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Enter the date the malignant bone neoplasm (primary or secondary) was diagnosed on the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Check this box if the Veteran has a current diagnosis of bursitis associated with the claimed condition(s).

Check this box if the bursitis affects the right side/ankle only. Fill only if 'Bursitis' is checked.

Check this box if the bursitis affects the left side/ankle only. Fill only if 'Bursitis' is checked.

Check this box if the bursitis affects both the right and left sides/ankles. Fill only if 'Bursitis' is checked.

Enter the ICD diagnosis code for the bursitis condition. Fill only if 'Bursitis' is checked.

Provide the date the bursitis was diagnosed for the right side. Fill only if 'Bursitis - Right', 'Bursitis - Both' is checked (any fields selection).

Provide the date the bursitis was diagnosed for the left side. Fill only if 'Bursitis - Left', 'Bursitis - Both' is checked (any fields selection).

List the condition(s) being claimed that pertain to this ankle conditions disability benefits questionnaire.

Describe the veteran’s current symptoms for the left-side condition, including severity, frequency, and any functional limitations. Fill only if '7A. Does the Veteran now have or has he or she ever had shin splints (medial tibial stress syndrome), stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)?' is 'Yes'.

Provide a detailed description of the veteran’s current symptoms for the right side/condition, including what is felt and how it affects function. Fill only if '7A. Does the Veteran now have or has he or she ever had shin splints (medial tibial stress syndrome), stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)?' is 'Yes'.

Check this box if the Veteran has a current diagnosis of degenerative arthritis that is not post-traumatic.

Check this box if the degenerative arthritis (other than post-traumatic) affects the right side only. Fill only if 'Degenerative arthritis (other than post-traumatic)' is checked.

Check this box if the degenerative arthritis (other than post-traumatic) affects the left side only. Fill only if 'Degenerative arthritis (other than post-traumatic)' is checked.

Check this box if the degenerative arthritis (other than post-traumatic) affects both the right and left sides. Fill only if 'Degenerative arthritis (other than post-traumatic)' is checked.

Enter the ICD diagnostic code for degenerative arthritis (other than post-traumatic). Fill only if 'Degenerative arthritis (other than post-traumatic)' is checked.

Enter the date degenerative arthritis (other than post-traumatic) was diagnosed for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Enter the date degenerative arthritis (other than post-traumatic) was diagnosed for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Check this box if the Veteran has a current diagnosis of a chronic or recurrent deltoid ligament sprain.

Check this box if the chronic/recurrent deltoid ligament sprain affects the right side. Fill only if 'Deltoid ligament sprain (chronic/recurrent)' is checked.

Check this box if the chronic/recurrent deltoid ligament sprain affects the left side. Fill only if 'Deltoid ligament sprain (chronic/recurrent)' is checked.

Check this box if the chronic/recurrent deltoid ligament sprain affects both the right and left sides. Fill only if 'Deltoid ligament sprain (chronic/recurrent)' is checked.

Enter the ICD diagnosis code for the deltoid ligament sprain (chronic/recurrent). Fill only if 'Deltoid ligament sprain (chronic/recurrent)' is checked.

Enter the date the deltoid ligament sprain (chronic/recurrent) was diagnosed for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Enter the date the deltoid ligament sprain (chronic/recurrent) was diagnosed for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Check this box if you did not review any records or evidence for this examination.

Check this box if you reviewed any records or evidence (e.g., service treatment records, VA records, private records) for this examination.

List the records or evidence reviewed (e.g., service treatment records, VA treatment records, private treatment records) and specify the date range covered. Fill only if 'Records reviewed' is 'Yes'.

Describe how the examination was conducted when it was not performed in person (e.g., telehealth, records review, phone interview). Fill only if 'No' is 'Yes'.

Enter the examiner's printed full name and professional title/credentials.

Enter the examiner's area of practice or medical specialty.

Enter the examiner's phone number and/or fax number.

Enter the examiner's National Provider Identifier (NPI) number.

Enter the examiner's medical license number and the state that issued the license.

Enter the examiner's mailing address.

Enter the examiner's signature to certify the information provided in this form.

Enter the date on which the examiner signed this form.

Enter the plantar flexion degree endpoint if the active ROM limitation due to pain, weakness, fatigability, incoordination, or other factors differs from the value recorded above. Fill only if 'Plantar Flexion Endpoint (Active ROM)' is different than above.

Enter the dorsiflexion degree endpoint if the active ROM limitation due to pain, weakness, fatigability, incoordination, or other factors differs from the value recorded above. Fill only if 'Dorsiflexion Endpoint (Active ROM)' is different than above.

Provide details describing any active range-of-motion limitation and the factors causing it (e.g., pain, weakness, fatigability, incoordination) and any relevant observations.

Enter the measured active range-of-motion endpoint for ankle plantar flexion in degrees.

Enter the measured active range-of-motion endpoint for ankle dorsiflexion in degrees.

Check this box if the patient reported or demonstrated pain during active plantar flexion range of motion testing of the first ankle.

Check this box if the patient reported or demonstrated pain during active dorsiflexion range of motion testing of the first ankle.

Check this box if the abnormal ankle range of motion itself contributes to a functional loss. Fill only if 'Initial ROM measurements' is 'Abnormal or outside of normal range'.

Check this box if the abnormal ankle range of motion itself does not contribute to a functional loss. Fill only if 'Initial ROM measurements' is 'Abnormal or outside of normal range'.

Provide an explanation of how the ankle’s abnormal range of motion itself contributes to functional loss. Fill only if 'Yes — ROM contributes to functional loss' is 'Yes'.

Enter the first ankle passive range-of-motion endpoint measurement for plantar flexion in degrees. Fill only if 'Plantar flexion passive ROM - Same as active ROM' is 'No'.

Check this box if the passive plantar flexion endpoint value is the same as the active plantar flexion ROM value.

Enter the first ankle passive range-of-motion endpoint measurement for dorsiflexion in degrees. Fill only if 'Dorsiflexion passive ROM - Same as active ROM' is 'No'.

Check this box if the passive dorsiflexion endpoint value is the same as the active dorsiflexion ROM value.

Check this box if pain is observed during passive plantar flexion range-of-motion testing of the first ankle.

Check this box if pain is observed during passive dorsiflexion range-of-motion testing of the first ankle.

Check this box if the first ankle testing can be performed during the examination.

Check this box if the first ankle testing cannot be performed, and provide an explanation in the space provided.

Provide an explanation for why ankle range of motion testing cannot be performed on the first ankle. Fill only if 'Can testing be performed? - No' is 'Yes'.

Check this box if the first ankle is the unclaimed joint and it is damaged. Fill only if 'Side affected' is 'Left'.

Check this box if the first ankle is the unclaimed joint and it is undamaged. Fill only if 'Side affected' is 'Left'.

Check this box if the examination is being conducted during a flare-up.

Check this box if the examination is not being conducted during a flare-up.

Check this box if procured evidence suggests pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability with flare-ups.

Check this box if procured evidence does not suggest significant functional limitation with flare-ups.

Check this box if pain is a factor that causes the functional loss during flare-ups. Fill only if 'Evidence suggests functional limitation with flare-ups: Yes' is 'Yes'.

Check this box if fatigability is a factor that causes the functional loss during flare-ups. Fill only if 'Evidence suggests functional limitation with flare-ups: Yes' is 'Yes'.

Check this box if weakness is a factor that causes the functional loss during flare-ups. Fill only if 'Evidence suggests functional limitation with flare-ups: Yes' is 'Yes'.

Check this box if lack of endurance is a factor that causes the functional loss during flare-ups. Fill only if 'Evidence suggests functional limitation with flare-ups: Yes' is 'Yes'.

Check this box if incoordination is a factor that causes the functional loss during flare-ups. Fill only if 'Evidence suggests functional limitation with flare-ups: Yes' is 'Yes'.

Check this box if another factor not listed causes the functional loss during flare-ups, and specify it in the provided space. Fill only if 'Evidence suggests functional limitation with flare-ups: Yes' is 'Yes'.

Enter any other factor not listed that causes functional loss during flare-ups. Fill only if 'Factor causing functional loss (flare-ups): Other' is 'Yes'.

Check this box if none of the listed factors apply as causes of functional loss during flare-ups. Fill only if 'Evidence suggests functional limitation with flare-ups: Yes' is 'Yes'.

Check this box if the examination is being conducted during a flare-up.

Check this box if the examination is not being conducted during a flare-up.

Check this box if procured evidence suggests pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability with flare-ups.

Check this box if procured evidence does not suggest significant functional limitation with flare-ups due to pain, fatigability, weakness, lack of endurance, or incoordination.

Check this box if pain is a factor that causes the functional loss during flare-ups. Fill only if 'Evidence suggests functional limitation with flare-ups: Yes' is 'Yes'.

Check this box if fatigability is a factor that causes the functional loss during flare-ups. Fill only if 'Evidence suggests functional limitation with flare-ups: Yes' is 'Yes'.

Check this box if weakness is a factor that causes the functional loss during flare-ups. Fill only if 'Evidence suggests functional limitation with flare-ups: Yes' is 'Yes'.

Check this box if lack of endurance is a factor that causes the functional loss during flare-ups. Fill only if 'Evidence suggests functional limitation with flare-ups: Yes' is 'Yes'.

Check this box if incoordination is a factor that causes the functional loss during flare-ups. Fill only if 'Evidence suggests functional limitation with flare-ups: Yes' is 'Yes'.

Check this box if another factor (not listed) causes the functional loss during flare-ups and you will specify it in the provided space. Fill only if 'Evidence suggests functional limitation with flare-ups: Yes' is 'Yes'.

Enter the other factor(s) not listed that cause functional loss during flare-ups. Fill only if 'Factor causing functional loss: Other' is 'Yes'.

Check this box if none of the listed factors apply as causes of the functional loss during flare-ups. Fill only if 'Evidence suggests functional limitation with flare-ups: Yes' is 'Yes'.

Check this box if the veteran has a current diagnosis of gout associated with the claimed condition(s).

Select this option if the gout affects the right side only. Fill only if 'Gout' is checked.

Select this option if the gout affects the left side only. Fill only if 'Gout' is checked.

Select this option if the gout affects both the right and left sides. Fill only if 'Gout' is checked.

Enter the ICD diagnostic code corresponding to the gout diagnosis. Fill only if 'Gout' is checked.

Enter the date the gout diagnosis was made for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Enter the date the gout diagnosis was made for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Check this box if the patient has heterotopic ossification.

Check this box if the heterotopic ossification is on the right side (select only one side option). Fill only if 'Heterotopic ossification' is checked.

Check this box if the heterotopic ossification is on the left side (select only one side option). Fill only if 'Heterotopic ossification' is checked.

Check this box if the heterotopic ossification affects both sides. Fill only if 'Heterotopic ossification' is checked.

Enter any details about the heterotopic ossification finding (e.g., location or other clarifying notes). Fill only if 'Heterotopic ossification' is checked.

Enter the heterotopic ossification details specific to the right side. Fill only if 'Right', 'Both' is checked (any fields selection).

Enter the heterotopic ossification details specific to the left side. Fill only if 'Left', 'Both' is checked (any fields selection).

Check this box if the Veteran has a current diagnosis of ankle/foot impingement (anterior or posterior) or trigonum syndrome/laterolateral impingement associated with the claimed condition(s).

Check this box if the impingement diagnosis affects the right side only. Fill only if 'Impingement (anterior/posterior or trigonum syndrome/laterolateral)' is checked.

Check this box if the impingement diagnosis affects the left side only. Fill only if 'Impingement (anterior/posterior or trigonum syndrome/laterolateral)' is checked.

Check this box if the impingement diagnosis affects both the right and left sides. Fill only if 'Impingement (anterior/posterior or trigonum syndrome/laterolateral)' is checked.

Enter the ICD diagnostic code for the impingement diagnosis (anterior/posterior, trigonum syndrome, or laterolateral) selected for this condition. Fill only if 'Impingement (anterior/posterior or trigonum syndrome/laterolateral)' is checked.

Enter the date the impingement diagnosis was made for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Enter the date the impingement diagnosis was made for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Check this box if the condition affects the range of motion (ROM) of the left knee. Fill only if '7A. Does the Veteran now have or has he or she ever had shin splints (medial tibial stress syndrome), stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)?' is 'Yes'.

Check this box if the condition does not affect the range of motion (ROM) of the left knee. Fill only if '7A. Does the Veteran now have or has he or she ever had shin splints (medial tibial stress syndrome), stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)?' is 'Yes'.

Check this box if this condition affects the range of motion (ROM) of the right knee. Fill only if '7A. Does the Veteran now have or has he or she ever had shin splints (medial tibial stress syndrome), stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)?' is 'Yes'.

Check this box if this condition does not affect the range of motion (ROM) of the right knee. Fill only if '7A. Does the Veteran now have or has he or she ever had shin splints (medial tibial stress syndrome), stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)?' is 'Yes'.

Check this box if the Veteran has a current diagnosis of chronic or recurrent lateral collateral ligament sprain.

Check this box if the chronic/recurrent lateral collateral ligament sprain affects the right side. Fill only if 'Lateral collateral ligament sprain (chronic/recurrent)' is checked.

Check this box if the chronic/recurrent lateral collateral ligament sprain affects the left side. Fill only if 'Lateral collateral ligament sprain (chronic/recurrent)' is checked.

Check this box if the chronic/recurrent lateral collateral ligament sprain affects both the right and left sides. Fill only if 'Lateral collateral ligament sprain (chronic/recurrent)' is checked.

Enter the ICD diagnosis code for the lateral collateral ligament sprain (chronic/recurrent). Fill only if 'Lateral collateral ligament sprain (chronic/recurrent)' is checked.

Provide the date the right-side lateral collateral ligament sprain (chronic/recurrent) was diagnosed. Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Provide the date the left-side lateral collateral ligament sprain (chronic/recurrent) was diagnosed. Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Check this box if there are no additional factors contributing to the left-side disability beyond those already addressed.

Check this box if the left-side condition interferes with the Veteran’s ability to sit.

Check this box if the left-side condition interferes with the Veteran’s ability to stand.

Check this box if swelling is present as an additional factor contributing to the left-side disability.

Check this box if the left-side condition causes difficulty walking or otherwise disturbs locomotion.

Check this box if there is deformity associated with the left-side condition contributing to disability.

Check this box if the left-side joint or body part has reduced movement compared to normal.

Check this box if the left-side joint or body part has excessive movement (hypermobile) compared to normal.

Check this box if the left-side condition causes weakened movement/strength contributing to disability.

Check this box if there is muscle atrophy due to disuse related to the left-side condition.

Check this box if the left-side condition causes unsteadiness or instability when standing.

Check this box if another additional factor contributes to the left-side disability and provide details in the adjacent description line.

If you selected “Other,” enter a brief description of the additional factor contributing to the disability. Fill only if 'Other (describe)' is 'Yes'.

Provide details describing the additional factors that contribute to the disability, including how they affect function.

Check this box if there is ankylosis (immobilization) of the left ankle.

Check this box if there is no ankylosis (immobilization) of the left ankle.

Check this box if the left ankle is ankylosed in plantar flexion at less than 30°. Fill only if 'Yes' is 'Yes'.

Check this box if the left ankle is ankylosed in plantar flexion between 30° and 40°. Fill only if 'Yes' is 'Yes'.

Check this box if the left ankle is ankylosed in plantar flexion at more than 40°. Fill only if 'Yes' is 'Yes'.

Check this box if the left ankle is ankylosed in dorsiflexion between 0° and 10°. Fill only if 'Yes' is 'Yes'.

Check this box if the left ankle is ankylosed in dorsiflexion at more than 10°. Fill only if 'Yes' is 'Yes'.

Check this box if left ankle ankylosis is accompanied by an abduction deformity. Fill only if 'Yes' is 'Yes'.

Check this box if left ankle ankylosis is accompanied by an adduction deformity. Fill only if 'Yes' is 'Yes'.

Check this box if left ankle ankylosis is accompanied by an inversion deformity. Fill only if 'Yes' is 'Yes'.

Check this box if left ankle ankylosis is accompanied by an eversion deformity. Fill only if 'Yes' is 'Yes'.

Check this box if there is no ankle ankylosis (so the ankle ankylosis angle in degrees does not apply). Fill only if 'No' is 'Yes'.

Enter the angle of left ankle ankylosis in plantar flexion, in degrees. Fill only if 'Yes' is 'Yes'.

Enter the angle of left ankle ankylosis in dorsiflexion, in degrees. Fill only if 'Yes' is 'Yes'.

Check this box if there is objective evidence of crepitus in the left ankle.

Check this box if there is no objective evidence of crepitus in the left ankle.

Enter the degree at which plantar flexion motion ends due to the identified limiting factor, if different from the value reported above. Fill only if 'Plantar flexion endpoint (45 degrees)' is different than the degree where plantar flexion is limited by pain/weakness/fatigability/incoordination/other.

Enter the degree at which dorsiflexion motion ends due to the identified limiting factor, if different from the value reported above. Fill only if 'Dorsiflexion endpoint (20 degrees)' is different than the degree where dorsiflexion is limited by pain/weakness/fatigability/incoordination/other.

Describe the factors (such as pain, weakness, fatigability, or incoordination) that specifically limit left ankle motion and note the degrees at which the limitation occurs.

Check this box if there is objective evidence of localized tenderness or pain on palpation of the left ankle joint or associated soft tissue.

Check this box if there is no objective evidence of localized tenderness or pain on palpation of the left ankle joint or associated soft tissue.

Enter any additional comments or explanation regarding pain in the left ankle, including how it presents and any relevant details. Fill only if 'Pain causes functional loss' is 'Yes'.

Check this box if there is evidence of pain in the left ankle.

Check this box if there is no evidence of pain in the left ankle.

Check this box if the left ankle pain occurs during weight-bearing activities. Fill only if 'Evidence of pain – Yes' is 'Yes'.

Check this box if the left ankle pain occurs when the ankle is not bearing weight. Fill only if 'Evidence of pain – Yes' is 'Yes'.

Check this box if the left ankle pain occurs with active (patient-initiated) motion. Fill only if 'Evidence of pain – Yes' is 'Yes'.

Check this box if the left ankle pain occurs with passive (examiner-assisted) motion. Fill only if 'Evidence of pain – Yes' is 'Yes'.

Check this box if the left ankle pain is present at rest or without movement. Fill only if 'Evidence of pain – Yes' is 'Yes'.

Check this box if the left ankle pain results in or causes functional loss (and describe it in the comments box). Fill only if 'Evidence of pain – Yes' is 'Yes'.

Check this box if the left ankle pain does not result in or cause functional loss. Fill only if 'Evidence of pain – Yes' is 'Yes'.

Check this box if the Veteran is able to perform repetitive-use testing with at least three repetitions for the left ankle.

Check this box if the Veteran is not able to perform repetitive-use testing with at least three repetitions for the left ankle.

Provide the reason the Veteran is not able to perform left ankle repetitive-use testing with at least three repetitions. Fill only if 'No' is 'Yes'.

Explain the objective evidence of localized tenderness or pain on palpation of the left ankle joint or associated soft tissue, including the location, severity, and relationship to the condition(s). Fill only if 'Yes' is 'Yes'.

Check this box if, on the LEFT ankle anterior drawer test, there is an absence of a firm end point with asymmetric or excessive motion.

Check this box if, on the LEFT ankle anterior drawer test, there is not an absence of a firm end point (i.e., a firm end point is present without asymmetric or excessive motion).

Check this box if you were unable to perform the LEFT ankle anterior drawer test.

Enter the estimated plantar flexion endpoint (in degrees) for this joint during flare-ups. Fill only if 'Does the Veteran report flare-ups of the ankle?' is 'Yes'.

Enter the estimated dorsiflexion endpoint (in degrees) for this joint during flare-ups. Fill only if 'Does the Veteran report flare-ups of the ankle?' is 'Yes'.

Provide a specific citation and discussion of the evidence used to support the flare-up range of motion estimates. Fill only if 'Does the Veteran report flare-ups of the ankle?' is 'Yes'.

Check this box if the muscle atrophy being reported is located in the left lower extremity (and you will specify the measurement location and provide circumference measurements). Fill only if 'Does the Veteran have muscle atrophy?' is 'Yes' and 'is the muscle atrophy due to the claimed condition in the diagnosis section?' is 'Yes'.

Describe the specific location of the left lower extremity muscle atrophy (e.g., how many cm above or below the ankle) and include the corresponding measurement details as instructed. Fill only if 'Does the Veteran have muscle atrophy?' is 'Yes' and 'is the muscle atrophy due to the claimed condition in the diagnosis section?' is 'Yes'.

Enter the circumference measurement of the more normal (less affected) side for the left lower extremity at the specified location. Fill only if 'Does the Veteran have muscle atrophy?' is 'Yes' and 'is the muscle atrophy due to the claimed condition in the diagnosis section?' is 'Yes'.

Enter the circumference measurement of the atrophied side for the left lower extremity at the specified location. Fill only if 'Does the Veteran have muscle atrophy?' is 'Yes' and 'is the muscle atrophy due to the claimed condition in the diagnosis section?' is 'Yes'.

Check this box if the Veteran has muscle atrophy.

Check this box if the Veteran does not have muscle atrophy.

Check this box if the Veteran’s muscle atrophy is due to the claimed condition listed in the diagnosis section. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran’s muscle atrophy is not due to the claimed condition listed in the diagnosis section (and provide a rationale). Fill only if 'Yes' is 'Yes'.

Provide the medical rationale explaining why the Veteran's muscle atrophy is not due to the claimed condition listed in the diagnosis section. Fill only if 'Yes', 'No' is 'Yes' and is 'Yes' (all).

Check this box if there is ankylosis of the left subastragalar or tarsal joint.

Check this box if there is no ankylosis of the left subastragalar or tarsal joint.

Check this box if left subastragalar/tarsal ankylosis is present and the joint is fixed in a good weight-bearing position. Fill only if 'Yes' is 'Yes'.

Check this box if left subastragalar/tarsal ankylosis is present and the joint is fixed in a poor weight-bearing position. Fill only if 'Yes' is 'Yes'.

Check this box if myositis is present/diagnosed for the patient.

Check this box if the myositis affects the right side only. Fill only if 'Myositis' is checked.

Check this box if the myositis affects the left side only. Fill only if 'Myositis' is checked.

Check this box if the myositis affects both the right and left sides. Fill only if 'Myositis' is checked.

Enter any details describing the myositis (such as the involved muscle(s), location, or other relevant notes). Fill only if 'Myositis' is checked.

Enter details describing the myositis affecting the right side. Fill only if 'Myositis – Right', 'Myositis – Both' is checked (any fields selection).

Enter details describing the myositis affecting the left side. Fill only if 'Myositis – Left', 'Myositis – Both' is checked (any fields selection).

Check this box if the Veteran does not currently have a diagnosis associated with any claimed condition(s) listed above (and provide findings/reasons in the Remarks section).

Check this box if the Veteran has a diagnosis of osteitis deformans associated with the claimed condition(s).

Check this box if osteitis deformans affects the right side only. Fill only if 'Osteitis deformans' is checked.

Check this box if osteitis deformans affects the left side only. Fill only if 'Osteitis deformans' is checked.

Check this box if osteitis deformans affects both the right and left sides. Fill only if 'Osteitis deformans' is checked.

Enter the ICD diagnosis code for osteitis deformans (Paget disease) associated with the claimed condition. Fill only if 'Osteitis deformans' is checked.

Enter the date osteitis deformans was diagnosed for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Enter the date osteitis deformans was diagnosed for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Check this box if the Veteran’s diagnosis includes osteochondritis dissecans and/or an osteochondral fracture.

Check this box if the osteochondritis dissecans/osteochondral fracture affects the right side only. Fill only if 'Osteochondritis dissecans (include osteochondral fracture)' is checked.

Check this box if the osteochondritis dissecans/osteochondral fracture affects the left side only. Fill only if 'Osteochondritis dissecans (include osteochondral fracture)' is checked.

Check this box if the osteochondritis dissecans/osteochondral fracture affects both the right and left sides. Fill only if 'Osteochondritis dissecans (include osteochondral fracture)' is checked.

Enter the ICD diagnostic code for osteochondritis dissecans (including osteochondral fracture). Fill only if 'Osteochondritis dissecans (include osteochondral fracture)' is checked.

Provide the date when osteochondritis dissecans (including osteochondral fracture) was diagnosed for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Provide the date when osteochondritis dissecans (including osteochondral fracture) was diagnosed for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Check this box if the Veteran has a current diagnosis of osteomalacia with residuals associated with the claimed condition(s).

Check this box if the osteomalacia residuals affect the right side. Fill only if 'Osteomalacia, residuals of' is checked.

Check this box if the osteomalacia residuals affect the left side. Fill only if 'Osteomalacia, residuals of' is checked.

Check this box if the osteomalacia residuals affect both the right and left sides. Fill only if 'Osteomalacia, residuals of' is checked.

Enter the ICD diagnostic code for the osteomalacia residuals diagnosis. Fill only if 'Osteomalacia, residuals of' is checked.

Enter the date the osteomalacia residuals diagnosis was made for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Enter the date the osteomalacia residuals diagnosis was made for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Check this box if the Veteran has a current diagnosis of residuals of osteoporosis associated with the claimed condition(s).

Check this box if the osteoporosis residuals affect the right side. Fill only if 'Osteoporosis, residuals of' is checked.

Check this box if the osteoporosis residuals affect the left side. Fill only if 'Osteoporosis, residuals of' is checked.

Check this box if the osteoporosis residuals affect both the right and left sides. Fill only if 'Osteoporosis, residuals of' is checked.

Enter the ICD diagnosis code for osteoporosis residuals. Fill only if 'Osteoporosis, residuals of' is checked.

Enter the date of diagnosis for osteoporosis residuals affecting the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Enter the date of diagnosis for osteoporosis residuals affecting the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Check this box if the diagnosis is not listed elsewhere on the form and you will specify it as an “Other” diagnosis.

Enter the name of the other diagnosis being reported as diagnosis #1. Fill only if 'Other (specify)' is checked.

Check this box if the specified “Other diagnosis #1” affects the right side only. Fill only if 'Other (specify)' is checked.

Check this box if the specified “Other diagnosis #1” affects the left side only. Fill only if 'Other (specify)' is checked.

Check this box if the specified “Other diagnosis #1” affects both the right and left sides. Fill only if 'Other (specify)' is checked.

Provide additional details for other diagnosis #1, such as the body area or location involved. Fill only if 'Other (specify)' is checked.

Enter any additional details specific to the right side for other diagnosis #1. Fill only if 'Other diagnosis #1 – Right', 'Other diagnosis #1 – Both' is checked (any fields selection).

Enter any additional details specific to the left side for other diagnosis #1. Fill only if 'Other diagnosis #1 – Left', 'Other diagnosis #1 – Both' is checked (any fields selection).

Enter the name of the second additional diagnosis to be reported. Fill only if 'Other (specify)' is checked.

Check this box if the specified Other diagnosis #2 applies to the right side only. Fill only if 'Other (specify)' is checked.

Check this box if the specified Other diagnosis #2 applies to the left side only. Fill only if 'Other (specify)' is checked.

Check this box if the specified Other diagnosis #2 applies to both the right and left sides. Fill only if 'Other (specify)' is checked.

Provide any additional specification or descriptive details for other diagnosis #2. Fill only if 'Other (specify)' is checked.

Enter the right-side information or findings related to other diagnosis #2. Fill only if 'Right', 'Both' is checked (any fields selection).

Enter the left-side information or findings related to other diagnosis #2. Fill only if 'Left', 'Both' is checked (any fields selection).

Enter the name of the third additional diagnosis being reported. Fill only if 'Other (specify)' is checked.

Check this box if Other diagnosis #3 applies to the right ankle/foot only. Fill only if 'Other (specify)' is checked.

Check this box if Other diagnosis #3 applies to the left ankle/foot only. Fill only if 'Other (specify)' is checked.

Check this box if Other diagnosis #3 applies to both ankles/feet. Fill only if 'Other (specify)' is checked.

Provide any additional details needed to specify this diagnosis (for example, the structure or location involved). Fill only if 'Other (specify)' is checked.

Enter the right-side specific details for this diagnosis, if applicable. Fill only if 'Right', 'Both' is checked (any fields selection).

Enter the left-side specific details for this diagnosis, if applicable. Fill only if 'Left', 'Both' is checked (any fields selection).

Provide a brief summary describing any other pertinent physical findings, complications, conditions, signs, or symptoms related to the diagnosed conditions. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran has any other pertinent physical findings, complications, conditions, signs, or symptoms related to the conditions listed in the diagnosis section.

Check this box if the Veteran does not have any other pertinent physical findings, complications, conditions, signs, or symptoms related to the conditions listed in the diagnosis section.

Describe who requested completion of this Disability Benefits Questionnaire if the requestor is not the Veteran/Claimant or a third party. Fill only if 'Other (please describe)' is 'Yes'.

Check this box if the veteran’s current diagnosis is an other specified arthropathy (not gout) associated with the claimed condition(s).

Enter the specific diagnosis name for the other specified form of arthropathy (excluding gout). Fill only if 'Other specified forms of arthropathy (excluding gout)' is checked.

Check this box if the other specified arthropathy (excluding gout) affects the right side only. Fill only if 'Other specified forms of arthropathy (excluding gout)' is checked.

Check this box if the other specified arthropathy (excluding gout) affects the left side only. Fill only if 'Other specified forms of arthropathy (excluding gout)' is checked.

Check this box if the other specified arthropathy (excluding gout) affects both the right and left sides. Fill only if 'Other specified forms of arthropathy (excluding gout)' is checked.

Enter the ICD diagnosis code corresponding to the other specified arthropathy diagnosis. Fill only if 'Other specified forms of arthropathy (excluding gout)' is checked.

Enter the date the condition was diagnosed for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Enter the date the condition was diagnosed for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Enter the full name of the patient/veteran.

Enter the patient/veteran's Social Security Number.

Enter the date the examination was performed.

Check this box if you are a VA Healthcare provider.

Check this box if you are not a VA Healthcare provider.

Check this box if you are completing this Disability Benefits Questionnaire at the request of the Veteran/Claimant.

Check this box if you are completing this questionnaire at the request of a third party, and list the requesting organization(s) or individual(s).

Check this box if the requestor does not fit the options above and describe who requested the questionnaire.

Check this box if the Veteran is being examined immediately after repeated use over time.

Check this box if the Veteran is not being examined immediately after repeated use over time.

Check this box if procured evidence (including the Veteran’s statements) suggests pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability with repeated use over time.

Check this box if procured evidence (including the Veteran’s statements) does not suggest pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability with repeated use over time.

Check this box if pain is a factor causing the functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'.

Check this box if fatigability is a factor causing the functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'.

Check this box if weakness is a factor causing the functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'.

Check this box if lack of endurance is a factor causing the functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'.

Check this box if incoordination is a factor causing the functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'.

Check this box if another factor (not listed) is causing the functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'.

Enter any other factor not listed that causes functional loss with repeated use over time. Fill only if 'Other' is 'Yes'.

Check this box if no factors apply or the functional-loss factors section is not applicable. Fill only if 'Yes' is 'Yes'.

Provide the estimated plantar flexion endpoint for this joint immediately after repeated use over time. Fill only if 'Yes' is 'Yes'.

Provide the estimated dorsiflexion endpoint for this joint immediately after repeated use over time. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran is being examined immediately after repeated use over time.

Check this box if the Veteran is not being examined immediately after repeated use over time.

Check this box if procured evidence (e.g., the Veteran’s statements) suggests pain, fatigability, weakness, lack of endurance, or incoordination significantly limits functional ability with repeated use over time.

Check this box if procured evidence does not suggest significant functional limitation with repeated use over time.

Check this box if pain is a factor causing the functional loss with repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time — Yes' is 'Yes'.

Check this box if fatigability is a factor causing the functional loss with repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time — Yes' is 'Yes'.

Check this box if weakness is a factor causing the functional loss with repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time — Yes' is 'Yes'.

Check this box if lack of endurance is a factor causing the functional loss with repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time — Yes' is 'Yes'.

Check this box if incoordination is a factor causing the functional loss with repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time — Yes' is 'Yes'.

Check this box if another factor (not listed) causes the functional loss with repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time — Yes' is 'Yes'.

Enter the other factor(s) (not listed) that cause functional loss with repeated use over time. Fill only if 'Factor causing functional loss — Other' is 'Yes'.

Check this box if none of the listed factors apply as causes of functional loss with repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time — Yes' is 'Yes'.

Provide the estimated plantar flexion endpoint range of motion immediately after repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time — Yes' is 'Yes'.

Provide the estimated dorsiflexion endpoint range of motion immediately after repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time — Yes' is 'Yes'.

Cite and discuss the specific evidence used to support the repeated-use-over-time findings for this joint, based on all procurable information. Fill only if 'Yes' is 'Yes'.

Provide a narrative citing and discussing the specific evidence used to support the repeated-use-over-time findings, based on all procurable evidence. Fill only if 'Evidence suggests functional limitation with repeated use over time — Yes' is 'Yes'.

Check this box if the patient has residuals (ongoing symptoms or limitations) from arthroscopic or other ankle surgery. Fill only if 'Arthroscopic or other ankle surgery' is 'Yes'.

Enter a description of any residual symptoms, limitations, or complications resulting from the Veteran’s arthroscopic or other ankle surgery. Fill only if 'Arthroscopic or other ankle surgery' is 'Yes'.

Check this box if the patient has any residual symptoms or limitations resulting from arthroscopic or other ankle surgery. Fill only if 'Arthroscopic or other ankle surgery' is 'Yes'.

Enter a detailed description of any current residuals or lasting effects from the arthroscopic or other ankle surgery for this second entry. Fill only if 'Arthroscopic or other ankle surgery' is 'Yes'.

Check this box if the Veteran has a diagnosis of retrocalcaneal bursitis associated with the claimed condition(s).

Check this box if the retrocalcaneal bursitis affects the right side. Fill only if 'Retrocalcaneal bursitis' is checked.

Check this box if the retrocalcaneal bursitis affects the left side. Fill only if 'Retrocalcaneal bursitis' is checked.

Check this box if the retrocalcaneal bursitis affects both the right and left sides. Fill only if 'Retrocalcaneal bursitis' is checked.

Enter the ICD diagnosis code for retrocalcaneal bursitis. Fill only if 'Retrocalcaneal bursitis' is checked.

Enter the date retrocalcaneal bursitis was diagnosed for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Enter the date retrocalcaneal bursitis was diagnosed for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Check this box if there are no additional factors contributing to the disability beyond those already addressed.

Check this box if the condition interferes with the Veteran’s ability to sit.

Check this box if the condition interferes with the Veteran’s ability to stand.

Check this box if swelling is present and contributes to the disability.

Check this box if the condition causes an abnormal or impaired gait/movement when walking or moving.

Check this box if a deformity is present and contributes to the disability.

Check this box if the joint/affected area has reduced movement compared with normal.

Check this box if the joint/affected area has increased or excessive movement compared with normal.

Check this box if weakness causes reduced strength or weakened movement that contributes to the disability.

Check this box if there is muscle atrophy due to disuse from the condition.

Check this box if the Veteran has instability while standing (e.g., unsteadiness) that contributes to the disability.

Check this box if another contributing factor applies that is not listed and provide details in the description area.

If you selected “Other,” enter the additional contributing factor to disability that is not listed among the provided options. Fill only if 'Other, describe' is 'Yes'.

Provide a detailed narrative describing the additional factors contributing to the disability, including relevant context and examples.

Check this box if the right ankle has ankylosis (immobilization of the joint).

Check this box if the right ankle does not have ankylosis.

Check this box if the right ankle ankylosis is fixed in plantar flexion at less than 30 degrees. Fill only if 'Ankylosis of the ankle: Yes' is 'Yes'.

Check this box if the right ankle ankylosis is fixed in plantar flexion between 30 and 40 degrees. Fill only if 'Ankylosis of the ankle: Yes' is 'Yes'.

Check this box if the right ankle ankylosis is fixed in plantar flexion at more than 40 degrees. Fill only if 'Ankylosis of the ankle: Yes' is 'Yes'.

Check this box if the right ankle ankylosis is fixed in dorsiflexion between 0 and 10 degrees. Fill only if 'Ankylosis of the ankle: Yes' is 'Yes'.

Check this box if the right ankle ankylosis is fixed in dorsiflexion at more than 10 degrees. Fill only if 'Ankylosis of the ankle: Yes' is 'Yes'.

Check this box if the right ankle ankylosis is accompanied by an abduction deformity. Fill only if 'Ankylosis of the ankle: Yes' is 'Yes'.

Check this box if the right ankle ankylosis is accompanied by an adduction deformity. Fill only if 'Ankylosis of the ankle: Yes' is 'Yes'.

Check this box if the right ankle ankylosis is accompanied by an inversion deformity. Fill only if 'Ankylosis of the ankle: Yes' is 'Yes'.

Check this box if the right ankle ankylosis is accompanied by an eversion deformity. Fill only if 'Ankylosis of the ankle: Yes' is 'Yes'.

Check this box if there is no ankle ankylosis, so the ankle ankylosis angle in degrees does not apply. Fill only if 'Ankylosis of the ankle: No' is 'Yes'.

Enter the right ankle ankylosis angle in degrees for plantar flexion. Fill only if 'Ankylosis of the ankle: Yes' is 'Yes'.

Enter the right ankle ankylosis angle in degrees for dorsiflexion. Fill only if 'Ankylosis of the ankle: Yes' is 'Yes'.

Check this box if there is objective (clinically observed) evidence of crepitus in the right ankle.

Check this box if there is no objective (clinically observed) evidence of crepitus in the right ankle.

Enter the plantar flexion degree at which limitation of motion occurs due to pain, weakness, fatigability, incoordination, or other factors (if different than the value reported above). Fill only if 'Plantar flexion endpoint (45 degrees)' is different than the degree where plantar flexion is limited by pain/weakness/fatigability/incoordination/other.

Enter the dorsiflexion degree at which limitation of motion occurs due to pain, weakness, fatigability, incoordination, or other factors (if different than the value reported above). Fill only if 'Dorsiflexion endpoint (20 degrees)' is different than the degree where dorsiflexion is limited by pain/weakness/fatigability/incoordination/other.

Describe the factors (such as pain, weakness, fatigability, incoordination, or other) that specifically cause the right ankle limitation of motion and how they affect motion.

Check this box if there is objective evidence of localized tenderness or pain on palpation of the right ankle joint or associated soft tissue.

Check this box if there is no objective evidence of localized tenderness or pain on palpation of the right ankle joint or associated soft tissue.

Enter any additional comments describing the right ankle pain, including relevant findings, triggers, limitations, and clinical observations. Fill only if 'Pain causes functional loss' is 'Yes'.

Check this box if there is evidence of pain in the right ankle.

Check this box if there is no evidence of pain in the right ankle.

Check this box if right ankle pain is present during weight-bearing. Fill only if 'Evidence of pain: Yes' is 'Yes'.

Check this box if right ankle pain is present during nonweight-bearing. Fill only if 'Evidence of pain: Yes' is 'Yes'.

Check this box if right ankle pain occurs with active (patient-initiated) motion. Fill only if 'Evidence of pain: Yes' is 'Yes'.

Check this box if right ankle pain occurs with passive (examiner-assisted) motion. Fill only if 'Evidence of pain: Yes' is 'Yes'.

Check this box if right ankle pain is present at rest or with non-movement. Fill only if 'Evidence of pain: Yes' is 'Yes'.

Check this box if the right ankle pain results in or causes functional loss (and describe in the comments box). Fill only if 'Evidence of pain: Yes' is 'Yes'.

Check this box if right ankle pain does not result in or cause functional loss. Fill only if 'Evidence of pain: Yes' is 'Yes'.

Check this box if the Veteran is able to perform repetitive-use testing with at least three repetitions for the right ankle.

Check this box if the Veteran is not able to perform repetitive-use testing with at least three repetitions for the right ankle.

Explain why the Veteran is not able to perform repetitive-use testing with at least three repetitions for the right ankle. Fill only if 'No' is 'Yes'.

Provide an explanation of any localized tenderness or pain on palpation of the right ankle joint or associated soft tissue, including the location, severity, and relationship to the condition(s). Fill only if 'Yes' is 'Yes'.

Check this box if the right Anterior Drawer Test shows absence of a firm end point with asymmetric or excessive motion.

Check this box if the right Anterior Drawer Test does not show absence of a firm end point with asymmetric or excessive motion.

Check this box if you are unable to perform the right Anterior Drawer Test.

Enter the estimated right ankle plantar flexion endpoint during flare-ups in degrees based on all procurable information. Fill only if 'Does the Veteran report flare-ups of the ankle?' is 'Yes'.

Enter the estimated right ankle dorsiflexion endpoint during flare-ups in degrees based on all procurable information. Fill only if 'Does the Veteran report flare-ups of the ankle?' is 'Yes'.

Provide a narrative citing and discussing the specific evidence used to support the estimated right ankle range of motion during flare-ups. Fill only if 'Does the Veteran report flare-ups of the ankle?' is 'Yes'.

Check this box if the muscle atrophy being reported is located in the right lower extremity. Fill only if 'Does the Veteran have muscle atrophy?' is 'Yes' and 'is the muscle atrophy due to the claimed condition in the diagnosis section?' is 'Yes'.

Describe the specific right lower extremity location where muscle atrophy is measured (e.g., a set distance above or below the ankle) and provide any related measurement details. Fill only if 'Does the Veteran have muscle atrophy?' is 'Yes' and 'is the muscle atrophy due to the claimed condition in the diagnosis section?' is 'Yes'.

Enter the circumference measurement of the more normal (unaffected) right lower extremity at the selected measurement location. Fill only if 'Does the Veteran have muscle atrophy?' is 'Yes' and 'is the muscle atrophy due to the claimed condition in the diagnosis section?' is 'Yes'.

Enter the circumference measurement of the atrophied right lower extremity at the selected measurement location. Fill only if 'Does the Veteran have muscle atrophy?' is 'Yes' and 'is the muscle atrophy due to the claimed condition in the diagnosis section?' is 'Yes'.

Check this box if the Veteran has muscle atrophy (for the right side, Section 4A).

Check this box if the Veteran does not have muscle atrophy (for the right side, Section 4A).

Check this box if the Veteran’s muscle atrophy is due to the claimed condition listed in the diagnosis section. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran’s muscle atrophy is not due to the claimed condition listed in the diagnosis section (and provide a rationale). Fill only if 'Yes' is 'Yes'.

Provide the rationale explaining why the Veteran's right muscle atrophy is not due to the claimed condition listed in the diagnosis section. Fill only if 'Yes', 'No' is 'Yes' and is 'Yes' (all).

Check this box if there is ankylosis of the right subastragalar or tarsal joint.

Check this box if there is no ankylosis of the right subastragalar or tarsal joint.

Check this box if right subastragalar/tarsal ankylosis is present and the joint is fixed in a good weight-bearing position. Fill only if 'Yes' is 'Yes'.

Check this box if right subastragalar/tarsal ankylosis is present and the joint is fixed in a poor weight-bearing position. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran has any scars or other skin disfigurement related to the diagnosed conditions or to their treatment.

Check this box if the Veteran does not have any scars or other skin disfigurement related to the diagnosed conditions or to their treatment.

Enter the plantar flexion degree endpoint if the limitation is specifically attributable to pain, weakness, fatigability, incoordination, or other factors and it differs from the ROM value recorded above. Fill only if 'Plantar Flexion Endpoint (Active ROM)' is different than above.

Enter the dorsiflexion degree endpoint if the limitation is specifically attributable to pain, weakness, fatigability, incoordination, or other factors and it differs from the ROM value recorded above. Fill only if 'Dorsiflexion Endpoint (Active ROM)' is different than above.

Provide details describing any active range of motion limitation attributable to pain, weakness, fatigability, incoordination, or other factors, including relevant observations and context.

Enter the measured active range-of-motion endpoint for the second ankle in plantar flexion, in degrees.

Enter the measured active range-of-motion endpoint for the second ankle in dorsiflexion, in degrees.

Check this box if the second ankle has pain during active range of motion testing in plantar flexion.

Check this box if the second ankle has pain during active range of motion testing in dorsiflexion.

Check this box if, when abnormal, the ankle’s range of motion itself contributes to a functional loss. Fill only if 'Initial ROM measurements' is 'Abnormal or outside of normal range'.

Check this box if, when abnormal, the ankle’s range of motion itself does not contribute to a functional loss. Fill only if 'Initial ROM measurements' is 'Abnormal or outside of normal range'.

Provide an explanation of how the second ankle’s abnormal range of motion contributes to functional loss. Fill only if 'Yes' is 'Yes'.

Enter the measured passive range-of-motion endpoint for plantar flexion of the second ankle in degrees. Fill only if 'Plantar flexion passive ROM - Same as active ROM' is 'No'.

Check this box if the passive plantar flexion endpoint measurement is the same as the active ROM value.

Enter the measured passive range-of-motion endpoint for dorsiflexion of the second ankle in degrees. Fill only if 'Dorsiflexion passive ROM - Same as active ROM' is 'No'.

Check this box if the passive dorsiflexion endpoint measurement is the same as the active ROM value.

Check this box if passive range of motion testing shows pain during plantar flexion in the second ankle.

Check this box if passive range of motion testing shows pain during dorsiflexion in the second ankle.

Check this box if testing of the second ankle can be performed.

Check this box if testing of the second ankle cannot be performed (and an explanation should be provided).

Provide an explanation for why testing cannot be performed for the second ankle. Fill only if 'No' is 'Yes'.

Check this box if the unclaimed second ankle joint is damaged. Fill only if 'Side affected' is 'Right'.

Check this box if the unclaimed second ankle joint is undamaged. Fill only if 'Side affected' is 'Right'.

Check this box if the diagnosed condition(s) impact the Veteran’s ability to perform any occupational task (e.g., standing, walking, lifting, sitting).

Check this box if the diagnosed condition(s) do not impact the Veteran’s ability to perform any occupational task.

Describe how the diagnosed condition(s) impact the Veteran’s ability to perform occupational tasks (e.g., standing, walking, lifting, sitting), including one or more examples. Fill only if 'Yes' is 'Yes'.

Enter any additional remarks or clarifications, identifying the section of the form the remark pertains to when appropriate. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'Yes'.

Provide a brief narrative describing the history of the Veteran’s ankle condition(s), including onset and course over time.

Check this box if the Veteran reports experiencing flare-ups of the ankle.

Check this box if the Veteran does not report any flare-ups of the ankle.

Describe the Veteran’s ankle flare-ups, including frequency, duration, characteristics, triggers, relieving factors, severity, and any functional impairment during flare-ups. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran currently has, or has ever had, Achilles tendonitis or an Achilles tendon rupture (left side). Fill only if 'Yes' is 'Yes'.

Describe the Veteran’s current symptoms related to left Achilles tendonitis or a left Achilles tendon rupture. Fill only if 'Achilles tendonitis or Achilles tendon rupture' is selected.

Check this box if the Veteran currently has or has ever had Achilles tendonitis or an Achilles tendon rupture (right side). Fill only if 'Yes' is 'Yes'.

Enter a detailed description of the Veteran’s current symptoms related to right Achilles tendonitis or right Achilles tendon rupture. Fill only if 'Achilles tendonitis or Achilles tendon rupture' is selected.

Check this box if the Veteran now has, or has ever had, any of the listed conditions (shin splints, stress fractures, Achilles tendinitis/rupture, malunion of calcaneus/talus, or a talectomy).

Check this box if the Veteran does not currently have and has never had any of the listed conditions (shin splints, stress fractures, Achilles tendinitis/rupture, malunion of calcaneus/talus, or a talectomy).

Check this box if the Veteran now has or has ever had any of the listed right-side conditions (e.g., shin splints, stress fractures, Achilles tendonitis/rupture, malunion of calcaneus/talus, or a talectomy/astragalectomy).

Check this box if the Veteran does not currently have and has never had any of the listed right-side conditions (including a talectomy/astragalectomy).

Check this box if the Veteran has (now or ever had) a malunion of the calcaneus (os calcis) or talus (astragalus). Fill only if 'Yes' is 'Yes'.

Check this box to indicate the malunion severity is a moderate deformity (left). Fill only if 'Malunion of calcaneus (os calcis) or talus (astragalus)' is selected.

Check this box to indicate the malunion severity is a marked deformity (left). Fill only if 'Malunion of calcaneus (os calcis) or talus (astragalus)' is selected.

Check this box if the Veteran has a malunion of the calcaneus (os calcis) or talus (astragalus). Fill only if 'Yes' is 'Yes'.

Check this box if the malunion of the calcaneus or talus results in a moderate deformity. Fill only if 'Malunion of calcaneus (os calcis) or talus (astragalus)' is selected.

Check this box if the malunion of the calcaneus or talus results in a marked deformity. Fill only if 'Malunion of calcaneus (os calcis) or talus (astragalus)' is selected.

Check this box if the Veteran currently has, or has ever had, shin splints (MTSS) on the left side. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran received no treatment for left shin splints (MTSS). Fill only if '"Shin Splints" (medial tibial stress syndrome - MTSS)' is selected.

Check this box if treatment for left shin splints (MTSS) lasted less than 12 consecutive months. Fill only if '"Shin Splints" (medial tibial stress syndrome - MTSS)' is selected.

Check this box if left shin splints (MTSS) required treatment for 12 consecutive months or more. Fill only if '"Shin Splints" (medial tibial stress syndrome - MTSS)' is selected.

Check this box if the Veteran has (now or ever had) shin splints/MTSS on the right side. Fill only if 'Yes' is 'Yes'.

Check this box if, for right-side shin splints/MTSS, no treatment was received. Fill only if '"Shin Splints" (medial tibial stress syndrome - MTSS)' is selected.

Check this box if treatment for right-side shin splints/MTSS lasted less than 12 consecutive months. Fill only if '"Shin Splints" (medial tibial stress syndrome - MTSS)' is selected.

Check this box if right-side shin splints/MTSS required treatment for 12 consecutive months or more. Fill only if '"Shin Splints" (medial tibial stress syndrome - MTSS)' is selected.

Check this box if the Veteran has a stress fracture of the lower leg (and complete the related questionnaire/ROM section if it affects knee range of motion). Fill only if 'Yes' is 'Yes'.

Describe the veteran's current symptoms related to a left lower-leg stress fracture. Fill only if 'Stress fracture of the lower leg' is selected.

Check this box if the Veteran has (now or ever had) a stress fracture of the lower leg and you need to complete the related musculoskeletal questionnaire/ROM section if applicable. Fill only if 'Yes' is 'Yes'.

Enter a description of the Veteran’s current symptoms related to the right lower-leg stress fracture. Fill only if 'Stress fracture of the lower leg' is selected.

Check this box if the Veteran has a current diagnosis of shin splints/medial tibial stress syndrome (including post-surgery or treatment).

Check this box if the shin splints/MTSS affects the right side only. Fill only if 'Shin splints / medial tibial stress syndrome (MTSS)' is checked.

Check this box if the shin splints/MTSS affects the left side only. Fill only if 'Shin splints / medial tibial stress syndrome (MTSS)' is checked.

Check this box if the shin splints/MTSS affects both the right and left sides. Fill only if 'Shin splints / medial tibial stress syndrome (MTSS)' is checked.

Enter the ICD diagnosis code for shin splints/medial tibial stress syndrome (MTSS). Fill only if 'Shin splints / medial tibial stress syndrome (MTSS)' is checked.

Enter the date the right-side shin splints/medial tibial stress syndrome (MTSS) was diagnosed. Fill only if 'Side affected: Right', 'Side affected: Both' is checked (any fields selection).

Enter the date the left-side shin splints/medial tibial stress syndrome (MTSS) was diagnosed. Fill only if 'Side affected: Left', 'Side affected: Both' is checked (any fields selection).

Check this box if the Veteran has not had any surgical procedures related to this condition.

Check this box if the Veteran has not had any surgical procedures for this condition (right side).

Check this box if the left talar tilt test shows asymmetric or excessive motion.

Check this box if the left talar tilt test does not show asymmetric or excessive motion.

Check this box if you were unable to perform the left talar tilt test (and provide an explanation in the space below).

Explain why the left talar tilt test could not be performed. Fill only if 'Unable to test' is 'Unable to test'.

Check this box if the right talar tilt test shows asymmetric or excessive motion.

Check this box if the right talar tilt test does not show asymmetric or excessive motion.

Check this box if you could not perform the right talar tilt test.

Provide the reason the right talar tilt test could not be performed. Fill only if 'Unable to test' is 'Unable to test'.

Check this box if the Veteran has had a talectomy procedure on the left side. Fill only if '7A. Does the Veteran now have or has he or she ever had shin splints (medial tibial stress syndrome), stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)?' is 'Yes'.

Describe the Veteran’s current left-side symptoms related to the talectomy condition. Fill only if 'Talectomy' is 'Yes'.

Check this box if the Veteran has had a talectomy on the right side (right foot/ankle). Fill only if '7A. Does the Veteran now have or has he or she ever had shin splints (medial tibial stress syndrome), stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)?' is 'Yes'.

Describe the Veteran's current right-side symptoms related to talectomy, including severity, frequency, and functional limitations. Fill only if 'Talectomy' is 'Yes'.

Check this box if the diagnosis is tendinitis (inflammation/irritation of a tendon).

Check this box if the tendinitis affects the right side. Fill only if 'Tendinitis' is checked.

Check this box if the tendinitis affects the left side. Fill only if 'Tendinitis' is checked.

Check this box if the tendinitis affects both the right and left sides. Fill only if 'Tendinitis' is checked.

Enter any additional details about the tendinitis diagnosis (e.g., tendon involved or other clarifying notes). Fill only if 'Tendinitis' is checked.

Enter details specific to tendinitis on the right side (e.g., tendon involved or location). Fill only if 'Right', 'Both' is checked (any fields selection).

Enter details specific to tendinitis on the left side (e.g., tendon involved or location). Fill only if 'Left', 'Both' is checked (any fields selection).

Check this box if the condition being documented is tendinopathy.

Check this box if the tendinopathy affects the right side (select one side option if known). Fill only if 'Tendinopathy' is checked.

Check this box if the tendinopathy affects the left side (select one side option if known). Fill only if 'Tendinopathy' is checked.

Check this box if the tendinopathy affects both sides (select one side option if known). Fill only if 'Tendinopathy' is checked.

Enter the tendon or anatomical area affected by tendinopathy and any relevant notes (e.g., specific tendon name). Fill only if 'Tendinopathy' is checked.

Enter the tendon or anatomical area affected on the right side. Fill only if 'Tendinopathy - Right', 'Tendinopathy - Both' is checked (any fields selection).

Enter the tendon or anatomical area affected on the left side. Fill only if 'Tendinopathy - Left', 'Tendinopathy - Both' is checked (any fields selection).

Check this box if the diagnosis is tendinosis.

Check this box if the tendinosis affects the right side only. Fill only if 'Tendinosis' is checked.

Check this box if the tendinosis affects the left side only. Fill only if 'Tendinosis' is checked.

Check this box if the tendinosis affects both the right and left sides. Fill only if 'Tendinosis' is checked.

Enter the name of the tendon or anatomical area affected by tendinosis. Fill only if 'Tendinosis' is checked.

Provide any additional tendinosis details specific to the right side (e.g., location or extent). Fill only if 'Tendinosis - Right', 'Tendinosis - Both' is checked (any fields selection).

Provide any additional tendinosis details specific to the left side (e.g., location or extent). Fill only if 'Tendinosis - Left', 'Tendinosis - Both' is checked (any fields selection).

Check this box if the Veteran has a current diagnosis of tendonitis involving the Achilles, peroneal, and/or posterior tibial tendon.

Check this box if the tendonitis diagnosis applies to the right side only. Fill only if 'Tendonitis (Achilles/peroneal/posterior tibial)' is checked.

Check this box if the tendonitis diagnosis applies to the left side only. Fill only if 'Tendonitis (Achilles/peroneal/posterior tibial)' is checked.

Check this box if the tendonitis diagnosis applies to both the right and left sides. Fill only if 'Tendonitis (Achilles/peroneal/posterior tibial)' is checked.

Enter the ICD diagnosis code for the tendonitis condition (Achilles/peroneal/posterior tibial). Fill only if 'Tendonitis (Achilles/peroneal/posterior tibial)' is checked.

Enter the date the right-sided tendonitis condition was diagnosed. Fill only if 'Tendonitis side affected: Right', 'Tendonitis side affected: Both' is checked (any fields selection).

Enter the date the left-sided tendonitis condition was diagnosed. Fill only if 'Tendonitis side affected: Left', 'Tendonitis side affected: Both' is checked (any fields selection).

Check this box if the diagnosis/condition is tenosynovitis.

Select this option if the tenosynovitis affects the right side. Fill only if 'Tenosynovitis' is checked.

Select this option if the tenosynovitis affects the left side. Fill only if 'Tenosynovitis' is checked.

Select this option if the tenosynovitis affects both the right and left sides. Fill only if 'Tenosynovitis' is checked.

Enter any general details about the tenosynovitis diagnosis (e.g., tendon/location or other clarifying notes). Fill only if 'Tenosynovitis' is checked.

Enter details specific to tenosynovitis affecting the right side (e.g., tendon/location or notes). Fill only if 'Right', 'Both' is checked (any fields selection).

Enter details specific to tenosynovitis affecting the left side (e.g., tendon/location or notes). Fill only if 'Left', 'Both' is checked (any fields selection).

Enter the name(s) of the third-party organization(s) or individual(s) requesting completion of this Disability Benefits Questionnaire. Fill only if 'Third party (organization or individual)' is 'Yes'.

Check this box if the Veteran has had a total ankle joint replacement surgery on the left ankle.

Enter the date the Veteran underwent the left total ankle joint replacement surgery. Fill only if 'Total ankle joint replacement' is 'Yes'.

Check this box if the left total ankle joint replacement resulted in no residual symptoms or functional limitations.

Check this box if the left total ankle joint replacement has residual weakness, pain, or limitation of motion of an intermediate degree.

Check this box if the left total ankle joint replacement has chronic residuals with severe painful motion and/or weakness.

Check this box if the left total ankle joint replacement has residuals not listed above and you will describe them in the space provided.

Describe any other residuals or ongoing symptoms resulting from the left total ankle joint replacement surgery. Fill only if 'Residuals: Other (describe)' is 'Yes'.

Check this box if the Veteran has had a total ankle joint replacement on the right side.

Enter the date the Veteran had the total ankle joint replacement surgery on the right ankle. Fill only if 'Total ankle joint replacement' is 'Yes'.

Check this box if there are no residual symptoms or limitations from the right total ankle joint replacement.

Check this box if the right total ankle joint replacement resulted in intermediate residual weakness, pain, or limitation of motion.

Check this box if the right total ankle joint replacement resulted in chronic severe painful motion or weakness.

Check this box if the right total ankle joint replacement has residuals not listed above and you will describe them.

Describe any other residuals or ongoing symptoms/limitations resulting from the right total ankle joint replacement. Fill only if 'Residuals: Other (describe)' is 'Yes'.

Check this box if the Veteran’s condition improved or responded to surgery and/or other treatment. Fill only if '7A. Does the Veteran now have or has he or she ever had shin splints (medial tibial stress syndrome), stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)?' is 'Yes'.

Check this box if the Veteran did not improve with shoe orthotics or other conservative treatment. Fill only if '7A. Does the Veteran now have or has he or she ever had shin splints (medial tibial stress syndrome), stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)?' is 'Yes'.

Check this box if the Veteran did not improve with surgery and also did not improve with shoe orthotics or other conservative treatment. Fill only if '7A. Does the Veteran now have or has he or she ever had shin splints (medial tibial stress syndrome), stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)?' is 'Yes'.

Check this box if the Veteran’s condition improved or responded to surgery and/or other treatment. Fill only if '7A. Does the Veteran now have or has he or she ever had shin splints (medial tibial stress syndrome), stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)?' is 'Yes'.

Check this box if the Veteran’s condition did not improve with shoe orthotics or other conservative (non-surgical) treatment. Fill only if '7A. Does the Veteran now have or has he or she ever had shin splints (medial tibial stress syndrome), stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)?' is 'Yes'.

Check this box if the Veteran’s condition did not improve with surgery and also did not improve with shoe orthotics or other conservative treatment. Fill only if '7A. Does the Veteran now have or has he or she ever had shin splints (medial tibial stress syndrome), stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of calcaneus (os calcis) or talus (astragalus), or has the Veteran had a talectomy (astragalectomy)?' is 'Yes'.

Check this box if the Veteran uses assistive devices as a normal mode of locomotion (even if other methods are occasionally possible).

Check this box if the Veteran does not use assistive devices as a normal mode of locomotion.

Check this box if the Veteran was examined in person (face-to-face).

Check this box if the Veteran was not examined in person.

Check this box if the Veteran is regularly seen as a patient in your clinic.

Check this box if the Veteran is not regularly seen as a patient in your clinic.