This form contains 739 fields organized into 179 sections, giving it a Form Complexity Index of 100/100 (very complex). Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
6A Impairment Present (Yes/No)
Yes	Radiobutton	Check this box if the Veteran has a flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation.
No	Radiobutton	Check this box if the Veteran does not have a flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation.
6B Comments
6B Comments	Text	Enter any additional comments or clarifying information related to the Section 6 other impairments findings.
8C. Comments, if any:
Comments	Text	Enter any additional comments or clarifying information relevant to this section.
Abnormal Findings Relationship to Diagnosed Conditions (11E)
Relationship of Abnormal Findings to Diagnosed Conditions	Text	Describe how any abnormal diagnostic test results relate to the diagnosed condition(s).
Additional Other Diagnoses List
Additional Other Diagnoses	Text	Enter any additional elbow or forearm diagnoses not already listed above, using the same format as the other diagnosis entries.
Arthritis Documentation and Side (11B)
Yes (arthritis documented)	Radiobutton	Check this box if degenerative or post-traumatic arthritis is documented based on imaging studies.
No (arthritis not documented)	Radiobutton	Check this box if degenerative or post-traumatic arthritis is not documented based on imaging studies.
Right	Radiobutton	Check this box if the documented degenerative or post-traumatic arthritis is on the right side. Fill only if 'Yes (arthritis documented)' is 'Yes'. Depends on: Yes (arthritis documented)
Left	Radiobutton	Check this box if the documented degenerative or post-traumatic arthritis is on the left side. Fill only if 'Yes (arthritis documented)' is 'Yes'. Depends on: Yes (arthritis documented)
Both	Radiobutton	Check this box if the documented degenerative or post-traumatic arthritis is present on both the right and left sides. Fill only if 'Yes (arthritis documented)' is 'Yes'. Depends on: Yes (arthritis documented)
Assistive Devices Details by Condition/Side
Assistive Devices by Condition and Side	Text	Describe each condition for which an assistive device is used, including the affected side (e.g., left/right/bilateral) and the specific assistive device used for that condition. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Brace Use Frequency
Brace	Checkbox	Check this box if the Veteran uses a brace as an assistive device. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Occasional	Radiobutton	Check this box if the Veteran uses the brace occasionally (not regularly or constantly). Fill only if 'Brace' is 'Yes'. Depends on: Brace
Regular	Radiobutton	Check this box if the Veteran uses the brace regularly as part of usual activities. Fill only if 'Brace' is 'Yes'. Depends on: Brace
Constant	Radiobutton	Check this box if the Veteran uses the brace constantly or nearly all the time. Fill only if 'Brace' is 'Yes'. Depends on: Brace
Claimed Conditions List
Claimed conditions	Text	List all claimed elbow and forearm conditions that pertain to this disability benefits questionnaire.
Comments (if any)
Comments (if any)	Text	Enter any additional comments, explanations, findings, or remarks related to the diagnoses and elbow/forearm condition(s) listed in this section. Fill only if 'No current diagnosis for any claimed condition' is 'Yes'. Depends on: No current diagnosis for any claimed condition
Condition History Summary
Condition history summary	Text	Describe the history of the Veteran’s elbow and/or forearm condition, including onset and course, as a brief summary.
Diagnosis Row - Ankylosis of elbow joint
Ankylosis of elbow joint	Checkbox	Check this box if the Veteran has a diagnosis of ankylosis of the elbow joint related to the claimed condition(s).
Side affected: Right	Radiobutton	Check this box if ankylosis of the elbow joint affects the right elbow only. Fill only if 'Ankylosis of elbow joint' is 'Yes'. Depends on: Ankylosis of elbow joint
Side affected: Left	Radiobutton	Check this box if ankylosis of the elbow joint affects the left elbow only. Fill only if 'Ankylosis of elbow joint' is 'Yes'. Depends on: Ankylosis of elbow joint
Side affected: Both	Radiobutton	Check this box if ankylosis of the elbow joint affects both elbows. Fill only if 'Ankylosis of elbow joint' is 'Yes'. Depends on: Ankylosis of elbow joint
Ankylosis of Elbow Joint ICD Code	Text	Enter the ICD diagnostic code for ankylosis of the elbow joint. Fill only if 'Ankylosis of elbow joint' is 'Yes'. Depends on: Ankylosis of elbow joint
Ankylosis of Elbow Joint Date of Diagnosis (Right)	Date	Enter the date ankylosis of the right elbow joint was diagnosed. Fill only if 'Ankylosis of elbow joint', 'Side affected: Right', 'Side affected: Both' are 'Yes' (all of field 59 and any of fields 60, 62). Depends on: Ankylosis of elbow joint, Side affected: Right, Side affected: Both
Ankylosis of Elbow Joint Date of Diagnosis (Left)	Date	Enter the date ankylosis of the left elbow joint was diagnosed. Fill only if 'Ankylosis of elbow joint', 'Side affected: Left', 'Side affected: Both' are 'Yes' (all of field 59 and any of fields 61, 62). Depends on: Ankylosis of elbow joint, Side affected: Left, Side affected: Both
Diagnosis Row - Arthritis, gonorrheal
Arthritis, gonorrheal	Checkbox	Check this box if the Veteran has a diagnosis of gonorrheal arthritis associated with the claimed condition(s).
Arthritis, gonorrheal - Right	Radiobutton	Check this box if gonorrheal arthritis affects the right elbow/forearm only. Fill only if 'Arthritis, gonorrheal' is 'Yes'. Depends on: Arthritis, gonorrheal
Arthritis, gonorrheal - Left	Radiobutton	Check this box if gonorrheal arthritis affects the left elbow/forearm only. Fill only if 'Arthritis, gonorrheal' is 'Yes'. Depends on: Arthritis, gonorrheal
Arthritis, gonorrheal - Both	Radiobutton	Check this box if gonorrheal arthritis affects both the right and left elbows/forearms. Fill only if 'Arthritis, gonorrheal' is 'Yes'. Depends on: Arthritis, gonorrheal
ICD Code - Arthritis, gonorrheal	Text	Enter the ICD diagnostic code for the condition “Arthritis, gonorrheal.” Fill only if 'Arthritis, gonorrheal' is 'Yes'. Depends on: Arthritis, gonorrheal
Date of Diagnosis (Right) - Arthritis, gonorrheal	Date	Enter the date this condition was diagnosed for the right side. Fill only if 'Arthritis, gonorrheal', 'Arthritis, gonorrheal - Right', 'Arthritis, gonorrheal - Both' are 'Yes' (all of field 73 and any of fields 74, 76). Depends on: Arthritis, gonorrheal, Arthritis, gonorrheal - Right, Arthritis, gonorrheal - Both
Date of Diagnosis (Left) - Arthritis, gonorrheal	Date	Enter the date this condition was diagnosed for the left side. Fill only if 'Arthritis, gonorrheal', 'Arthritis, gonorrheal - Left', 'Arthritis, gonorrheal - Both' are 'Yes' (all of field 73 and any of fields 75, 76). Depends on: Arthritis, gonorrheal, Arthritis, gonorrheal - Left, Arthritis, gonorrheal - Both
Diagnosis Row - Arthritis, pneumococcic
Arthritis, pneumococcic	Checkbox	Check this box if the Veteran has a diagnosis of pneumococcal arthritis associated with the claimed condition(s).
Side affected: Right	Radiobutton	Check this box if pneumococcal arthritis affects the Veteran’s right elbow/forearm. Fill only if 'Arthritis, pneumococcic' is 'Yes'. Depends on: Arthritis, pneumococcic
Side affected: Left	Radiobutton	Check this box if pneumococcal arthritis affects the Veteran’s left elbow/forearm. Fill only if 'Arthritis, pneumococcic' is 'Yes'. Depends on: Arthritis, pneumococcic
Side affected: Both	Radiobutton	Check this box if pneumococcal arthritis affects both the right and left elbows/forearms. Fill only if 'Arthritis, pneumococcic' is 'Yes'. Depends on: Arthritis, pneumococcic
Pneumococcic Arthritis ICD Code	Text	Enter the ICD diagnosis code for pneumococcic arthritis. Fill only if 'Arthritis, pneumococcic' is 'Yes'. Depends on: Arthritis, pneumococcic
Pneumococcic Arthritis Date of Diagnosis (Right)	Date	Enter the date pneumococcic arthritis was diagnosed for the right side. Fill only if 'Arthritis, pneumococcic', 'Side affected: Right', 'Side affected: Both' are 'Yes' (all of field 80 and any of fields 81, 83). Depends on: Arthritis, pneumococcic, Side affected: Right, Side affected: Both
Pneumococcic Arthritis Date of Diagnosis (Left)	Date	Enter the date pneumococcic arthritis was diagnosed for the left side. Fill only if 'Arthritis, pneumococcic', 'Side affected: Left', 'Side affected: Both' are 'Yes' (all of field 80 and any of fields 82, 83). Depends on: Arthritis, pneumococcic, Side affected: Left, Side affected: Both
Diagnosis Row - Arthritis, post-traumatic
Arthritis, post-traumatic	Checkbox	Check this box if the Veteran has a diagnosis of post-traumatic arthritis related to the claimed condition.
Side affected: Right	Radiobutton	Check this box if the post-traumatic arthritis affects the right elbow/forearm only. Fill only if 'Arthritis, post-traumatic' is 'Yes'. Depends on: Arthritis, post-traumatic
Side affected: Left	Radiobutton	Check this box if the post-traumatic arthritis affects the left elbow/forearm only. Fill only if 'Arthritis, post-traumatic' is 'Yes'. Depends on: Arthritis, post-traumatic
Side affected: Both	Radiobutton	Check this box if the post-traumatic arthritis affects both the right and left elbows/forearms. Fill only if 'Arthritis, post-traumatic' is 'Yes'. Depends on: Arthritis, post-traumatic
ICD Code (Arthritis, post-traumatic)	Text	Enter the ICD diagnostic code for the post-traumatic arthritis condition. Fill only if 'Arthritis, post-traumatic' is 'Yes'. Depends on: Arthritis, post-traumatic
Date of Diagnosis - Right (Arthritis, post-traumatic)	Date	Enter the date the clinician first diagnosed post-traumatic arthritis in the right elbow/forearm. Fill only if 'Arthritis, post-traumatic', 'Side affected: Right', 'Side affected: Both' are 'Yes' (all of field 108 and any of fields 109, 111). Depends on: Arthritis, post-traumatic, Side affected: Right, Side affected: Both
Date of Diagnosis - Left (Arthritis, post-traumatic)	Date	Enter the date the clinician first diagnosed post-traumatic arthritis in the left elbow/forearm. Fill only if 'Arthritis, post-traumatic', 'Side affected: Left', 'Side affected: Both' are 'Yes' (all of field 108 and any of fields 110, 111). Depends on: Arthritis, post-traumatic, Side affected: Left, Side affected: Both
Diagnosis Row - Arthritis, rheumatoid (multi-joint)
Arthritis, rheumatoid (multi-joint)	Checkbox	Check this box if the Veteran has a diagnosis of rheumatoid arthritis affecting multiple joints associated with the claimed condition(s).
Side affected: Right	Radiobutton	Check this box if the rheumatoid (multi-joint) arthritis affects the right side. Fill only if 'Arthritis, rheumatoid (multi-joint)' is 'Yes'. Depends on: Arthritis, rheumatoid (multi-joint)
Side affected: Left	Radiobutton	Check this box if the rheumatoid (multi-joint) arthritis affects the left side. Fill only if 'Arthritis, rheumatoid (multi-joint)' is 'Yes'. Depends on: Arthritis, rheumatoid (multi-joint)
Side affected: Both	Radiobutton	Check this box if the rheumatoid (multi-joint) arthritis affects both the right and left sides. Fill only if 'Arthritis, rheumatoid (multi-joint)' is 'Yes'. Depends on: Arthritis, rheumatoid (multi-joint)
ICD Code (Rheumatoid Arthritis, Multi-joint)	Text	Enter the ICD diagnostic code for the Veteran’s rheumatoid arthritis (multi-joint) condition. Fill only if 'Arthritis, rheumatoid (multi-joint)' is 'Yes'. Depends on: Arthritis, rheumatoid (multi-joint)
Date of Diagnosis (Right)	Date	Enter the date the Veteran was diagnosed with rheumatoid arthritis (multi-joint) affecting the right side. Fill only if 'Arthritis, rheumatoid (multi-joint)', 'Side affected: Right', 'Side affected: Both' are 'Yes' (all of field 101 and any of fields 102, 104). Depends on: Arthritis, rheumatoid (multi-joint), Side affected: Right, Side affected: Both
Date of Diagnosis (Left)	Date	Enter the date the Veteran was diagnosed with rheumatoid arthritis (multi-joint) affecting the left side. Fill only if 'Arthritis, rheumatoid (multi-joint)', 'Side affected: Left', 'Side affected: Both' are 'Yes' (all of field 101 and any of fields 103, 104). Depends on: Arthritis, rheumatoid (multi-joint), Side affected: Left, Side affected: Both
Diagnosis Row - Arthritis, streptococcic
Arthritis, streptococcic	Checkbox	Check this box if the claimed condition diagnosed is streptococcic arthritis.
Arthritis, streptococcic - Right	Radiobutton	Check this box if the streptococcic arthritis affects the right side. Fill only if 'Arthritis, streptococcic' is 'Yes'. Depends on: Arthritis, streptococcic
Arthritis, streptococcic - Left	Radiobutton	Check this box if the streptococcic arthritis affects the left side. Fill only if 'Arthritis, streptococcic' is 'Yes'. Depends on: Arthritis, streptococcic
Arthritis, streptococcic - Both	Radiobutton	Check this box if the streptococcic arthritis affects both sides. Fill only if 'Arthritis, streptococcic' is 'Yes'. Depends on: Arthritis, streptococcic
ICD Code (Arthritis, streptococcic)	Text	Enter the ICD diagnostic code for the Veteran’s streptococcic arthritis diagnosis. Fill only if 'Arthritis, streptococcic' is 'Yes'. Depends on: Arthritis, streptococcic
Date of Diagnosis – Right (Arthritis, streptococcic)	Date	Enter the date streptococcic arthritis was diagnosed for the right side. Fill only if 'Arthritis, streptococcic', 'Arthritis, streptococcic - Right', 'Arthritis, streptococcic - Both' are 'Yes' (all of field 87 and any of fields 88, 90). Depends on: Arthritis, streptococcic, Arthritis, streptococcic - Right, Arthritis, streptococcic - Both
Date of Diagnosis – Left (Arthritis, streptococcic)	Date	Enter the date streptococcic arthritis was diagnosed for the left side. Fill only if 'Arthritis, streptococcic', 'Arthritis, streptococcic - Left', 'Arthritis, streptococcic - Both' are 'Yes' (all of field 87 and any of fields 89, 90). Depends on: Arthritis, streptococcic, Arthritis, streptococcic - Left, Arthritis, streptococcic - Both
Diagnosis Row - Arthritis, syphilitic
Arthritis, syphilitic	Checkbox	Check this box if the Veteran has a diagnosis of syphilitic arthritis associated with the claimed condition(s).
Arthritis, syphilitic - Side affected: Right	Radiobutton	Check this box if the syphilitic arthritis affects the right side (right elbow/forearm). Fill only if 'Arthritis, syphilitic' is 'Yes'. Depends on: Arthritis, syphilitic
Arthritis, syphilitic - Side affected: Left	Radiobutton	Check this box if the syphilitic arthritis affects the left side (left elbow/forearm). Fill only if 'Arthritis, syphilitic' is 'Yes'. Depends on: Arthritis, syphilitic
Arthritis, syphilitic - Side affected: Both	Radiobutton	Check this box if the syphilitic arthritis affects both sides (both elbows/forearms). Fill only if 'Arthritis, syphilitic' is 'Yes'. Depends on: Arthritis, syphilitic
Arthritis, syphilitic - ICD code	Text	Enter the ICD diagnosis code for syphilitic arthritis. Fill only if 'Arthritis, syphilitic' is 'Yes'. Depends on: Arthritis, syphilitic
Arthritis, syphilitic - Date of diagnosis (Right)	Date	Enter the date syphilitic arthritis was diagnosed for the right side. Fill only if 'Arthritis, syphilitic', 'Arthritis, syphilitic - Side affected: Right', 'Arthritis, syphilitic - Side affected: Both' are 'Yes' (all of field 94 and any of fields 95, 97). Depends on: Arthritis, syphilitic, Arthritis, syphilitic - Side affected: Right, Arthritis, syphilitic - Side affected: Both
Arthritis, syphilitic - Date of diagnosis (Left)	Date	Enter the date syphilitic arthritis was diagnosed for the left side. Fill only if 'Arthritis, syphilitic', 'Arthritis, syphilitic - Side affected: Left', 'Arthritis, syphilitic - Side affected: Both' are 'Yes' (all of field 94 and any of fields 96, 97). Depends on: Arthritis, syphilitic, Arthritis, syphilitic - Side affected: Left, Arthritis, syphilitic - Side affected: Both
Diagnosis Row - Arthritis, typhoid
Arthritis, typhoid	Checkbox	Check this box if the Veteran has a diagnosis of typhoid arthritis associated with the claimed condition(s).
Arthritis, typhoid - Right	Radiobutton	Check this box if the typhoid arthritis affects the right side. Fill only if 'Arthritis, typhoid' is 'Yes'. Depends on: Arthritis, typhoid
Arthritis, typhoid - Left	Radiobutton	Check this box if the typhoid arthritis affects the left side. Fill only if 'Arthritis, typhoid' is 'Yes'. Depends on: Arthritis, typhoid
Arthritis, typhoid - Both	Radiobutton	Check this box if the typhoid arthritis affects both sides. Fill only if 'Arthritis, typhoid' is 'Yes'. Depends on: Arthritis, typhoid
Arthritis, Typhoid ICD Code	Text	Enter the ICD diagnostic code for the Veteran’s typhoid arthritis condition. Fill only if 'Arthritis, typhoid' is 'Yes'. Depends on: Arthritis, typhoid
Arthritis, Typhoid Date of Diagnosis (Right)	Date	Enter the date the Veteran was diagnosed with typhoid arthritis affecting the right side. Fill only if 'Arthritis, typhoid', 'Arthritis, typhoid - Right', 'Arthritis, typhoid - Both' are 'Yes' (all of field 115 and any of fields 116, 118). Depends on: Arthritis, typhoid, Arthritis, typhoid - Right, Arthritis, typhoid - Both
Arthritis, Typhoid Date of Diagnosis (Left)	Date	Enter the date the Veteran was diagnosed with typhoid arthritis affecting the left side. Fill only if 'Arthritis, typhoid', 'Arthritis, typhoid - Left', 'Arthritis, typhoid - Both' are 'Yes' (all of field 115 and any of fields 117, 118). Depends on: Arthritis, typhoid, Arthritis, typhoid - Left, Arthritis, typhoid - Both
Diagnosis Row - Bones, neoplasm, benign
Bones, neoplasm, benign	Checkbox	Check this box if the Veteran has a diagnosis of a benign bone neoplasm related to the claimed condition(s).
Bones, neoplasm, benign - Right	Radiobutton	Check this box if the benign bone neoplasm affects the right side. Fill only if 'Bones, neoplasm, benign' is 'Yes'. Depends on: Bones, neoplasm, benign
Bones, neoplasm, benign - Left	Radiobutton	Check this box if the benign bone neoplasm affects the left side. Fill only if 'Bones, neoplasm, benign' is 'Yes'. Depends on: Bones, neoplasm, benign
Bones, neoplasm, benign - Both	Radiobutton	Check this box if the benign bone neoplasm affects both the right and left sides. Fill only if 'Bones, neoplasm, benign' is 'Yes'. Depends on: Bones, neoplasm, benign
Bones Neoplasm (Benign) ICD Code	Text	Enter the ICD diagnostic code for the benign bone neoplasm diagnosis. Fill only if 'Bones, neoplasm, benign' is 'Yes'. Depends on: Bones, neoplasm, benign
Bones Neoplasm (Benign) Date of Diagnosis (Right)	Date	Enter the date the benign bone neoplasm was diagnosed on the right side. Fill only if 'Bones, neoplasm, benign', 'Bones, neoplasm, benign - Right', 'Bones, neoplasm, benign - Both' are 'Yes' (all of field 144 and any of fields 145, 147). Depends on: Bones, neoplasm, benign, Bones, neoplasm, benign - Right, Bones, neoplasm, benign - Both
Bones Neoplasm (Benign) Date of Diagnosis (Left)	Date	Enter the date the benign bone neoplasm was diagnosed on the left side. Fill only if 'Bones, neoplasm, benign', 'Bones, neoplasm, benign - Left', 'Bones, neoplasm, benign - Both' are 'Yes' (all of field 144 and any of fields 146, 147). Depends on: Bones, neoplasm, benign, Bones, neoplasm, benign - Left, Bones, neoplasm, benign - Both
Diagnosis Row - Bursitis
Bursitis	Checkbox	Check this box if the Veteran has a diagnosis of bursitis related to the claimed elbow/forearm condition.
Bursitis - Right side	Radiobutton	Check this box if the bursitis affects the right side only. Fill only if 'Bursitis' is 'Yes'. Depends on: Bursitis
Bursitis - Left side	Radiobutton	Check this box if the bursitis affects the left side only. Fill only if 'Bursitis' is 'Yes'. Depends on: Bursitis
Bursitis - Both sides	Radiobutton	Check this box if the bursitis affects both the right and left sides. Fill only if 'Bursitis' is 'Yes'. Depends on: Bursitis
Bursitis ICD Code	Text	Enter the ICD diagnosis code for the bursitis condition. Fill only if 'Bursitis' is 'Yes'. Depends on: Bursitis
Bursitis Date of Diagnosis (Right)	Date	Enter the date the bursitis diagnosis was made for the right side. Fill only if 'Bursitis', 'Bursitis - Right side', 'Bursitis - Both sides' are 'Yes' (all of field 165 and any of fields 166, 168). Depends on: Bursitis, Bursitis - Right side, Bursitis - Both sides
Bursitis Date of Diagnosis (Left)	Date	Enter the date the bursitis diagnosis was made for the left side. Fill only if 'Bursitis', 'Bursitis - Left side', 'Bursitis - Both sides' are 'Yes' (all of field 165 and any of fields 167, 168). Depends on: Bursitis, Bursitis - Left side, Bursitis - Both sides
Diagnosis Row - Degenerative arthritis (other than post-traumatic)
Degenerative arthritis (other than post-traumatic)	Checkbox	Check this box if the Veteran has a diagnosis of degenerative arthritis that is not due to a post-traumatic cause.
Side affected: Right	Radiobutton	Check this box if the degenerative arthritis (other than post-traumatic) affects the right elbow/forearm only. Fill only if 'Degenerative arthritis (other than post-traumatic)' is 'Yes'. Depends on: Degenerative arthritis (other than post-traumatic)
Side affected: Left	Radiobutton	Check this box if the degenerative arthritis (other than post-traumatic) affects the left elbow/forearm only. Fill only if 'Degenerative arthritis (other than post-traumatic)' is 'Yes'. Depends on: Degenerative arthritis (other than post-traumatic)
Side affected: Both	Radiobutton	Check this box if the degenerative arthritis (other than post-traumatic) affects both the right and left elbows/forearms. Fill only if 'Degenerative arthritis (other than post-traumatic)' is 'Yes'. Depends on: Degenerative arthritis (other than post-traumatic)
ICD Code	Text	Enter the ICD diagnosis code for degenerative arthritis (other than post-traumatic). Fill only if 'Degenerative arthritis (other than post-traumatic)' is 'Yes'. Depends on: Degenerative arthritis (other than post-traumatic)
Date of Diagnosis (Right)	Date	Provide the date the degenerative arthritis (other than post-traumatic) was diagnosed for the right side. Fill only if 'Degenerative arthritis (other than post-traumatic)', 'Side affected: Right', 'Side affected: Both' are 'Yes' (all of field 66 and any of fields 67, 69). Depends on: Degenerative arthritis (other than post-traumatic), Side affected: Right, Side affected: Both
Date of Diagnosis (Left)	Date	Provide the date the degenerative arthritis (other than post-traumatic) was diagnosed for the left side. Fill only if 'Degenerative arthritis (other than post-traumatic)', 'Side affected: Left', 'Side affected: Both' are 'Yes' (all of field 66 and any of fields 68, 69). Depends on: Degenerative arthritis (other than post-traumatic), Side affected: Left, Side affected: Both
Diagnosis Row - Dislocation, elbow
Dislocation, elbow	Checkbox	Check this box if the Veteran has a diagnosis of elbow dislocation associated with the claimed condition(s).
Side affected: Right	Radiobutton	Check this box if the elbow dislocation diagnosis affects the right elbow. Fill only if 'Dislocation, elbow' is 'Yes'. Depends on: Dislocation, elbow
Side affected: Left	Radiobutton	Check this box if the elbow dislocation diagnosis affects the left elbow. Fill only if 'Dislocation, elbow' is 'Yes'. Depends on: Dislocation, elbow
Side affected: Both	Radiobutton	Check this box if the elbow dislocation diagnosis affects both elbows. Fill only if 'Dislocation, elbow' is 'Yes'. Depends on: Dislocation, elbow
Dislocation, elbow ICD code	Text	Enter the ICD diagnosis code for the elbow dislocation. Fill only if 'Dislocation, elbow' is 'Yes'. Depends on: Dislocation, elbow
Dislocation, elbow date of diagnosis (Right)	Date	Enter the date the right elbow dislocation was diagnosed. Fill only if 'Dislocation, elbow', 'Side affected: Right', 'Side affected: Both' are 'Yes' (all of field 38 and any of fields 39, 41). Depends on: Dislocation, elbow, Side affected: Right, Side affected: Both
Dislocation, elbow date of diagnosis (Left)	Date	Enter the date the left elbow dislocation was diagnosed. Fill only if 'Dislocation, elbow', 'Side affected: Left', 'Side affected: Both' are 'Yes' (all of field 38 and any of fields 40, 41). Depends on: Dislocation, elbow, Side affected: Left, Side affected: Both
Diagnosis Row - Gout
Gout	Checkbox	Check this box if the claimed condition includes a current diagnosis of gout.
Gout - Side affected: Right	Radiobutton	Check this box if the gout diagnosis affects the right elbow/forearm only. Fill only if 'Gout' is 'Yes'. Depends on: Gout
Gout - Side affected: Left	Radiobutton	Check this box if the gout diagnosis affects the left elbow/forearm only. Fill only if 'Gout' is 'Yes'. Depends on: Gout
Gout - Side affected: Both	Radiobutton	Check this box if the gout diagnosis affects both the right and left elbows/forearms. Fill only if 'Gout' is 'Yes'. Depends on: Gout
Gout ICD Code	Text	Enter the ICD diagnosis code for the Veteran's gout. Fill only if 'Gout' is 'Yes'. Depends on: Gout
Gout Date of Diagnosis (Right)	Date	Enter the date the Veteran was diagnosed with gout affecting the right side. Fill only if 'Gout', 'Gout - Side affected: Right', 'Gout - Side affected: Both' are 'Yes' (all of field 158 and any of fields 159, 161). Depends on: Gout, Gout - Side affected: Right, Gout - Side affected: Both
Gout Date of Diagnosis (Left)	Date	Enter the date the Veteran was diagnosed with gout affecting the left side. Fill only if 'Gout', 'Gout - Side affected: Left', 'Gout - Side affected: Both' are 'Yes' (all of field 158 and any of fields 160, 161). Depends on: Gout, Gout - Side affected: Left, Gout - Side affected: Both
Diagnosis Row - Heterotopic ossification
Heterotopic ossification	Checkbox	Check this box if heterotopic ossification is a diagnosed condition associated with the claimed elbow/forearm condition.
Heterotopic ossification - Right	Radiobutton	Check this box if the heterotopic ossification affects the right side. Fill only if 'Heterotopic ossification' is 'Yes'. Depends on: Heterotopic ossification
Heterotopic ossification - Left	Radiobutton	Check this box if the heterotopic ossification affects the left side. Fill only if 'Heterotopic ossification' is 'Yes'. Depends on: Heterotopic ossification
Heterotopic ossification - Both	Radiobutton	Check this box if the heterotopic ossification affects both the right and left sides. Fill only if 'Heterotopic ossification' is 'Yes'. Depends on: Heterotopic ossification
Row 26 - Heterotopic ossification: ICD code	Text	Enter the ICD diagnosis code corresponding to heterotopic ossification for this condition. Fill only if 'Row 26 - Heterotopic ossification' is 'Yes'. Fill only if 'Heterotopic ossification' is 'Yes'. Depends on: Heterotopic ossification
Row 26 - Heterotopic ossification: Date of diagnosis (Right)	Date	Enter the date when heterotopic ossification was diagnosed for the right side. Fill only if 'Row 26 - Heterotopic ossification' is 'Yes'. Fill only if 'Heterotopic ossification', 'Heterotopic ossification - Right', 'Heterotopic ossification - Both' are 'Yes' (all of field 179 and any of fields 180, 182). Depends on: Heterotopic ossification, Heterotopic ossification - Right, Heterotopic ossification - Both
Row 26 - Heterotopic ossification: Date of diagnosis (Left)	Date	Enter the date when heterotopic ossification was diagnosed for the left side. Fill only if 'Row 26 - Heterotopic ossification' is 'Yes'. Fill only if 'Heterotopic ossification', 'Heterotopic ossification - Left', 'Heterotopic ossification - Both' are 'Yes' (all of field 179 and any of fields 181, 182). Depends on: Heterotopic ossification, Heterotopic ossification - Left, Heterotopic ossification - Both
Diagnosis Row - Instability (medial/posterolateral rotatory)
Instability (medial/posterolateral rotatory)	Checkbox	Check this box if the Veteran has a diagnosis of elbow instability (medial and/or posterolateral rotatory) associated with the claimed condition.
Side affected: Right	Radiobutton	Select this option if the diagnosed instability affects the right elbow only. Fill only if 'Instability (medial/posterolateral rotatory)' is 'Yes'. Depends on: Instability (medial/posterolateral rotatory)
Side affected: Left	Radiobutton	Select this option if the diagnosed instability affects the left elbow only. Fill only if 'Instability (medial/posterolateral rotatory)' is 'Yes'. Depends on: Instability (medial/posterolateral rotatory)
Side affected: Both	Radiobutton	Select this option if the diagnosed instability affects both elbows. Fill only if 'Instability (medial/posterolateral rotatory)' is 'Yes'. Depends on: Instability (medial/posterolateral rotatory)
Instability ICD Code	Text	Enter the ICD diagnostic code for the elbow/forearm instability (medial/posterolateral rotatory) condition. Fill only if 'Instability (medial/posterolateral rotatory)' is 'Yes'. Depends on: Instability (medial/posterolateral rotatory)
Instability Diagnosis Date (Right)	Date	Enter the date the instability (medial/posterolateral rotatory) condition was diagnosed for the right side. Fill only if 'Instability (medial/posterolateral rotatory)', 'Side affected: Right', 'Side affected: Both' are 'Yes' (all of field 31 and any of fields 32, 34). Depends on: Instability (medial/posterolateral rotatory), Side affected: Right, Side affected: Both
Instability Diagnosis Date (Left)	Date	Enter the date the instability (medial/posterolateral rotatory) condition was diagnosed for the left side. Fill only if 'Instability (medial/posterolateral rotatory)', 'Side affected: Left', 'Side affected: Both' are 'Yes' (all of field 31 and any of fields 33, 34). Depends on: Instability (medial/posterolateral rotatory), Side affected: Left, Side affected: Both
Diagnosis Row - Lateral epicondylitis
Lateral epicondylitis	Checkbox	Check this box if the Veteran has a diagnosis of lateral epicondylitis associated with the claimed condition(s).
Lateral epicondylitis - Side affected: Right	Radiobutton	Select this option if the lateral epicondylitis affects the right side. Fill only if 'Lateral epicondylitis' is 'Yes'. Depends on: Lateral epicondylitis
Lateral epicondylitis - Side affected: Left	Radiobutton	Select this option if the lateral epicondylitis affects the left side. Fill only if 'Lateral epicondylitis' is 'Yes'. Depends on: Lateral epicondylitis
Lateral epicondylitis - Side affected: Both	Radiobutton	Select this option if the lateral epicondylitis affects both the right and left sides. Fill only if 'Lateral epicondylitis' is 'Yes'. Depends on: Lateral epicondylitis
Lateral epicondylitis ICD code	Text	Enter the ICD diagnosis code for the Veteran's lateral epicondylitis. Fill only if 'Lateral epicondylitis' is 'Yes'. Depends on: Lateral epicondylitis
Lateral epicondylitis date of diagnosis (Right)	Date	Enter the date the Veteran was diagnosed with lateral epicondylitis affecting the right side. Fill only if 'Lateral epicondylitis', 'Lateral epicondylitis - Side affected: Right', 'Lateral epicondylitis - Side affected: Both' are 'Yes' (all of field 17 and any of fields 18, 20). Depends on: Lateral epicondylitis, Lateral epicondylitis - Side affected: Right, Lateral epicondylitis - Side affected: Both
Lateral epicondylitis date of diagnosis (Left)	Date	Enter the date the Veteran was diagnosed with lateral epicondylitis affecting the left side. Fill only if 'Lateral epicondylitis', 'Lateral epicondylitis - Side affected: Left', 'Lateral epicondylitis - Side affected: Both' are 'Yes' (all of field 17 and any of fields 19, 20). Depends on: Lateral epicondylitis, Lateral epicondylitis - Side affected: Left, Lateral epicondylitis - Side affected: Both
Diagnosis Row - Medial epicondylitis
Medial epicondylitis	Checkbox	Check this box if the Veteran has a current diagnosis of medial epicondylitis associated with the claimed elbow/forearm condition.
Medial epicondylitis - Right	Radiobutton	Check this box if the medial epicondylitis affects the right side. Fill only if 'Medial epicondylitis' is 'Yes'. Depends on: Medial epicondylitis
Medial epicondylitis - Left	Radiobutton	Check this box if the medial epicondylitis affects the left side. Fill only if 'Medial epicondylitis' is 'Yes'. Depends on: Medial epicondylitis
Medial epicondylitis - Both	Radiobutton	Check this box if the medial epicondylitis affects both the right and left sides. Fill only if 'Medial epicondylitis' is 'Yes'. Depends on: Medial epicondylitis
Medial epicondylitis ICD code	Text	Enter the ICD diagnosis code for the medial epicondylitis condition. Fill only if 'Medial epicondylitis' is 'Yes'. Depends on: Medial epicondylitis
Medial epicondylitis diagnosis date (Right)	Date	Enter the date the right-sided medial epicondylitis was diagnosed. Fill only if 'Medial epicondylitis', 'Medial epicondylitis - Right', 'Medial epicondylitis - Both' are 'Yes' (all of field 24 and any of fields 25, 27). Depends on: Medial epicondylitis, Medial epicondylitis - Right, Medial epicondylitis - Both
Medial epicondylitis diagnosis date (Left)	Date	Enter the date the left-sided medial epicondylitis was diagnosed. Fill only if 'Medial epicondylitis', 'Medial epicondylitis - Left', 'Medial epicondylitis - Both' are 'Yes' (all of field 24 and any of fields 26, 27). Depends on: Medial epicondylitis, Medial epicondylitis - Left, Medial epicondylitis - Both
Diagnosis Row - Myositis
Myositis	Checkbox	Check this box if the Veteran has a current diagnosis of myositis related to the claimed condition(s).
Myositis - Right	Radiobutton	Select this option if the myositis affects the right side only. Fill only if 'Myositis' is 'Yes'. Depends on: Myositis
Myositis - Left	Radiobutton	Select this option if the myositis affects the left side only. Fill only if 'Myositis' is 'Yes'. Depends on: Myositis
Myositis - Both	Radiobutton	Select this option if the myositis affects both the right and left sides. Fill only if 'Myositis' is 'Yes'. Depends on: Myositis
Myositis ICD Code	Text	Enter the ICD diagnosis code corresponding to the myositis diagnosis. Fill only if 'Myositis' is 'Yes'. Depends on: Myositis
Myositis Date of Diagnosis (Right)	Date	Enter the date myositis was diagnosed for the right side. Fill only if 'Myositis', 'Myositis - Right', 'Myositis - Both' are 'Yes' (all of field 172 and any of fields 173, 175). Depends on: Myositis, Myositis - Right, Myositis - Both
Myositis Date of Diagnosis (Left)	Date	Enter the date myositis was diagnosed for the left side. Fill only if 'Myositis', 'Myositis - Left', 'Myositis - Both' are 'Yes' (all of field 172 and any of fields 174, 175). Depends on: Myositis, Myositis - Left, Myositis - Both
Diagnosis Row - Olecranon bursitis
Olecranon bursitis	Checkbox	Check this box if the Veteran has a diagnosis of olecranon bursitis associated with the claimed condition(s).
Olecranon bursitis - Right	Radiobutton	Check this box if olecranon bursitis affects the right side. Fill only if 'Olecranon bursitis' is 'Yes'. Depends on: Olecranon bursitis
Olecranon bursitis - Left	Radiobutton	Check this box if olecranon bursitis affects the left side. Fill only if 'Olecranon bursitis' is 'Yes'. Depends on: Olecranon bursitis
Olecranon bursitis - Both	Radiobutton	Check this box if olecranon bursitis affects both the right and left sides. Fill only if 'Olecranon bursitis' is 'Yes'. Depends on: Olecranon bursitis
Olecranon Bursitis ICD Code	Text	Enter the ICD diagnostic code corresponding to olecranon bursitis. Fill only if 'Olecranon bursitis' is 'Yes'. Depends on: Olecranon bursitis
Olecranon Bursitis Date of Diagnosis (Right)	Date	Enter the date olecranon bursitis was diagnosed for the right side. Fill only if 'Olecranon bursitis', 'Olecranon bursitis - Right', 'Olecranon bursitis - Both' are 'Yes' (all of field 3 and any of fields 4, 6). Depends on: Olecranon bursitis, Olecranon bursitis - Right, Olecranon bursitis - Both
Olecranon Bursitis Date of Diagnosis (Left)	Date	Enter the date olecranon bursitis was diagnosed for the left side. Fill only if 'Olecranon bursitis', 'Olecranon bursitis - Left', 'Olecranon bursitis - Both' are 'Yes' (all of field 3 and any of fields 5, 6). Depends on: Olecranon bursitis, Olecranon bursitis - Left, Olecranon bursitis - Both
Diagnosis Row - Osteitis deformans
Osteitis deformans	Checkbox	Check this box if the Veteran has a diagnosis of osteitis deformans (Paget disease of bone) related to the claimed elbow/forearm condition.
Osteitis deformans - Right	Radiobutton	Check this box if osteitis deformans affects the right side. Fill only if 'Osteitis deformans' is 'Yes'. Depends on: Osteitis deformans
Osteitis deformans - Left	Radiobutton	Check this box if osteitis deformans affects the left side. Fill only if 'Osteitis deformans' is 'Yes'. Depends on: Osteitis deformans
Osteitis deformans - Both	Radiobutton	Check this box if osteitis deformans affects both the right and left sides. Fill only if 'Osteitis deformans' is 'Yes'. Depends on: Osteitis deformans
Osteitis deformans ICD code	Text	Enter the ICD diagnosis code for osteitis deformans. Fill only if 'Osteitis deformans' is 'Yes'. Depends on: Osteitis deformans
Osteitis deformans date of diagnosis (right)	Date	Enter the date osteitis deformans was diagnosed for the right side. Fill only if 'Osteitis deformans', 'Osteitis deformans - Right', 'Osteitis deformans - Both' are 'Yes' (all of field 151 and any of fields 152, 154). Depends on: Osteitis deformans, Osteitis deformans - Right, Osteitis deformans - Both
Osteitis deformans date of diagnosis (left)	Date	Enter the date osteitis deformans was diagnosed for the left side. Fill only if 'Osteitis deformans', 'Osteitis deformans - Left', 'Osteitis deformans - Both' are 'Yes' (all of field 151 and any of fields 153, 154). Depends on: Osteitis deformans, Osteitis deformans - Left, Osteitis deformans - Both
Diagnosis Row - Osteoarthritis, elbow
Osteoarthritis, elbow	Checkbox	Check this box if the Veteran has a diagnosis of osteoarthritis of the elbow associated with the claimed condition(s).
Osteoarthritis, elbow – Right	Radiobutton	Check this box if the diagnosed elbow osteoarthritis affects the right elbow. Fill only if 'Osteoarthritis, elbow' is 'Yes'. Depends on: Osteoarthritis, elbow
Osteoarthritis, elbow – Left	Radiobutton	Check this box if the diagnosed elbow osteoarthritis affects the left elbow. Fill only if 'Osteoarthritis, elbow' is 'Yes'. Depends on: Osteoarthritis, elbow
Osteoarthritis, elbow – Both	Radiobutton	Check this box if the diagnosed elbow osteoarthritis affects both elbows (bilateral). Fill only if 'Osteoarthritis, elbow' is 'Yes'. Depends on: Osteoarthritis, elbow
Osteoarthritis (Elbow) ICD Code	Text	Enter the ICD diagnostic code for the Veteran’s elbow osteoarthritis. Fill only if 'Osteoarthritis, elbow' is 'Yes'. Depends on: Osteoarthritis, elbow
Osteoarthritis (Elbow) Date of Diagnosis - Right	Date	Enter the date when osteoarthritis of the right elbow was diagnosed. Fill only if 'Osteoarthritis, elbow', 'Osteoarthritis, elbow – Right', 'Osteoarthritis, elbow – Both' are 'Yes' (all of field 45 and any of fields 46, 48). Depends on: Osteoarthritis, elbow, Osteoarthritis, elbow – Right, Osteoarthritis, elbow – Both
Osteoarthritis (Elbow) Date of Diagnosis - Left	Date	Enter the date when osteoarthritis of the left elbow was diagnosed. Fill only if 'Osteoarthritis, elbow', 'Osteoarthritis, elbow – Left', 'Osteoarthritis, elbow – Both' are 'Yes' (all of field 45 and any of fields 47, 48). Depends on: Osteoarthritis, elbow, Osteoarthritis, elbow – Left, Osteoarthritis, elbow – Both
Diagnosis Row - Osteomalacia, residuals of
Osteomalacia, residuals of	Checkbox	Check this box if the claimed condition includes residuals of osteomalacia.
Osteomalacia residuals - Right	Radiobutton	Check this box if residuals of osteomalacia affect the right side. Fill only if 'Osteomalacia, residuals of' is 'Yes'. Depends on: Osteomalacia, residuals of
Osteomalacia residuals - Left	Radiobutton	Check this box if residuals of osteomalacia affect the left side. Fill only if 'Osteomalacia, residuals of' is 'Yes'. Depends on: Osteomalacia, residuals of
Osteomalacia residuals - Both	Radiobutton	Check this box if residuals of osteomalacia affect both sides. Fill only if 'Osteomalacia, residuals of' is 'Yes'. Depends on: Osteomalacia, residuals of
Osteomalacia Residuals ICD Code	Text	Enter the ICD code for the diagnosis of osteomalacia, residuals of. Fill only if 'Osteomalacia, residuals of' is 'Yes'. Depends on: Osteomalacia, residuals of
Osteomalacia Residuals Date of Diagnosis (Right)	Date	Enter the date of diagnosis for osteomalacia, residuals of, affecting the right side. Fill only if 'Osteomalacia, residuals of', 'Osteomalacia residuals - Right', 'Osteomalacia residuals - Both' are 'Yes' (all of field 137 and any of fields 138, 140). Depends on: Osteomalacia, residuals of, Osteomalacia residuals - Right, Osteomalacia residuals - Both
Osteomalacia Residuals Date of Diagnosis (Left)	Date	Enter the date of diagnosis for osteomalacia, residuals of, affecting the left side. Fill only if 'Osteomalacia, residuals of', 'Osteomalacia residuals - Left', 'Osteomalacia residuals - Both' are 'Yes' (all of field 137 and any of fields 139, 140). Depends on: Osteomalacia, residuals of, Osteomalacia residuals - Left, Osteomalacia residuals - Both
Diagnosis Row - Osteoporosis, residuals of
Osteoporosis, residuals of	Checkbox	Check this box if the claimed diagnosis is residuals of osteoporosis.
Side affected: Right	Radiobutton	Check this box if the osteoporosis residuals affect the right side. Fill only if 'Osteoporosis, residuals of' is 'Yes'. Depends on: Osteoporosis, residuals of
Side affected: Left	Radiobutton	Check this box if the osteoporosis residuals affect the left side. Fill only if 'Osteoporosis, residuals of' is 'Yes'. Depends on: Osteoporosis, residuals of
Side affected: Both	Radiobutton	Check this box if the osteoporosis residuals affect both sides. Fill only if 'Osteoporosis, residuals of' is 'Yes'. Depends on: Osteoporosis, residuals of
Osteoporosis residuals ICD code	Text	Enter the ICD diagnostic code for the osteoporosis residuals diagnosis. Fill only if 'Osteoporosis, residuals of' is 'Yes'. Depends on: Osteoporosis, residuals of
Osteoporosis residuals date of diagnosis (Right)	Date	Enter the date of diagnosis for osteoporosis residuals affecting the right side. Fill only if 'Osteoporosis, residuals of', 'Side affected: Right', 'Side affected: Both' are 'Yes' (all of field 130 and any of fields 131, 133). Depends on: Osteoporosis, residuals of, Side affected: Right, Side affected: Both
Osteoporosis residuals date of diagnosis (Left)	Date	Enter the date of diagnosis for osteoporosis residuals affecting the left side. Fill only if 'Osteoporosis, residuals of', 'Side affected: Left', 'Side affected: Both' are 'Yes' (all of field 130 and any of fields 132, 133). Depends on: Osteoporosis, residuals of, Side affected: Left, Side affected: Both
Diagnosis Row - Other specified forms of arthropathy (excluding gout)
Other specified forms of arthropathy (excluding gout)	Checkbox	Check this box if the claimed condition includes another specified form of arthropathy (not gout).
Side affected: Right	Radiobutton	Check this box if the other specified arthropathy affects the right elbow/forearm only. Fill only if 'Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Other specified forms of arthropathy (excluding gout)
Side affected: Left	Radiobutton	Check this box if the other specified arthropathy affects the left elbow/forearm only. Fill only if 'Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Other specified forms of arthropathy (excluding gout)
Side affected: Both	Radiobutton	Check this box if the other specified arthropathy affects both the right and left elbows/forearms. Fill only if 'Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Other specified forms of arthropathy (excluding gout)
ICD Code (Other Specified Arthropathy)	Text	Enter the ICD diagnosis code for the other specified form of arthropathy (excluding gout). Fill only if 'Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Other specified forms of arthropathy (excluding gout)
Date of Diagnosis (Right)	Date	Enter the date this condition was diagnosed for the right side. Fill only if 'Other specified forms of arthropathy (excluding gout)', 'Side affected: Right', 'Side affected: Both' are 'Yes' (all of field 122 and any of fields 123, 125). Depends on: Other specified forms of arthropathy (excluding gout), Side affected: Right, Side affected: Both
Date of Diagnosis (Left)	Date	Enter the date this condition was diagnosed for the left side. Fill only if 'Other specified forms of arthropathy (excluding gout)', 'Side affected: Left', 'Side affected: Both' are 'Yes' (all of field 122 and any of fields 124, 125). Depends on: Other specified forms of arthropathy (excluding gout), Side affected: Left, Side affected: Both
Specify Other Arthropathy (Excluding Gout)	Text	Specify the other form of arthropathy (excluding gout) that applies to the claimed condition. Fill only if 'Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Other specified forms of arthropathy (excluding gout)
Diagnosis Row - Tendinitis
Tendinitis	Checkbox	Check this box if the claimed elbow/forearm condition includes a diagnosis of tendinitis.
Tendinitis - Side affected: Right	Radiobutton	Check this box if the tendinitis affects the right side only. Fill only if 'Tendinitis' is 'Yes'. Depends on: Tendinitis
Tendinitis - Side affected: Left	Radiobutton	Check this box if the tendinitis affects the left side only. Fill only if 'Tendinitis' is 'Yes'. Depends on: Tendinitis
Tendinitis - Side affected: Both	Radiobutton	Check this box if the tendinitis affects both the right and left sides. Fill only if 'Tendinitis' is 'Yes'. Depends on: Tendinitis
Tendinitis ICD Code	Text	Enter the ICD diagnosis code associated with the tendinitis diagnosis. Fill only if 'Tendinitis' is 'Yes'. Depends on: Tendinitis
Tendinitis Date of Diagnosis (Right)	Date	Provide the date the tendinitis was diagnosed for the right side. Fill only if 'Tendinitis', 'Tendinitis - Side affected: Right', 'Tendinitis - Side affected: Both' are 'Yes' (all of field 193 and any of fields 194, 196). Depends on: Tendinitis, Tendinitis - Side affected: Right, Tendinitis - Side affected: Both
Tendinitis Date of Diagnosis (Left)	Date	Provide the date the tendinitis was diagnosed for the left side. Fill only if 'Tendinitis', 'Tendinitis - Side affected: Left', 'Tendinitis - Side affected: Both' are 'Yes' (all of field 193 and any of fields 195, 196). Depends on: Tendinitis, Tendinitis - Side affected: Left, Tendinitis - Side affected: Both
Diagnosis Row - Tendinopathy (select one if known)
Tendinopathy (select one if known)	Checkbox	Check this box if the Veteran has a diagnosis of tendinopathy associated with the claimed condition(s).
Tendinopathy side affected: Right	Radiobutton	Select this option if the tendinopathy affects the right side only. Fill only if 'Tendinopathy (select one if known)' is 'Yes'. Depends on: Tendinopathy (select one if known)
Tendinopathy side affected: Left	Radiobutton	Select this option if the tendinopathy affects the left side only. Fill only if 'Tendinopathy (select one if known)' is 'Yes'. Depends on: Tendinopathy (select one if known)
Tendinopathy side affected: Both	Radiobutton	Select this option if the tendinopathy affects both the right and left sides. Fill only if 'Tendinopathy (select one if known)' is 'Yes'. Depends on: Tendinopathy (select one if known)
Tendinopathy ICD Code	Text	Enter the ICD code for the tendinopathy diagnosis. Fill only if 'Tendinopathy (select one if known)' is 'Yes'. Depends on: Tendinopathy (select one if known)
Tendinopathy Date of Diagnosis (Right)	Date	Provide the date the right-side tendinopathy was diagnosed. Fill only if 'Tendinopathy (select one if known)', 'Tendinopathy side affected: Right', 'Tendinopathy side affected: Both' are 'Yes' (all of field 186 and any of fields 187, 189). Depends on: Tendinopathy (select one if known), Tendinopathy side affected: Right, Tendinopathy side affected: Both
Tendinopathy Date of Diagnosis (Left)	Date	Provide the date the left-side tendinopathy was diagnosed. Fill only if 'Tendinopathy (select one if known)', 'Tendinopathy side affected: Left', 'Tendinopathy side affected: Both' are 'Yes' (all of field 186 and any of fields 188, 189). Depends on: Tendinopathy (select one if known), Tendinopathy side affected: Left, Tendinopathy side affected: Both
Diagnosis Row - Tendinosis
Tendinosis	Checkbox	Check this box if the claimed elbow/forearm condition diagnosis includes tendinosis.
Tendinosis - Right	Radiobutton	Check this box if the tendinosis diagnosis affects the right side. Fill only if 'Tendinosis' is 'Yes'. Depends on: Tendinosis
Tendinosis - Left	Radiobutton	Check this box if the tendinosis diagnosis affects the left side. Fill only if 'Tendinosis' is 'Yes'. Depends on: Tendinosis
Tendinosis - Both	Radiobutton	Check this box if the tendinosis diagnosis affects both sides. Fill only if 'Tendinosis' is 'Yes'. Depends on: Tendinosis
Tendinosis ICD Code	Text	Enter the ICD diagnostic code associated with the tendinosis diagnosis. Fill only if 'Tendinosis' is 'Yes'. Depends on: Tendinosis
Tendinosis Diagnosis Date (Right)	Date	Enter the date the right-side tendinosis was diagnosed. Fill only if 'Tendinosis', 'Tendinosis - Right', 'Tendinosis - Both' are 'Yes' (all of field 200 and any of fields 201, 203). Depends on: Tendinosis, Tendinosis - Right, Tendinosis - Both
Tendinosis Diagnosis Date (Left)	Date	Enter the date the left-side tendinosis was diagnosed. Fill only if 'Tendinosis', 'Tendinosis - Left', 'Tendinosis - Both' are 'Yes' (all of field 200 and any of fields 202, 203). Depends on: Tendinosis, Tendinosis - Left, Tendinosis - Both
Diagnosis Row - Tenosynovitis
Tenosynovitis	Checkbox	Check this box if the Veteran has a diagnosis of tenosynovitis related to the claimed condition(s).
Tenosynovitis - Right	Radiobutton	Check this box if the tenosynovitis affects the right side only. Fill only if 'Tenosynovitis' is 'Yes'. Depends on: Tenosynovitis
Tenosynovitis - Left	Radiobutton	Check this box if the tenosynovitis affects the left side only. Fill only if 'Tenosynovitis' is 'Yes'. Depends on: Tenosynovitis
Tenosynovitis - Both	Radiobutton	Check this box if the tenosynovitis affects both the right and left sides. Fill only if 'Tenosynovitis' is 'Yes'. Depends on: Tenosynovitis
Tenosynovitis ICD Code	Text	Enter the ICD diagnosis code for the tenosynovitis condition. Fill only if 'Tenosynovitis' is 'Yes'. Depends on: Tenosynovitis
Tenosynovitis Date of Diagnosis (Right)	Date	Enter the date when tenosynovitis was diagnosed for the right side. Fill only if 'Tenosynovitis', 'Tenosynovitis - Right', 'Tenosynovitis - Both' are 'Yes' (all of field 207 and any of fields 208, 210). Depends on: Tenosynovitis, Tenosynovitis - Right, Tenosynovitis - Both
Tenosynovitis Date of Diagnosis (Left)	Date	Enter the date when tenosynovitis was diagnosed for the left side. Fill only if 'Tenosynovitis', 'Tenosynovitis - Left', 'Tenosynovitis - Both' are 'Yes' (all of field 207 and any of fields 209, 210). Depends on: Tenosynovitis, Tenosynovitis - Left, Tenosynovitis - Both
Diagnosis Row - Total elbow arthroplasty
Total elbow arthroplasty	Checkbox	Check this box if the Veteran has a diagnosis of total elbow arthroplasty associated with the claimed condition(s).
Side affected: Right	Radiobutton	Check this box if the total elbow arthroplasty affects the right elbow. Fill only if 'Total elbow arthroplasty' is 'Yes'. Depends on: Total elbow arthroplasty
Side affected: Left	Radiobutton	Check this box if the total elbow arthroplasty affects the left elbow. Fill only if 'Total elbow arthroplasty' is 'Yes'. Depends on: Total elbow arthroplasty
Side affected: Both	Radiobutton	Check this box if the total elbow arthroplasty affects both elbows. Fill only if 'Total elbow arthroplasty' is 'Yes'. Depends on: Total elbow arthroplasty
Total elbow arthroplasty ICD code	Text	Enter the ICD diagnosis code corresponding to the total elbow arthroplasty. Fill only if 'Total elbow arthroplasty' is 'Yes'. Depends on: Total elbow arthroplasty
Total elbow arthroplasty date of diagnosis (Right)	Date	Enter the date of diagnosis for total elbow arthroplasty affecting the right side. Fill only if 'Total elbow arthroplasty', 'Side affected: Right', 'Side affected: Both' are 'Yes' (all of field 52 and any of fields 53, 55). Depends on: Total elbow arthroplasty, Side affected: Right, Side affected: Both
Total elbow arthroplasty date of diagnosis (Left)	Date	Enter the date of diagnosis for total elbow arthroplasty affecting the left side. Fill only if 'Total elbow arthroplasty', 'Side affected: Left', 'Side affected: Both' are 'Yes' (all of field 52 and any of fields 54, 55). Depends on: Total elbow arthroplasty, Side affected: Left, Side affected: Both
Diagnosis Row - Tricep tendinitis
Tricep tendinitis	Checkbox	Check this box if the Veteran has a diagnosis of tricep tendinitis associated with the claimed condition(s).
Tricep tendinitis - Side affected: Right	Radiobutton	Check this box if the diagnosed tricep tendinitis affects the right side only. Fill only if 'Tricep tendinitis' is 'Yes'. Depends on: Tricep tendinitis
Tricep tendinitis - Side affected: Left	Radiobutton	Check this box if the diagnosed tricep tendinitis affects the left side only. Fill only if 'Tricep tendinitis' is 'Yes'. Depends on: Tricep tendinitis
Tricep tendinitis - Side affected: Both	Radiobutton	Check this box if the diagnosed tricep tendinitis affects both sides. Fill only if 'Tricep tendinitis' is 'Yes'. Depends on: Tricep tendinitis
Tricep tendinitis ICD code	Text	Enter the ICD diagnostic code for the Veteran’s tricep tendinitis. Fill only if 'Tricep tendinitis' is 'Yes'. Depends on: Tricep tendinitis
Tricep tendinitis date of diagnosis (Right)	Date	Provide the date the Veteran was diagnosed with tricep tendinitis affecting the right side. Fill only if 'Tricep tendinitis', 'Tricep tendinitis - Side affected: Right', 'Tricep tendinitis - Side affected: Both' are 'Yes' (all of field 10 and any of fields 11, 13). Depends on: Tricep tendinitis, Tricep tendinitis - Side affected: Right, Tricep tendinitis - Side affected: Both
Tricep tendinitis date of diagnosis (Left)	Date	Provide the date the Veteran was diagnosed with tricep tendinitis affecting the left side. Fill only if 'Tricep tendinitis', 'Tricep tendinitis - Side affected: Left', 'Tricep tendinitis - Side affected: Both' are 'Yes' (all of field 10 and any of fields 12, 13). Depends on: Tricep tendinitis, Tricep tendinitis - Side affected: Left, Tricep tendinitis - Side affected: Both
DOMINANT HAND
Right	Radiobutton	Check this box if the veteran’s dominant hand is the right hand.
Left	Radiobutton	Check this box if the veteran’s dominant hand is the left hand.
Ambidextrous	Radiobutton	Check this box if the veteran uses both hands equally as their dominant hand.
Effective Function Loss Determination (10A)
Yes	Radiobutton	Check this box if, due to the Veteran’s elbow and/or forearm condition(s), upper-extremity function is so diminished that amputation with prosthesis would equally serve the Veteran.
No	Radiobutton	Check this box if the Veteran still has effective upper-extremity function and would not be equally well-served by amputation with prosthesis.
Right upper	Checkbox	If you answered “Yes,” check this box to indicate the right upper extremity is affected by the loss of effective function. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left upper	Checkbox	If you answered “Yes,” check this box to indicate the left upper extremity is affected by the loss of effective function. Fill only if 'Yes' is 'Yes'. Depends on: Yes
EVIDENCE REVIEW
No records were reviewed	Radiobutton	Check this box if no evidence/records were reviewed for this examination.
Records reviewed	Radiobutton	Check this box if you reviewed any evidence/records for this examination.
Evidence Reviewed and Date Range	Text	List the specific evidence/records reviewed (e.g., service treatment records, VA treatment records, private treatment records) and the applicable date range covered. Fill only if 'Records reviewed' is 'Yes'. Depends on: Records reviewed
Examiner Identification and Contact Details
Examiner Printed Name and Title	Text	Enter the examiner’s printed name and professional title/credentials (e.g., MD, DO, DDS, DMD, PhD, PsyD, NP, PA-C).
Examiner Specialty/Area of Practice	Text	Enter the examiner’s area of practice or specialty (e.g., Cardiology, Orthopedics, Psychology/Psychiatry, General Practice).
Examiner Phone/Fax Numbers	Text	Enter the examiner’s phone number and/or fax number.
National Provider Identifier (NPI)	Number	Enter the examiner’s National Provider Identifier (NPI) number.
Medical License Number and State	Text	Enter the examiner’s medical license number and the issuing state.
Examiner Address	Text	Enter the examiner’s mailing or business address.
Examiner Signature and Date
Examiner Signature	Text	Enter the examiner's signature to certify that the information provided is accurate, complete, and current.
Date Signed	Date	Enter the date the examiner signed the certification.
Flail Joint (Laterality)
Flail joint	Checkbox	Check this box when the Veteran has a flail joint; if checked, also indicate the affected side by selecting Right, Left, or Both. Fill only if '6A - Yes' is 'Yes'. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right	Radiobutton	Check this box if the Veteran’s flail joint condition affects the right side only. Fill only if 'Flail joint' is 'Yes'. Depends on: Flail joint
Left	Radiobutton	Check this box if the Veteran’s flail joint condition affects the left side only. Fill only if 'Flail joint' is 'Yes'. Depends on: Flail joint
Both	Radiobutton	Check this box if the Veteran’s flail joint condition affects both the right and left sides. Fill only if 'Flail joint' is 'Yes'. Depends on: Flail joint
Flare-ups (Elbow/Forearm) Yes/No and Description
Yes	Radiobutton	Check this box if the Veteran reports having flare-ups of the elbow or forearm.
No	Radiobutton	Check this box if the Veteran does not report having flare-ups of the elbow or forearm.
Flare-ups Description (Elbow/Forearm)	Text	Describe the Veteran's elbow/forearm flare-ups, including frequency, duration, characteristics, precipitating and alleviating factors, and the severity and functional impact during flare-ups. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Functional Loss/Impairment Over Time Yes/No and Description
Yes	Radiobutton	Check this box if the Veteran reports any functional loss or functional impairment of the joint or extremity over time.
No	Radiobutton	Check this box if the Veteran does not report any functional loss or functional impairment of the joint or extremity over time.
Functional Loss/Impairment Description Over Time	Text	Enter the Veteran's description, in their own words, of any functional loss or functional impairment of the joint or extremity over time. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Imaging Studies Performed (11A)
Yes	Radiobutton	Check this box if imaging studies have been performed in conjunction with this examination.
No	Radiobutton	Check this box if no imaging studies have been performed in conjunction with this examination.
Imaging Test Details Summary (11C)
Imaging Test Type, Date, and Results Summary	Text	Enter the type of imaging test or procedure performed, the date it was performed, and a brief summary of the results. Fill only if 'Yes' is 'Yes'. Depends on: Yes
In-Person Examination and If Not, How Conducted
Examined in person - Yes	Radiobutton	Check this box if the Veteran was examined in person (face-to-face) for this evaluation.
Examined in person - No	Radiobutton	Check this box if the Veteran was not examined in person for this evaluation (and the exam was conducted by another method).
How Examination Was Conducted (If Not In Person)	Text	Describe how the examination was conducted when the Veteran was not examined in person (e.g., telehealth/telephone, records review, or other method). Fill only if 'Examined in person - No' is 'Yes'. Depends on: Examined in person - No
Joint Fracture - Marked Cubitus Valgus Deformity (Laterality)
With marked cubitus valgus deformity	Checkbox	Check this box if the Veteran’s joint fracture involves a marked cubitus valgus deformity. Fill only if 'Joint fracture' is 'Yes'. Depends on: Joint fracture
Marked cubitus valgus deformity – Right	Radiobutton	Check this box if the marked cubitus valgus deformity is on the right side. Fill only if 'With marked cubitus valgus deformity' is 'Yes'. Depends on: With marked cubitus valgus deformity
Marked cubitus valgus deformity – Left	Radiobutton	Check this box if the marked cubitus valgus deformity is on the left side. Fill only if 'With marked cubitus valgus deformity' is 'Yes'. Depends on: With marked cubitus valgus deformity
Marked cubitus valgus deformity – Both	Radiobutton	Check this box if the marked cubitus valgus deformity affects both sides. Fill only if 'With marked cubitus valgus deformity' is 'Yes'. Depends on: With marked cubitus valgus deformity
Joint Fracture - Marked Cubitus Varus Deformity (Laterality)
With marked cubitus varus deformity	Checkbox	Check this box if the Veteran has a joint fracture with marked cubitus varus deformity. Fill only if 'Joint fracture' is 'Yes'. Depends on: Joint fracture
Right	Radiobutton	Check this box if the marked cubitus varus deformity due to joint fracture affects the right side only. Fill only if 'With marked cubitus varus deformity' is 'Yes'. Depends on: With marked cubitus varus deformity
Left	Radiobutton	Check this box if the marked cubitus varus deformity due to joint fracture affects the left side only. Fill only if 'With marked cubitus varus deformity' is 'Yes'. Depends on: With marked cubitus varus deformity
Both	Radiobutton	Check this box if the marked cubitus varus deformity due to joint fracture affects both sides. Fill only if 'With marked cubitus varus deformity' is 'Yes'. Depends on: With marked cubitus varus deformity
Joint Fracture - Ununited Fracture of Head of Radius (Laterality)
With ununited fracture of head of radius	Checkbox	Check this box if the Veteran’s joint fracture includes an ununited fracture of the head of the radius. Fill only if 'Joint fracture' is 'Yes'. Depends on: Joint fracture
Right	Radiobutton	Check this box if the ununited fracture of the head of the radius affects the right side only. Fill only if 'With ununited fracture of head of radius' is 'Yes'. Depends on: With ununited fracture of head of radius
Left	Radiobutton	Check this box if the ununited fracture of the head of the radius affects the left side only. Fill only if 'With ununited fracture of head of radius' is 'Yes'. Depends on: With ununited fracture of head of radius
Both	Radiobutton	Check this box if the ununited fracture of the head of the radius affects both the right and left sides. Fill only if 'With ununited fracture of head of radius' is 'Yes'. Depends on: With ununited fracture of head of radius
Joint Fracture (Laterality)
Joint fracture	Checkbox	Check this box if the Veteran has a joint fracture. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right	Radiobutton	Check this box if the joint fracture affects the right side. Fill only if 'Joint fracture' is 'Yes'. Depends on: Joint fracture
Left	Radiobutton	Check this box if the joint fracture affects the left side. Fill only if 'Joint fracture' is 'Yes'. Depends on: Joint fracture
Both	Radiobutton	Check this box if the joint fracture affects both the right and left sides. Fill only if 'Joint fracture' is 'Yes'. Depends on: Joint fracture
Left Active ROM Limitation Endpoints (If different than above)
Flexion Degree Endpoint (Limitation Due to Factors)	Number	Enter the flexion range-of-motion endpoint in degrees when limitation is specifically attributable to pain, weakness, fatigability, incoordination, or other factors, if different from the active ROM value above. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Extension Degree Endpoint (Limitation Due to Factors)	Number	Enter the extension range-of-motion endpoint in degrees when limitation is specifically attributable to pain, weakness, fatigability, incoordination, or other factors, if different from the active ROM value above. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Forearm Supination Degree Endpoint (Limitation Due to Factors)	Number	Enter the forearm supination range-of-motion endpoint in degrees when limitation is specifically attributable to pain, weakness, fatigability, incoordination, or other factors, if different from the active ROM value above. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Forearm Pronation Degree Endpoint (Limitation Due to Factors)	Number	Enter the forearm pronation range-of-motion endpoint in degrees when limitation is specifically attributable to pain, weakness, fatigability, incoordination, or other factors, if different from the active ROM value above. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Left Active ROM Measurements (Degrees)
Flexion endpoint (145 degrees)	Checkbox	Check this box when you are reporting the active ROM measurement for elbow flexion (endpoint normal value 145°) and will enter the measured degrees. Fill only if 'Can testing be performed?' is 'Yes'. Depends on: Yes
Flexion Endpoint (Left Active ROM)	Number	Enter the measured active flexion endpoint for the left joint in degrees. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Extension endpoint (0 degrees)	Checkbox	Check this box when you are reporting the active ROM measurement for elbow extension (endpoint normal value 0°) and will enter the measured degrees. Fill only if 'Can testing be performed?' is 'Yes'. Depends on: Yes
Extension Endpoint (Left Active ROM)	Number	Enter the measured active extension endpoint for the left joint in degrees. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Forearm supination endpoint (85 degrees)	Checkbox	Check this box when you are reporting the active ROM measurement for forearm supination (endpoint normal value 85°) and will enter the measured degrees. Fill only if 'Can testing be performed?' is 'Yes'. Depends on: Yes
Forearm Supination Endpoint (Left Active ROM)	Number	Enter the measured active forearm supination endpoint for the left joint in degrees. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Forearm pronation endpoint (80 degrees)	Checkbox	Check this box when you are reporting the active ROM measurement for forearm pronation (endpoint normal value 80°) and will enter the measured degrees. Fill only if 'Can testing be performed?' is 'Yes'. Depends on: Yes
Forearm Pronation Endpoint (Left Active ROM)	Number	Enter the measured active forearm pronation endpoint for the left joint in degrees. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Left Active ROM Notes/Description
Left Active ROM Notes/Description	Text	Enter notes describing the left joint’s active range of motion findings, including any pain, weakness, fatigability, incoordination, or other factors affecting motion. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Left Active ROM Pain (Select all that apply)
Flexion	Checkbox	Check this box if active flexion range of motion exhibited pain during the examination. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Forearm supination	Checkbox	Check this box if active forearm supination range of motion exhibited pain during the examination. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Extension	Checkbox	Check this box if active extension range of motion exhibited pain during the examination. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Forearm pronation	Checkbox	Check this box if active forearm pronation range of motion exhibited pain during the examination. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Left Elbow - Additional Loss After Three Repetitions
Yes	Radiobutton	Check this box if there is additional loss of function or range of motion in the left elbow after three repetitions. Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions? (Left elbow)' is 'Yes'. Depends on: Yes
No	Radiobutton	Check this box if there is no additional loss of function or range of motion in the left elbow after three repetitions. Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions? (Left elbow)' is 'Yes'. Depends on: Yes
Left Elbow - Arthroscopic or Other Elbow Surgery Details
Arthroscopic or other elbow surgery	Checkbox	Check this box if the Veteran has had arthroscopic surgery or any other (non-replacement) surgical procedure on the left elbow.
Left Elbow Surgery Type	Text	Enter the type of arthroscopic or other surgical procedure performed on the Veteran's left elbow. Fill only if 'Arthroscopic or other elbow surgery' is selected. Depends on: Arthroscopic or other elbow surgery
Left Elbow Surgery Date	Date	Enter the date the arthroscopic or other left elbow surgery was performed. Fill only if 'Arthroscopic or other elbow surgery' is selected. Depends on: Arthroscopic or other elbow surgery
Left Elbow Surgery Residuals Description	Text	Describe any residuals or ongoing effects resulting from the arthroscopic or other left elbow surgery. Fill only if 'Arthroscopic or other elbow surgery' is selected. Depends on: Arthroscopic or other elbow surgery
Left Elbow - Functional Loss Factors After Three Repetitions
Pain	Checkbox	Check this box if pain causes the additional functional loss after three repetitions. Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions? (Left elbow)' is 'Yes'. Depends on: Yes
Fatigability	Checkbox	Check this box if fatigability causes the additional functional loss after three repetitions. Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions? (Left elbow)' is 'Yes'. Depends on: Yes
Weakness	Checkbox	Check this box if weakness causes the additional functional loss after three repetitions. Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions? (Left elbow)' is 'Yes'. Depends on: Yes
Lack of endurance	Checkbox	Check this box if lack of endurance causes the additional functional loss after three repetitions. Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions? (Left elbow)' is 'Yes'. Depends on: Yes
Incoordination	Checkbox	Check this box if incoordination causes the additional functional loss after three repetitions. Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions? (Left elbow)' is 'Yes'. Depends on: Yes
N/A	Checkbox	Check this box if none of the listed factors apply as causes of the additional functional loss after three repetitions. Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions? (Left elbow)' is 'Yes'. Depends on: Yes
Other (specify)	Checkbox	Check this box if another factor not listed causes the additional functional loss after three repetitions, and specify the factor. Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions? (Left elbow)' is 'Yes'. Depends on: Yes
Other Functional Loss Factor (Specify)	Text	Enter any other factor causing additional functional loss of the left elbow after three repetitions that is not listed (e.g., pain, fatigability, weakness). Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Left Elbow - No Surgery
No surgery	Checkbox	Check this box if the Veteran has not had any surgical procedures performed on the left elbow.
Left Elbow - Repeated Use Over Time Evidence/Rationale
Left Elbow Repeated Use Over Time Evidence/Rationale	Text	Cite and discuss the specific evidence and rationale used to support the left elbow findings for repeated use over time, based on all procurable evidence.
Left Elbow - Repeated Use Over Time Functional Loss
Yes – Examined immediately after repeated use over time (Left elbow)	Radiobutton	Check this box if the Veteran is being examined immediately after repeated use over time of the left elbow.
No – Not examined immediately after repeated use over time (Left elbow)	Radiobutton	Check this box if the Veteran is not being examined immediately after repeated use over time of the left elbow.
Yes – Evidence suggests repeated use over time significantly limits functional ability (Left elbow)	Radiobutton	Check this box if procured evidence (including the Veteran’s statements) indicates repeated use over time significantly limits left elbow functional ability due to pain, fatigability, weakness, lack of endurance, or incoordination.
No – Evidence does not suggest significant functional limitation with repeated use over time (Left elbow)	Radiobutton	Check this box if procured evidence does not indicate repeated use over time significantly limits left elbow functional ability.
Pain	Checkbox	Check this box if pain contributes to the left elbow functional loss with repeated use over time. Fill only if 'Yes – Evidence suggests repeated use over time significantly limits functional ability (Left elbow)' is 'Yes'. Depends on: Yes – Evidence suggests repeated use over time significantly limits functional ability (Left elbow)
Fatigability	Checkbox	Check this box if fatigability contributes to the left elbow functional loss with repeated use over time. Fill only if 'Yes – Evidence suggests repeated use over time significantly limits functional ability (Left elbow)' is 'Yes'. Depends on: Yes – Evidence suggests repeated use over time significantly limits functional ability (Left elbow)
Weakness	Checkbox	Check this box if weakness contributes to the left elbow functional loss with repeated use over time. Fill only if 'Yes – Evidence suggests repeated use over time significantly limits functional ability (Left elbow)' is 'Yes'. Depends on: Yes – Evidence suggests repeated use over time significantly limits functional ability (Left elbow)
Lack of endurance	Checkbox	Check this box if lack of endurance contributes to the left elbow functional loss with repeated use over time. Fill only if 'Yes – Evidence suggests repeated use over time significantly limits functional ability (Left elbow)' is 'Yes'. Depends on: Yes – Evidence suggests repeated use over time significantly limits functional ability (Left elbow)
Incoordination	Checkbox	Check this box if incoordination contributes to the left elbow functional loss with repeated use over time. Fill only if 'Yes – Evidence suggests repeated use over time significantly limits functional ability (Left elbow)' is 'Yes'. Depends on: Yes – Evidence suggests repeated use over time significantly limits functional ability (Left elbow)
N/A	Checkbox	Check this box if no listed factors apply as causes of left elbow functional loss with repeated use over time. Fill only if 'Yes – Evidence suggests repeated use over time significantly limits functional ability (Left elbow)' is 'Yes'. Depends on: Yes – Evidence suggests repeated use over time significantly limits functional ability (Left elbow)
Other (specify)	Checkbox	Check this box if another factor (not listed) contributes to left elbow functional loss with repeated use over time and you will specify it in the provided space.
Other Functional Loss Factor (Specify)	Text	If you selected “Other” as a factor contributing to functional loss after repeated use over time for the left elbow, describe the other factor. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Left Elbow - Repeated Use Over Time ROM Estimates
Left Elbow Flexion Endpoint (Repeated Use Over Time Estimate)	Text	Enter the estimated flexion endpoint for the left elbow after repeated use over time, in degrees. Fill only if 'Yes – Evidence suggests repeated use over time significantly limits functional ability (Left elbow)' is 'Yes'. Depends on: Yes – Evidence suggests repeated use over time significantly limits functional ability (Left elbow)
Left Elbow Extension Endpoint (Repeated Use Over Time Estimate)	Text	Enter the estimated extension endpoint for the left elbow after repeated use over time, in degrees. Fill only if 'Yes – Evidence suggests repeated use over time significantly limits functional ability (Left elbow)' is 'Yes'. Depends on: Yes – Evidence suggests repeated use over time significantly limits functional ability (Left elbow)
Left Forearm Supination Endpoint (Repeated Use Over Time Estimate)	Text	Enter the estimated forearm supination endpoint for the left side after repeated use over time, in degrees. Fill only if 'Yes – Evidence suggests repeated use over time significantly limits functional ability (Left elbow)' is 'Yes'. Depends on: Yes – Evidence suggests repeated use over time significantly limits functional ability (Left elbow)
Left Forearm Pronation Endpoint (Repeated Use Over Time Estimate)	Text	Enter the estimated forearm pronation endpoint for the left side after repeated use over time, in degrees. Fill only if 'Yes – Evidence suggests repeated use over time significantly limits functional ability (Left elbow)' is 'Yes'. Depends on: Yes – Evidence suggests repeated use over time significantly limits functional ability (Left elbow)
Left Elbow - ROM Endpoints After Three Repetitions
Flexion Endpoint After Three Repetitions	Number	Enter the measured left elbow flexion endpoint after three repetitions. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Extension Endpoint After Three Repetitions	Number	Enter the measured left elbow extension endpoint after three repetitions. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Supination Endpoint After Three Repetitions	Number	Enter the measured left elbow supination endpoint after three repetitions. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Pronation Endpoint After Three Repetitions	Number	Enter the measured left elbow pronation endpoint after three repetitions. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left Elbow - Total Elbow Joint Replacement Details
Total elbow joint replacement	Checkbox	Check this box if the Veteran has had a total elbow joint replacement (left elbow).
Left Elbow Replacement Surgery Date	Date	Enter the date the Veteran had the left total elbow joint replacement surgery. Fill only if 'Total elbow joint replacement' is selected. Depends on: Total elbow joint replacement
Residuals: None	Checkbox	Check this box if there are no residual symptoms or limitations following the left total elbow joint replacement. Fill only if 'Total elbow joint replacement' is selected. Depends on: Total elbow joint replacement
Residuals: Intermediate degrees of residual weakness, pain, or limitation of motion	Checkbox	Check this box if the Veteran has intermediate residual weakness, pain, or limitation of motion after the left total elbow joint replacement. Fill only if 'Total elbow joint replacement' is selected. Depends on: Total elbow joint replacement
Residuals: Chronic residuals consisting of severe painful motion or weakness	Checkbox	Check this box if the Veteran has chronic residuals with severe painful motion or weakness following the left total elbow joint replacement. Fill only if 'Total elbow joint replacement' is selected. Depends on: Total elbow joint replacement
Residuals: Other (describe)	Checkbox	Check this box if the Veteran has residuals other than the options listed and provide a description in the space provided. Fill only if 'Total elbow joint replacement' is selected. Depends on: Total elbow joint replacement
Left Elbow Replacement Residuals Description	Text	Describe any residual symptoms or limitations following the left total elbow joint replacement (e.g., pain, weakness, limited motion, or other effects). Fill only if 'Residuals: Other (describe)' is selected. Depends on: Residuals: Other (describe)
Left Elbow Additional Contributing Factors (Checkboxes)
None	Checkbox	Check this box if there are no additional factors (beyond those already addressed) contributing to the left elbow disability.
Interference with sitting	Checkbox	Check this box if the left elbow condition interferes with the Veteran’s ability to sit.
Interference with standing	Checkbox	Check this box if the left elbow condition interferes with the Veteran’s ability to stand.
Swelling	Checkbox	Check this box if swelling is an additional factor contributing to the left elbow disability.
Disturbance of locomotion	Checkbox	Check this box if the left elbow condition contributes to difficulty with walking or overall movement (disturbance of locomotion).
Deformity	Checkbox	Check this box if deformity of the left elbow is present and contributes to the disability.
Less movement than normal	Checkbox	Check this box if the left elbow has reduced movement compared with normal and this contributes to the disability.
More movement than normal	Checkbox	Check this box if the left elbow has excessive movement (hypermobility) compared with normal and this contributes to the disability.
Weakened movement	Checkbox	Check this box if weakness or weakened movement in the left elbow contributes to the disability.
Atrophy of disuse	Checkbox	Check this box if muscle atrophy due to disuse related to the left elbow condition is present and contributes to the disability.
Instability of station	Checkbox	Check this box if the left elbow condition contributes to instability or unsteadiness of the Veteran’s stance (instability of station).
Other (describe)	Checkbox	Check this box if there is another additional contributing factor not listed, and describe it in the space provided.
Left Elbow Additional Contributing Factors Description
Left Elbow Additional Contributing Factors Description	Text	Describe any additional factors contributing to the left elbow disability (e.g., swelling, deformity, instability, interference with sitting/standing, or other factors selected above).
Left Elbow Can Testing Be Performed (Yes/No)
Yes	Radiobutton	Check this box if testing can be performed for the left elbow.
No	Radiobutton	Check this box if testing cannot be performed for the left elbow.
Left Elbow Flare-up Examination (Yes/No)
Yes	Radiobutton	Check this box if the left elbow examination is being conducted during a flare-up. Fill only if 'Does the Veteran report flare-ups of the elbow or forearm?' is 'Yes'. Depends on: Yes
No	Radiobutton	Check this box if the left elbow examination is not being conducted during a flare-up. Fill only if 'Does the Veteran report flare-ups of the elbow or forearm?' is 'Yes'. Depends on: Yes
Left Elbow Flare-up Functional Limitation Evidence (Yes/No)
Yes	Radiobutton	Check this box if procured evidence (including lay testimony) suggests pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability with left elbow flare-ups. Fill only if 'Does the Veteran report flare-ups of the elbow or forearm?' is 'Yes'. Depends on: Yes
No	Radiobutton	Check this box if procured evidence (including lay testimony) does not suggest pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability with left elbow flare-ups. Fill only if 'Does the Veteran report flare-ups of the elbow or forearm?' is 'Yes'. Depends on: Yes
Left Elbow Flare-up Functional Loss Factors
Pain	Checkbox	Check this box if pain contributes to the left elbow functional loss during flare-ups. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Fatigability	Checkbox	Check this box if fatigability contributes to the left elbow functional loss during flare-ups. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Weakness	Checkbox	Check this box if weakness contributes to the left elbow functional loss during flare-ups. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Lack of endurance	Checkbox	Check this box if lack of endurance contributes to the left elbow functional loss during flare-ups. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Incoordination	Checkbox	Check this box if incoordination contributes to the left elbow functional loss during flare-ups. Fill only if 'Yes' is 'Yes'. Depends on: Yes
N/A	Checkbox	Check this box if none of the listed factors cause left elbow functional loss during flare-ups. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other (specify)	Checkbox	Check this box if another factor not listed contributes to left elbow functional loss during flare-ups and you will provide details in the space provided. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other Functional Loss Factor (Left Elbow)	Text	Enter any other factor not listed that contributes to functional loss of the left elbow during flare-ups. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Left Elbow Flare-up Range of Motion Estimates
Left Elbow Flare-up Flexion Endpoint (Degrees)	Number	Enter the estimated left elbow flexion endpoint in degrees during flare-ups based on the available evidence. Fill only if 'Does the Veteran report flare-ups of the elbow or forearm?' is 'Yes'. Depends on: Yes
Left Elbow Flare-up Extension Endpoint (Degrees)	Number	Enter the estimated left elbow extension endpoint in degrees during flare-ups based on the available evidence. Fill only if 'Does the Veteran report flare-ups of the elbow or forearm?' is 'Yes'. Depends on: Yes
Left Elbow Flare-up Forearm Supination Endpoint (Degrees)	Number	Enter the estimated left forearm supination endpoint in degrees during flare-ups based on the available evidence. Fill only if 'Does the Veteran report flare-ups of the elbow or forearm?' is 'Yes'. Depends on: Yes
Left Elbow Flare-up Forearm Pronation Endpoint (Degrees)	Number	Enter the estimated left forearm pronation endpoint in degrees during flare-ups based on the available evidence. Fill only if 'Does the Veteran report flare-ups of the elbow or forearm?' is 'Yes'. Depends on: Yes
Left Elbow Flare-up Rationale/Narrative
Left Elbow Flare-up Evidence and Rationale	Text	Provide a detailed narrative citing and discussing all procurable evidence supporting the estimated functional loss and range-of-motion limitations for the left elbow during flare-ups. Fill only if 'Does the Veteran report flare-ups of the elbow or forearm?' is 'Yes'. Depends on: Yes
Left Elbow Functional Loss Explanation
Left Elbow ROM Functional Loss Explanation	Text	Explain how the left elbow range of motion contributes to functional loss, if applicable. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left Elbow If Testing Cannot Be Performed Explanation
Left Elbow Testing Not Performed Explanation	Text	Provide an explanation for why left elbow testing cannot be performed. Fill only if 'No' is 'No'. Depends on: No
Left Elbow Initial ROM Status
All normal	Checkbox	Check this box if the left elbow initial range of motion (ROM) measurements are within normal limits.
Abnormal or outside of normal range	Checkbox	Check this box if the left elbow initial ROM measurements are abnormal or outside the normal range.
Unable to test	Checkbox	Check this box if you were unable to perform initial ROM testing for the left elbow.
Not indicated	Checkbox	Check this box if initial ROM testing for the left elbow was not indicated.
Left Elbow Localized Tenderness or Pain on Palpation
Yes	Radiobutton	Check this box if there is objective evidence of localized tenderness or pain on palpation of the left elbow joint or associated soft tissue.
No	Radiobutton	Check this box if there is no objective evidence of localized tenderness or pain on palpation of the left elbow joint or associated soft tissue.
Left Elbow Localized Tenderness/Pain Explanation	Text	Describe the objective evidence of localized tenderness or pain on palpation of the left elbow joint or associated soft tissue, including the location, severity, and relationship to the condition(s). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left Elbow Muscle Atrophy (Location and Measurements)
Left upper extremity (location/measurements provided)	Checkbox	Check this box when documenting muscle atrophy in the left upper extremity and you will specify the measurement location (e.g., “10 cm above or below elbow”) and measurements for normal vs. atrophied side. Fill only if 'Left elbow muscle atrophy - Yes', 'Left elbow atrophy due to claimed condition - Yes' is 'Yes' (all fields). Depends on: Left elbow muscle atrophy - Yes, Left elbow atrophy due to claimed condition - Yes
Atrophy Measurement Location (Left Upper Extremity)	Text	Enter the specific location where the circumference measurements were taken for the left upper extremity (e.g., a stated distance above or below the elbow). Fill only if 'Left elbow muscle atrophy - Yes', 'Left elbow atrophy due to claimed condition - Yes' is 'Yes' (all fields). Depends on: Left elbow muscle atrophy - Yes, Left elbow atrophy due to claimed condition - Yes
Circumference of Normal Side (cm)	Number	Enter the circumference measurement of the normal (unaffected) side for comparison. Fill only if 'Left elbow muscle atrophy - Yes', 'Left elbow atrophy due to claimed condition - Yes' is 'Yes' (all fields). Depends on: Left elbow muscle atrophy - Yes, Left elbow atrophy due to claimed condition - Yes
Circumference of Atrophied Side (cm)	Number	Enter the circumference measurement of the atrophied (affected) side. Fill only if 'Left elbow muscle atrophy - Yes', 'Left elbow atrophy due to claimed condition - Yes' is 'Yes' (all fields). Depends on: Left elbow muscle atrophy - Yes, Left elbow atrophy due to claimed condition - Yes
Left Elbow Muscle Atrophy (Presence, Relation to Claimed Condition, Rationale)
Left elbow muscle atrophy - Yes	Radiobutton	Check this box if the Veteran has muscle atrophy in the left elbow.
Left elbow muscle atrophy - No	Radiobutton	Check this box if the Veteran does not have muscle atrophy in the left elbow.
Left elbow atrophy due to claimed condition - Yes	Radiobutton	Check this box if the left elbow muscle atrophy is due to the claimed condition listed in the diagnosis section.
Left elbow atrophy due to claimed condition - No	Radiobutton	Check this box if the left elbow muscle atrophy is not due to the claimed condition listed in the diagnosis section.
Left Elbow Muscle Atrophy Rationale (If Not Due to Claimed Condition)	Text	Provide the rationale explaining why the Veteran's left elbow muscle atrophy is not due to the claimed condition listed in the diagnosis section. Fill only if 'Left elbow atrophy due to claimed condition - No' is 'No'. Depends on: Left elbow atrophy due to claimed condition - No
Left Elbow Muscle Atrophy Comments
Left Elbow Muscle Atrophy Comments	Text	Enter any additional comments or explanatory notes regarding muscle atrophy of the left elbow.
Left Elbow Objective Evidence of Crepitus
Objective evidence of crepitus: Yes	Radiobutton	Check this box if there is objective evidence of crepitus in the left elbow.
Objective evidence of crepitus: No	Radiobutton	Check this box if there is no objective evidence of crepitus in the left elbow.
Left Elbow Outside Normal but Normal for Veteran Description
Left Elbow Outside Normal but Normal for Veteran Description	Text	Describe why the left elbow range of motion is outside the normal range but is considered normal for the Veteran (e.g., due to age, body habitus, or another non-elbow condition). Fill only if 'Abnormal or outside of normal range' is selected. Depends on: Abnormal or outside of normal range
Left Elbow Pain Evidence and Functional Impact
Yes	Radiobutton	Check this box if there is evidence of left elbow pain.
No	Radiobutton	Check this box if there is no evidence of left elbow pain.
Weight-bearing	Checkbox	Check this box if pain is evident during weight-bearing. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Non-weightbearing	Checkbox	Check this box if pain is evident during non-weightbearing. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Active motion	Checkbox	Check this box if pain is evident during active motion. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Passive motion	Checkbox	Check this box if pain is evident during passive motion. Fill only if 'Yes' is 'Yes'. Depends on: Yes
On rest/non-movement	Checkbox	Check this box if pain is evident at rest or without movement. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Does not result in/cause functional loss	Checkbox	Check this box if the pain does not result in or cause functional loss. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Causes functional loss (if checked, describe below)	Checkbox	Check this box if the pain causes functional loss and provide details in the space below.
Left Elbow Functional Loss Description	Text	Describe how left elbow pain causes functional loss, including the specific limitations or activities affected. Fill only if 'Causes functional loss (if checked, describe below)' is 'Yes'. Depends on: Causes functional loss (if checked, describe below)
Left Elbow Repetitive-Use Testing Ability (3+ Repetitions)
Yes	Radiobutton	Check this box if the Veteran is able to perform repetitive-use testing of the left elbow with at least three repetitions.
No	Radiobutton	Check this box if the Veteran is not able to perform repetitive-use testing of the left elbow with at least three repetitions.
Left Elbow Repetitive-Use Testing Not Performed Explanation	Text	Explain why the Veteran is not able to perform repetitive-use testing of the left elbow with at least three repetitions. Fill only if 'No' is 'Yes'. Depends on: No
Left Elbow ROM Contributes to Functional Loss (Yes/No)
Yes	Radiobutton	Check this box if the left elbow range of motion (when abnormal) itself contributes to a functional loss.
No	Radiobutton	Check this box if the left elbow range of motion (when abnormal) does not itself contribute to a functional loss.
Left Elbow Unable to Test / Not Indicated Explanation
Left Elbow Unable to Test/Not Indicated Explanation	Text	Provide an explanation for why the left elbow range of motion could not be tested or was not indicated. Fill only if 'Unable to test', 'Not indicated' is selected (any). Depends on: Unable to test, Not indicated
Left Elbow/Forearm Ankylosis Angle (Degrees)
Left elbow/forearm ankylosis angle	Number	Enter the measured angle of ankylosis for the left elbow and/or forearm in degrees. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left Elbow/Forearm Ankylosis Present
Yes	Radiobutton	Check this box if the Veteran has ankylosis (immobility) of the left elbow and/or forearm.
No	Radiobutton	Check this box if the Veteran does not have ankylosis (immobility) of the left elbow and/or forearm.
Left Elbow/Forearm Ankylosis Severity
Favorable ankylosis (70° to 90°)	Radiobutton	Check this box if the left elbow/forearm has favorable ankylosis with the joint fixed at an angle between 70 and 90 degrees. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Intermediate ankylosis (>90° or 50° to 70°)	Radiobutton	Check this box if the left elbow/forearm has intermediate ankylosis with the joint fixed at an angle of more than 90 degrees or between 50 and 70 degrees. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Unfavorable ankylosis	Radiobutton	Check this box if the left elbow/forearm ankylosis is unfavorable (not meeting the favorable or intermediate criteria). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Unfavorable: angle less than 50°	Checkbox	Check this box if the left elbow/forearm ankylosis is unfavorable and the joint is fixed at an angle of less than 50 degrees. Fill only if 'Unfavorable ankylosis' is 'Yes'. Depends on: Unfavorable ankylosis
Unfavorable: complete loss of supination	Checkbox	Check this box if the left elbow/forearm ankylosis includes complete loss of supination. Fill only if 'Unfavorable ankylosis' is 'Yes'. Depends on: Unfavorable ankylosis
Unfavorable: complete loss of pronation	Checkbox	Check this box if the left elbow/forearm ankylosis includes complete loss of pronation. Fill only if 'Unfavorable ankylosis' is 'Yes'. Depends on: Unfavorable ankylosis
Left Forearm Pronation Degree Endpoint
Left forearm pronation endpoint (degrees)	Number	Enter the left forearm pronation degree endpoint if it is different from the value reported above. Fill only if 'Forearm pronation endpoint (80 degrees)' is different than the value recorded above. Depends on: Forearm pronation endpoint (80 degrees)
Left forearm pronation endpoint details	Number	Provide any notes or explanation describing the left forearm pronation degree endpoint if it differs from the value reported above. Fill only if 'Forearm pronation endpoint (80 degrees)' is different than the value recorded above. Depends on: Forearm pronation endpoint (80 degrees)
Left Joint Condition (Damaged/Undamaged)
Damaged	Radiobutton	Check this box if the unclaimed left joint is damaged. Fill only if 'Side affected' is 'Right'. Depends on: Side affected: Right
Undamaged	Radiobutton	Check this box if the unclaimed left joint is undamaged (and range of motion testing will be conducted). Fill only if 'Side affected' is 'Right'. Depends on: Side affected: Right
Left Passive ROM Limitation Endpoints (If different than above)
Passive ROM Flexion Degree Endpoint (If Different)	Text	Enter the passive flexion range-of-motion degree endpoint if it differs from the value reported above. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Passive ROM Extension Degree Endpoint (If Different)	Text	Enter the passive extension range-of-motion degree endpoint if it differs from the value reported above. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Passive ROM Forearm Supination Degree Endpoint (If Different)	Text	Enter the passive forearm supination range-of-motion degree endpoint if it differs from the value reported above. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Left Passive ROM Measurements (Degrees / Same as Active ROM)
Left Passive ROM Flexion Endpoint (Degrees)	Number	Enter the measured left-side passive flexion endpoint value. Fill only if 'Undamaged', 'Flexion passive ROM same as active ROM' 2 is 'Yes' and 40 is 'No' (all). Depends on: Undamaged, Flexion passive ROM same as active ROM
Flexion passive ROM same as active ROM	Checkbox	Check this box if the passive flexion ROM measurement is the same as the active flexion ROM measurement. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Left Passive ROM Extension Endpoint (Degrees)	Number	Enter the measured left-side passive extension endpoint value. Fill only if 'Undamaged', 'Extension passive ROM same as active ROM' 2 is 'Yes' and 42 is 'No' (all). Depends on: Undamaged, Extension passive ROM same as active ROM
Extension passive ROM same as active ROM	Checkbox	Check this box if the passive extension ROM measurement is the same as the active extension ROM measurement. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Left Passive ROM Forearm Supination Endpoint (Degrees)	Number	Enter the measured left-side passive forearm supination endpoint value. Fill only if 'Undamaged', 'Forearm supination passive ROM same as active ROM' 2 is 'Yes' and 44 is 'No' (all). Depends on: Undamaged, Forearm supination passive ROM same as active ROM
Forearm supination passive ROM same as active ROM	Checkbox	Check this box if the passive forearm supination ROM measurement is the same as the active forearm supination ROM measurement. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Left Passive ROM Forearm Pronation Endpoint (Degrees)	Number	Enter the measured left-side passive forearm pronation endpoint value. Fill only if 'Undamaged', 'Forearm pronation passive ROM same as active ROM' 2 is 'Yes' and 46 is 'No' (all). Depends on: Undamaged, Forearm pronation passive ROM same as active ROM
Forearm pronation passive ROM same as active ROM	Checkbox	Check this box if the passive forearm pronation ROM measurement is the same as the active forearm pronation ROM measurement. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Left Passive ROM Pain (Select all that apply)
Flexion	Checkbox	Check this box if passive range-of-motion testing showed pain during elbow flexion. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Forearm supination	Checkbox	Check this box if passive range-of-motion testing showed pain during forearm supination. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Extension	Checkbox	Check this box if passive range-of-motion testing showed pain during elbow extension. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Forearm pronation	Checkbox	Check this box if passive range-of-motion testing showed pain during forearm pronation. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Loss of Effective Function Details/Summary (10B)
Loss of Effective Function Summary	Text	Provide, for each affected extremity, the condition causing the loss of function, a description of the loss of effective function, and specific examples in a brief narrative summary. Fill only if 'Right upper', 'Left upper' is 'Yes' (any). Depends on: Right upper, Left upper
No Current Diagnosis Checkbox
No current diagnosis for any claimed condition	Checkbox	Check this box if the Veteran does not have a current diagnosis associated with any of the claimed condition(s) listed above (and explain findings and reasons in the Remarks section).
Other Assistive Device and Frequency
Other assistive device	Checkbox	Check this box if the Veteran uses an assistive device other than the options listed and specify it on the line provided. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other Assistive Device	Text	Enter the name of any other assistive device the Veteran uses that is not listed. Fill only if 'Other assistive device' is 'Yes'. Depends on: Other assistive device
Other device frequency: Occasional	Radiobutton	Check this box if the Veteran uses the other assistive device only occasionally. Fill only if 'Other assistive device' is 'Yes'. Depends on: Other assistive device
Other device frequency: Regular	Radiobutton	Check this box if the Veteran uses the other assistive device on a regular basis. Fill only if 'Other assistive device' is 'Yes'. Depends on: Other assistive device
Other device frequency: Constant	Radiobutton	Check this box if the Veteran uses the other assistive device constantly. Fill only if 'Other assistive device' is 'Yes'. Depends on: Other assistive device
Other Diagnosis #1
Other Diagnosis #1 Name	Text	Enter the name of the first additional diagnosis related to the claimed elbow/forearm condition. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other diagnosis #1 – Right	Radiobutton	Check this box if the condition listed as Other diagnosis #1 affects the right side only. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other diagnosis #1 – Left	Radiobutton	Check this box if the condition listed as Other diagnosis #1 affects the left side only. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other diagnosis #1 – Both	Radiobutton	Check this box if the condition listed as Other diagnosis #1 affects both the right and left sides. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other Diagnosis #1 ICD Code	Text	Enter the ICD diagnostic code for Other Diagnosis #1, if known. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other Diagnosis #1 Date of Diagnosis (Right)	Date	Enter the date this diagnosis was made for the right side, if applicable. Fill only if 'Other (specify)', 'Other diagnosis #1 – Right', 'Other diagnosis #1 – Both' are 'Yes' (all of field 214 and any of fields 216, 218). Depends on: Other (specify), Other diagnosis #1 – Right, Other diagnosis #1 – Both
Other Diagnosis #1 Date of Diagnosis (Left)	Date	Enter the date this diagnosis was made for the left side, if applicable. Fill only if 'Other (specify)', 'Other diagnosis #1 – Left', 'Other diagnosis #1 – Both' are 'Yes' (all of field 214 and any of fields 217, 218). Depends on: Other (specify), Other diagnosis #1 – Left, Other diagnosis #1 – Both
Other Diagnosis #2
Other Diagnosis #2 Name	Text	Enter the name of the second additional elbow/forearm diagnosis being reported. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other diagnosis #2 - Right	Radiobutton	Check this box if Other diagnosis #2 affects the right side. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other diagnosis #2 - Left	Radiobutton	Check this box if Other diagnosis #2 affects the left side. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other diagnosis #2 - Both	Radiobutton	Check this box if Other diagnosis #2 affects both the right and left sides. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other Diagnosis #2 ICD Code	Text	Enter the ICD diagnostic code corresponding to Other Diagnosis #2. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other Diagnosis #2 Date of Diagnosis (Right)	Date	Enter the date this diagnosis was made for the right side, if applicable. Fill only if 'Other (specify)', 'Other diagnosis #2 - Right', 'Other diagnosis #2 - Both' are 'Yes' (all of field 214 and any of fields 223, 225). Depends on: Other (specify), Other diagnosis #2 - Right, Other diagnosis #2 - Both
Other Diagnosis #2 Date of Diagnosis (Left)	Date	Enter the date this diagnosis was made for the left side, if applicable. Fill only if 'Other (specify)', 'Other diagnosis #2 - Left', 'Other diagnosis #2 - Both' are 'Yes' (all of field 214 and any of fields 224, 225). Depends on: Other (specify), Other diagnosis #2 - Left, Other diagnosis #2 - Both
Other Diagnosis Option (specify)
Other (specify)	Checkbox	Check this box if the Veteran has an elbow/forearm diagnosis not listed above, and then specify the other diagnosis in the space provided.
Other Significant Diagnostic Findings and Details (11D)
Yes	Radiobutton	Check this box if there are other significant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es) that were reviewed with this exam.
No	Radiobutton	Check this box if there are no other significant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es) that were reviewed with this exam.
Other Significant Diagnostic Findings Summary	Text	Enter the type of diagnostic test or procedure, the date performed, and a brief summary of any other significant findings or results related to the claimed condition(s) or diagnosis(es). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Painful Flexion/Extension Related to Claimed Condition (Relation and Details)
Yes	Radiobutton	Check this box if the complaint of painful motion (on flexion and/or extension) is related to the claimed condition(s) identified in the diagnosis section. Fill only if 'Painful motion on flexion/extension: Yes' is 'Yes'. Depends on: Painful motion on flexion/extension: Yes
No	Radiobutton	Check this box if the complaint of painful motion (on flexion and/or extension) is not related to the claimed condition(s) identified in the diagnosis section. Fill only if 'Painful motion on flexion/extension: Yes' is 'Yes'. Depends on: Painful motion on flexion/extension: Yes
Painful Motion Related Claimed Condition(s)	Text	List the claimed diagnosis condition(s) that the Veteran’s painful motion on flexion and/or extension is related to. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Painful Motion Attributed To (If Not Related)	Text	Describe what the Veteran’s painful motion on flexion and/or extension is attributed to if it is not related to the claimed condition(s). Fill only if 'No' is 'Yes'. Depends on: No
Painful Motion on Flexion/Extension (Presence, Type, and Side)
Painful motion on flexion/extension: Yes	Radiobutton	Check this box if the Veteran has complaints of painful motion on flexion and/or extension.
Painful motion on flexion/extension: No	Radiobutton	Check this box if the Veteran does not have complaints of painful motion on flexion or extension.
Painful motion type: Flexion	Checkbox	Check this box if the painful motion occurs with elbow flexion. Fill only if 'Painful motion on flexion/extension: Yes' is 'Yes'. Depends on: Painful motion on flexion/extension: Yes
Flexion painful motion side: Right	Radiobutton	Check this box if painful motion on flexion is present on the right side only. Fill only if 'Painful motion type: Flexion' is 'Yes'. Depends on: Painful motion type: Flexion
Flexion painful motion side: Left	Radiobutton	Check this box if painful motion on flexion is present on the left side only. Fill only if 'Painful motion type: Flexion' is 'Yes'. Depends on: Painful motion type: Flexion
Flexion painful motion side: Both	Radiobutton	Check this box if painful motion on flexion is present on both right and left sides. Fill only if 'Painful motion type: Flexion' is 'Yes'. Depends on: Painful motion type: Flexion
Painful motion type: Extension	Checkbox	Check this box if the painful motion occurs with elbow extension. Fill only if 'Painful motion on flexion/extension: Yes' is 'Yes'. Depends on: Painful motion on flexion/extension: Yes
Extension painful motion side: Right	Radiobutton	Check this box if painful motion on extension is present on the right side only. Fill only if 'Painful motion type: Extension' is 'Yes'. Depends on: Painful motion type: Extension
Extension painful motion side: Left	Radiobutton	Check this box if painful motion on extension is present on the left side only. Fill only if 'Painful motion type: Extension' is 'Yes'. Depends on: Painful motion type: Extension
Extension painful motion side: Both	Radiobutton	Check this box if painful motion on extension is present on both right and left sides. Fill only if 'Painful motion type: Extension' is 'Yes'. Depends on: Painful motion type: Extension
Painful Motion on Supination/Pronation (Presence, Type, and Side)
Painful motion on supination/pronation: Yes	Radiobutton	Check this box if the Veteran reports painful motion with forearm supination and/or pronation.
Painful motion on supination/pronation: No	Radiobutton	Check this box if the Veteran does not report painful motion with forearm supination or pronation.
Forearm supination	Checkbox	Check this box if the Veteran has painful motion during forearm supination. Fill only if 'Painful motion on supination/pronation: Yes' is 'Yes'. Depends on: Painful motion on supination/pronation: Yes
Forearm supination side: Right	Radiobutton	Check this box if painful forearm supination is present on the right side. Fill only if 'Forearm supination' is 'Yes'. Depends on: Forearm supination
Forearm supination side: Left	Radiobutton	Check this box if painful forearm supination is present on the left side. Fill only if 'Forearm supination' is 'Yes'. Depends on: Forearm supination
Forearm supination side: Both	Radiobutton	Check this box if painful forearm supination is present on both sides. Fill only if 'Forearm supination' is 'Yes'. Depends on: Forearm supination
Forearm pronation	Checkbox	Check this box if the Veteran has painful motion during forearm pronation. Fill only if 'Painful motion on supination/pronation: Yes' is 'Yes'. Depends on: Painful motion on supination/pronation: Yes
Forearm pronation side: Right	Radiobutton	Check this box if painful forearm pronation is present on the right side. Fill only if 'Forearm pronation' is 'Yes'. Depends on: Forearm pronation
Forearm pronation side: Left	Radiobutton	Check this box if painful forearm pronation is present on the left side. Fill only if 'Forearm pronation' is 'Yes'. Depends on: Forearm pronation
Forearm pronation side: Both	Radiobutton	Check this box if painful forearm pronation is present on both sides. Fill only if 'Forearm pronation' is 'Yes'. Depends on: Forearm pronation
Painful Supination/Pronation Related to Claimed Condition (Relation and Details)
Related to claimed condition(s) - Yes	Radiobutton	Check this box if the Veteran’s painful forearm supination/pronation is related to the claimed condition(s) identified in the diagnosis section. Fill only if 'Painful motion on supination/pronation: Yes' is 'Yes'. Depends on: Painful motion on supination/pronation: Yes
Related to claimed condition(s) - No	Radiobutton	Check this box if the Veteran’s painful forearm supination/pronation is not related to the claimed condition(s) identified in the diagnosis section. Fill only if 'Painful motion on supination/pronation: Yes' is 'Yes'. Depends on: Painful motion on supination/pronation: Yes
Related Claimed Condition(s)	Text	Enter the claimed condition(s) that the Veteran’s painful forearm supination and/or pronation is related to. Fill only if 'Related to claimed condition(s) - Yes' is 'Yes'. Depends on: Related to claimed condition(s) - Yes
If Not Related, Attributed Cause	Text	If the painful forearm supination and/or pronation is not related to the claimed condition(s), describe what the painful motion is attributed to. Fill only if 'Related to claimed condition(s) - No' is 'Yes'. Depends on: Related to claimed condition(s) - No
Patient/Veteran Identification and Exam Date
Patient/Veteran Name	Text	Enter the full name of the patient/veteran.
Patient/Veteran Social Security Number	Text	Enter the patient/veteran’s Social Security Number.
Date of Examination	Date	Enter the date the examination was performed.
Questionnaire Requested By
Veteran/Claimant	Checkbox	Check this box if you are completing this Disability Benefits Questionnaire at the request of the Veteran/Claimant.
Third party	Checkbox	Check this box if you are completing this Disability Benefits Questionnaire at the request of a third party (and list the organization(s) or individual(s)).
Third-Party Requester Name(s)	Text	Enter the name(s) of the third-party organization(s) or individual(s) requesting that this Disability Benefits Questionnaire be completed. Fill only if 'Third party' is 'Yes'. Depends on: Third party
Other	Checkbox	Check this box if you are completing this Disability Benefits Questionnaire at the request of someone else not listed above and provide a description.
Other Requester Description	Text	Describe who requested completion of this Disability Benefits Questionnaire if the requester is not the Veteran/Claimant or a third party listed above. Fill only if 'Other' is 'Yes'. Depends on: Other
Radius - Malunion with Bad Alignment (Laterality)
Malunion of radius, with bad alignment	Checkbox	Check this box if the Veteran has a malunion of the radius with bad alignment. Fill only if 'Radius, impairment of' is 'Yes'. Depends on: Radius, impairment of
Right	Radiobutton	Select this option if the malunion of the radius with bad alignment affects the right side only. Fill only if 'Malunion of radius, with bad alignment' is 'Yes'. Depends on: Malunion of radius, with bad alignment
Left	Radiobutton	Select this option if the malunion of the radius with bad alignment affects the left side only. Fill only if 'Malunion of radius, with bad alignment' is 'Yes'. Depends on: Malunion of radius, with bad alignment
Both	Radiobutton	Select this option if the malunion of the radius with bad alignment affects both sides. Fill only if 'Malunion of radius, with bad alignment' is 'Yes'. Depends on: Malunion of radius, with bad alignment
Radius - Nonunion Lower Half with Loss of Bone Substance and Marked Deformity (Laterality)
Nonunion in lower half with false movement (loss of bone substance and marked deformity)	Checkbox	Check this box if the Veteran has a radius nonunion in the lower half with false movement, with loss of bone substance (1 inch (2.5 cm) or more) and marked deformity. Fill only if 'Radius, impairment of' is 'Yes'. Depends on: Radius, impairment of
Right	Radiobutton	Check this box if this radius condition applies to the right side. Fill only if 'Nonunion in lower half with false movement (loss of bone substance and marked deformity)' is 'Yes'. Depends on: Nonunion in lower half with false movement (loss of bone substance and marked deformity)
Left	Radiobutton	Check this box if this radius condition applies to the left side. Fill only if 'Nonunion in lower half with false movement (loss of bone substance and marked deformity)' is 'Yes'. Depends on: Nonunion in lower half with false movement (loss of bone substance and marked deformity)
Both	Radiobutton	Check this box if this radius condition applies to both the right and left sides. Fill only if 'Nonunion in lower half with false movement (loss of bone substance and marked deformity)' is 'Yes'. Depends on: Nonunion in lower half with false movement (loss of bone substance and marked deformity)
Radius - Nonunion Lower Half without Loss of Bone Substance or Deformity (Laterality)
Nonunion in lower half (false movement) — without loss of bone substance or deformity	Checkbox	Check this box if the Veteran has a radius nonunion in the lower half with false movement, without loss of bone substance or deformity. Fill only if 'Radius, impairment of' is 'Yes'. Depends on: Radius, impairment of
Right	Radiobutton	Check this box if this condition affects the right radius/arm. Fill only if 'Nonunion in lower half (false movement) — without loss of bone substance or deformity' is 'Yes'. Depends on: Nonunion in lower half (false movement) — without loss of bone substance or deformity
Left	Radiobutton	Check this box if this condition affects the left radius/arm. Fill only if 'Nonunion in lower half (false movement) — without loss of bone substance or deformity' is 'Yes'. Depends on: Nonunion in lower half (false movement) — without loss of bone substance or deformity
Both	Radiobutton	Check this box if this condition affects both radii/arms. Fill only if 'Nonunion in lower half (false movement) — without loss of bone substance or deformity' is 'Yes'. Depends on: Nonunion in lower half (false movement) — without loss of bone substance or deformity
Radius - Nonunion Upper Half (Laterality)
Nonunion in upper half	Checkbox	Check this box if the Veteran has a nonunion in the upper half of the radius. Fill only if 'Radius, impairment of' is 'Yes'. Depends on: Radius, impairment of
Right	Radiobutton	Check this box if the radius nonunion in the upper half affects the right side only. Fill only if 'Nonunion in upper half' is 'Yes'. Depends on: Nonunion in upper half
Left	Radiobutton	Check this box if the radius nonunion in the upper half affects the left side only. Fill only if 'Nonunion in upper half' is 'Yes'. Depends on: Nonunion in upper half
Both	Radiobutton	Check this box if the radius nonunion in the upper half affects both sides. Fill only if 'Nonunion in upper half' is 'Yes'. Depends on: Nonunion in upper half
Radius and Ulna - Nonunion with Flail False Joint (Laterality)
Radius and ulna, nonunion of, with flail false joint	Checkbox	Check this box if the Veteran has nonunion of the radius and ulna with a flail false joint. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right	Radiobutton	Check this box if the nonunion with flail false joint affects the right side. Fill only if 'Radius and ulna, nonunion of, with flail false joint' is 'Yes'. Depends on: Radius and ulna, nonunion of, with flail false joint
Left	Radiobutton	Check this box if the nonunion with flail false joint affects the left side. Fill only if 'Radius and ulna, nonunion of, with flail false joint' is 'Yes'. Depends on: Radius and ulna, nonunion of, with flail false joint
Both	Radiobutton	Check this box if the nonunion with flail false joint affects both sides. Fill only if 'Radius and ulna, nonunion of, with flail false joint' is 'Yes'. Depends on: Radius and ulna, nonunion of, with flail false joint
Radius Impairment Indicated
Radius, impairment of	Checkbox	Check this box if the Veteran has an impairment of the radius requiring completion of the related details below. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right Active ROM Limitation Endpoints (If different than above)
Right Flexion Limitation Endpoint (Degrees)	Number	Enter the right joint flexion degree endpoint attributable to limitation (if different than the ROM value recorded above). Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Right Extension Limitation Endpoint (Degrees)	Number	Enter the right joint extension degree endpoint attributable to limitation (if different than the ROM value recorded above). Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Right Forearm Supination Limitation Endpoint (Degrees)	Number	Enter the right forearm supination degree endpoint attributable to limitation (if different than the ROM value recorded above). Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Right Forearm Pronation Limitation Endpoint (Degrees)	Number	Enter the right forearm pronation degree endpoint attributable to limitation (if different than the ROM value recorded above). Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Right Active ROM Measurements (Degrees)
Flexion endpoint (145 degrees)	Checkbox	Check this box if you performed right active elbow flexion range-of-motion testing and are recording the flexion endpoint value in degrees. Fill only if 'Can testing be performed?' is 'Yes'. Depends on: Yes
Flexion Endpoint (Right Active ROM)	Text	Enter the measured right-side active range of motion endpoint for elbow flexion in degrees. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Extension endpoint (0 degrees)	Checkbox	Check this box if you performed right active elbow extension range-of-motion testing and are recording the extension endpoint value in degrees. Fill only if 'Can testing be performed?' is 'Yes'. Depends on: Yes
Extension Endpoint (Right Active ROM)	Text	Enter the measured right-side active range of motion endpoint for elbow extension in degrees. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Forearm supination endpoint (85 degrees)	Checkbox	Check this box if you performed right active forearm supination range-of-motion testing and are recording the supination endpoint value in degrees. Fill only if 'Can testing be performed?' is 'Yes'. Depends on: Yes
Forearm Supination Endpoint (Right Active ROM)	Text	Enter the measured right-side active range of motion endpoint for forearm supination in degrees. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Forearm pronation endpoint (80 degrees)	Checkbox	Check this box if you performed right active forearm pronation range-of-motion testing and are recording the pronation endpoint value in degrees. Fill only if 'Can testing be performed?' is 'Yes'. Depends on: Yes
Forearm Pronation Endpoint (Right Active ROM)	Text	Enter the measured right-side active range of motion endpoint for forearm pronation in degrees. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Right Active ROM Notes/Description
Right Active ROM Notes/Description	Text	Enter any notes or narrative description related to the right joint active range of motion (ROM) findings, including relevant observations, limitations, or context. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Right Active ROM Pain (Select all that apply)
Flexion	Checkbox	Check this box if the patient had pain during active ROM flexion on examination. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Forearm supination	Checkbox	Check this box if the patient had pain during active ROM forearm supination on examination. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Extension	Checkbox	Check this box if the patient had pain during active ROM extension on examination. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Forearm pronation	Checkbox	Check this box if the patient had pain during active ROM forearm pronation on examination. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Right Elbow - Additional Loss After Three Repetitions
Yes	Radiobutton	Check this box if there is additional loss of function or range of motion in the right elbow after three repetitions. Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions? (Right elbow)' is 'Yes'. Depends on: Yes
No	Radiobutton	Check this box if there is no additional loss of function or range of motion in the right elbow after three repetitions. Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions? (Right elbow)' is 'Yes'. Depends on: Yes
Right Elbow - Arthroscopic or Other Elbow Surgery Details
Arthroscopic or other elbow surgery	Checkbox	Check this box if the Veteran has had arthroscopic surgery or any other (non-replacement) surgical procedure on the right elbow.
Right Elbow Surgery Type	Text	Enter the type of arthroscopic or other elbow surgery performed on the Veteran’s right elbow. Fill only if 'Arthroscopic or other elbow surgery' is selected. Depends on: Arthroscopic or other elbow surgery
Right Elbow Surgery Date	Date	Enter the date the arthroscopic or other right elbow surgery was performed. Fill only if 'Arthroscopic or other elbow surgery' is selected. Depends on: Arthroscopic or other elbow surgery
Right Elbow Surgery Residuals Description	Text	Describe any residuals or ongoing effects from the arthroscopic or other right elbow surgery. Fill only if 'Arthroscopic or other elbow surgery' is selected. Depends on: Arthroscopic or other elbow surgery
Right Elbow - Functional Loss Factors After Three Repetitions
Pain	Checkbox	Check this box if pain causes the additional functional loss after three repetitions of the right elbow. Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions? (Right elbow)' is 'Yes'. Depends on: Yes
Fatigability	Checkbox	Check this box if fatigability causes the additional functional loss after three repetitions of the right elbow. Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions? (Right elbow)' is 'Yes'. Depends on: Yes
Weakness	Checkbox	Check this box if weakness causes the additional functional loss after three repetitions of the right elbow. Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions? (Right elbow)' is 'Yes'. Depends on: Yes
Lack of endurance	Checkbox	Check this box if lack of endurance causes the additional functional loss after three repetitions of the right elbow. Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions? (Right elbow)' is 'Yes'. Depends on: Yes
Incoordination	Checkbox	Check this box if incoordination causes the additional functional loss after three repetitions of the right elbow. Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions? (Right elbow)' is 'Yes'. Depends on: Yes
N/A	Checkbox	Check this box if none of the listed factors apply as a cause of additional functional loss after three repetitions of the right elbow. Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions? (Right elbow)' is 'Yes'. Depends on: Yes
Other (specify)	Checkbox	Check this box if another factor (not listed) causes the additional functional loss after three repetitions of the right elbow, and specify it on the provided line. Fill only if 'Is the Veteran able to perform repetitive-use testing with at least three repetitions? (Right elbow)' is 'Yes'. Depends on: Yes
Other Functional Loss Factor (Specify)	Text	Specify any other factor(s) causing functional loss after three repetitions of right elbow motion that are not listed above. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Right Elbow - No Surgery
No surgery	Checkbox	Check this box if the Veteran has not had any surgical procedures on the right elbow.
Right Elbow - Repeated Use Over Time Evidence/Rationale
Right elbow repeated-use evidence/rationale	Text	Provide a narrative citing and discussing the evidence used to support the repeated use over time assessment for the right elbow.
Right Elbow - Repeated Use Over Time Functional Loss
Examined immediately after repeated use over time - Yes	Radiobutton	Check this box if the Veteran is being examined immediately after repeated use over time (right elbow).
Examined immediately after repeated use over time - No	Radiobutton	Check this box if the Veteran is not being examined immediately after repeated use over time (right elbow).
Evidence suggests functional limitation with repeated use over time - Yes	Radiobutton	Check this box if procured evidence (including the Veteran’s statements) suggests pain, fatigability, weakness, lack of endurance, or incoordination significantly limits right elbow function with repeated use over time.
Evidence suggests functional limitation with repeated use over time - No	Radiobutton	Check this box if procured evidence does not suggest significant right elbow functional limitation with repeated use over time due to pain, fatigability, weakness, lack of endurance, or incoordination.
Pain	Checkbox	Check this box if pain contributes to the right elbow functional loss with repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'. Depends on: Evidence suggests functional limitation with repeated use over time - Yes
Fatigability	Checkbox	Check this box if fatigability contributes to the right elbow functional loss with repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'. Depends on: Evidence suggests functional limitation with repeated use over time - Yes
Weakness	Checkbox	Check this box if weakness contributes to the right elbow functional loss with repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'. Depends on: Evidence suggests functional limitation with repeated use over time - Yes
Lack of endurance	Checkbox	Check this box if lack of endurance contributes to the right elbow functional loss with repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'. Depends on: Evidence suggests functional limitation with repeated use over time - Yes
Incoordination	Checkbox	Check this box if incoordination contributes to the right elbow functional loss with repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'. Depends on: Evidence suggests functional limitation with repeated use over time - Yes
N/A	Checkbox	Check this box if none of the listed factors apply as causes of right elbow functional loss with repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'. Depends on: Evidence suggests functional limitation with repeated use over time - Yes
Other (specify)	Checkbox	Check this box if another factor (not listed) contributes to right elbow functional loss with repeated use over time and will be specified.
Other Functional Loss Factor (Specify)	Text	Describe any other factor not listed that causes functional loss in the right elbow with repeated use over time. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Right Elbow - Repeated Use Over Time ROM Estimates
Flexion Endpoint Estimate After Repeated Use	Number	Enter the estimated right elbow flexion endpoint in degrees immediately after repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'. Depends on: Evidence suggests functional limitation with repeated use over time - Yes
Extension Endpoint Estimate After Repeated Use	Number	Enter the estimated right elbow extension endpoint in degrees immediately after repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'. Depends on: Evidence suggests functional limitation with repeated use over time - Yes
Forearm Supination Endpoint Estimate After Repeated Use	Number	Enter the estimated right forearm supination endpoint in degrees immediately after repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'. Depends on: Evidence suggests functional limitation with repeated use over time - Yes
Forearm Pronation Endpoint Estimate After Repeated Use	Number	Enter the estimated right forearm pronation endpoint in degrees immediately after repeated use over time. Fill only if 'Evidence suggests functional limitation with repeated use over time - Yes' is 'Yes'. Depends on: Evidence suggests functional limitation with repeated use over time - Yes
Right Elbow - ROM Endpoints After Three Repetitions
Flexion Endpoint After 3 Repetitions (Right Elbow)	Number	Enter the right elbow flexion endpoint measurement after completing three repetitions. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Extension Endpoint After 3 Repetitions (Right Elbow)	Number	Enter the right elbow extension endpoint measurement after completing three repetitions. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Supination Endpoint After 3 Repetitions (Right Elbow)	Number	Enter the right forearm supination endpoint measurement after completing three repetitions. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Pronation Endpoint After 3 Repetitions (Right Elbow)	Number	Enter the right forearm pronation endpoint measurement after completing three repetitions. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right Elbow - Total Elbow Joint Replacement Details
Total elbow joint replacement	Checkbox	Check this box if the Veteran has had a total elbow joint replacement surgery on the right elbow.
Total Elbow Joint Replacement Date (Right Elbow)	Date	Enter the date the right elbow total elbow joint replacement surgery was performed. Fill only if 'Total elbow joint replacement' is selected. Depends on: Total elbow joint replacement
Residuals: None	Checkbox	Check this box if there are no residual symptoms or functional limitations following the right total elbow joint replacement. Fill only if 'Total elbow joint replacement' is selected. Depends on: Total elbow joint replacement
Residuals: Intermediate degrees of residual weakness, pain, or limitation of motion	Checkbox	Check this box if the right elbow replacement resulted in intermediate residual weakness, pain, or limitation of motion. Fill only if 'Total elbow joint replacement' is selected. Depends on: Total elbow joint replacement
Residuals: Chronic residuals consisting of severe painful motion or weakness	Checkbox	Check this box if the right elbow replacement resulted in chronic residuals with severe painful motion or weakness. Fill only if 'Total elbow joint replacement' is selected. Depends on: Total elbow joint replacement
Residuals: Other (describe)	Checkbox	Check this box if the right elbow replacement has residuals not listed above, and provide details in the description area. Fill only if 'Total elbow joint replacement' is selected. Depends on: Total elbow joint replacement
Residuals Description (Right Elbow Total Replacement)	Text	Describe any residual symptoms or complications from the right elbow total elbow joint replacement (including details if 'Other' residuals applies). Fill only if 'Residuals: Other (describe)' is selected. Depends on: Residuals: Other (describe)
Right Elbow Additional Contributing Factors (Checkboxes)
None	Checkbox	Check this box if there are no additional contributing factors to the right elbow disability beyond those already addressed above.
Interference with sitting	Checkbox	Check this box if the right elbow condition interferes with the Veteran’s ability to sit.
Interference with standing	Checkbox	Check this box if the right elbow condition interferes with the Veteran’s ability to stand.
Swelling	Checkbox	Check this box if swelling is an additional contributing factor associated with the right elbow disability.
Disturbance of locomotion	Checkbox	Check this box if the right elbow condition causes a disturbance of locomotion (difficulty with walking/moving about).
Deformity	Checkbox	Check this box if deformity of the right elbow is present as an additional contributing factor to disability.
Less movement than normal	Checkbox	Check this box if the right elbow has less movement than normal (reduced range of motion) contributing to disability.
More movement than normal	Checkbox	Check this box if the right elbow has more movement than normal (excess motion/hypermobility) contributing to disability.
Weakened movement	Checkbox	Check this box if weakened movement due to the right elbow condition is an additional contributing factor.
Atrophy of disuse	Checkbox	Check this box if there is muscle atrophy from disuse related to the right elbow condition.
Instability of station	Checkbox	Check this box if the right elbow condition causes instability of station (unsteadiness/instability while standing).
Other, describe	Checkbox	Check this box if there is another additional contributing factor not listed, and provide a description in the space provided.
Right Elbow Additional Contributing Factors Description
Right Elbow Additional Contributing Factors Description	Text	Describe any additional factors contributing to the right elbow disability (e.g., functional interference, swelling, deformity, instability, weakened movement, or other relevant impacts).
Right Elbow Can Testing Be Performed (Yes/No)
Yes	Radiobutton	Check this box if right elbow testing can be performed.
No	Radiobutton	Check this box if right elbow testing cannot be performed.
Right Elbow Flare-up Examination (Yes/No)
Yes	Radiobutton	Check this box if the right elbow examination is being conducted during a flare-up. Fill only if 'Does the Veteran report flare-ups of the elbow or forearm?' is 'Yes'. Depends on: Yes
No	Radiobutton	Check this box if the right elbow examination is not being conducted during a flare-up. Fill only if 'Does the Veteran report flare-ups of the elbow or forearm?' is 'Yes'. Depends on: Yes
Right Elbow Flare-up Functional Limitation Evidence (Yes/No)
Yes	Radiobutton	Check this box if procured evidence (e.g., Veteran statements) suggests pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits right elbow functional ability with flare-ups. Fill only if 'Does the Veteran report flare-ups of the elbow or forearm?' is 'Yes'. Depends on: Yes
No	Radiobutton	Check this box if procured evidence does not suggest pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits right elbow functional ability with flare-ups. Fill only if 'Does the Veteran report flare-ups of the elbow or forearm?' is 'Yes'. Depends on: Yes
Right Elbow Flare-up Functional Loss Factors
Pain	Checkbox	Check this box if pain is a factor that causes functional loss during right elbow flare-ups. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Fatigability	Checkbox	Check this box if fatigability is a factor that causes functional loss during right elbow flare-ups. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Weakness	Checkbox	Check this box if weakness is a factor that causes functional loss during right elbow flare-ups. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Lack of endurance	Checkbox	Check this box if lack of endurance is a factor that causes functional loss during right elbow flare-ups. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Incoordination	Checkbox	Check this box if incoordination is a factor that causes functional loss during right elbow flare-ups. Fill only if 'Yes' is 'Yes'. Depends on: Yes
N/A	Checkbox	Check this box if none of the listed factors apply as causes of functional loss during right elbow flare-ups. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other (specify)	Checkbox	Check this box if another factor not listed causes functional loss during right elbow flare-ups and you will specify it. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other factor (specify)	Text	Enter the other factor(s) causing right elbow functional loss during flare-ups that are not listed above. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Right Elbow Flare-up Range of Motion Estimates
Flexion Endpoint (Flare-ups)	Text	Enter the estimated right elbow flexion endpoint in degrees during flare-ups. Fill only if 'Does the Veteran report flare-ups of the elbow or forearm?' is 'Yes'. Depends on: Yes
Extension Endpoint (Flare-ups)	Text	Enter the estimated right elbow extension endpoint in degrees during flare-ups. Fill only if 'Does the Veteran report flare-ups of the elbow or forearm?' is 'Yes'. Depends on: Yes
Forearm Supination Endpoint (Flare-ups)	Text	Enter the estimated right forearm supination endpoint in degrees during flare-ups. Fill only if 'Does the Veteran report flare-ups of the elbow or forearm?' is 'Yes'. Depends on: Yes
Forearm Pronation Endpoint (Flare-ups)	Text	Enter the estimated right forearm pronation endpoint in degrees during flare-ups. Fill only if 'Does the Veteran report flare-ups of the elbow or forearm?' is 'Yes'. Depends on: Yes
Right Elbow Flare-up Rationale/Narrative
Right Elbow Flare-up Evidence Narrative	Text	Cite and discuss the specific evidence used to estimate the right elbow’s functional loss and range of motion during flare-ups, based on all procurable information (including lay statements and medical records). Fill only if 'Does the Veteran report flare-ups of the elbow or forearm?' is 'Yes'. Depends on: Yes
Right Elbow Functional Loss Explanation
Right Elbow ROM Functional Loss Explanation	Text	Provide an explanation of how the right elbow range of motion abnormality contributes to functional loss. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right Elbow If Testing Cannot Be Performed Explanation
Right Elbow Testing Not Performed Explanation	Text	Provide an explanation for why right elbow testing cannot be performed. Fill only if 'No' is 'No'. Depends on: No
Right Elbow Initial ROM Status
All normal	Checkbox	Check this box if the right elbow initial ROM measurements are within the normal range.
Abnormal or outside of normal range	Checkbox	Check this box if the right elbow initial ROM measurements are abnormal or outside the normal range.
Unable to test	Checkbox	Check this box if you are unable to perform ROM testing for the right elbow.
Not indicated	Checkbox	Check this box if right elbow initial ROM measurements are not indicated/required.
Right Elbow Localized Tenderness or Pain on Palpation
Yes	Radiobutton	Check this box if there is objective evidence of localized tenderness or pain on palpation of the right elbow joint or associated soft tissue.
No	Radiobutton	Check this box if there is no objective evidence of localized tenderness or pain on palpation of the right elbow joint or associated soft tissue.
Right Elbow Tenderness/Pain on Palpation Explanation	Text	Explain the objective localized tenderness or pain on palpation in the right elbow or associated soft tissue, including the location, severity, and how it relates to the condition(s). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right Elbow Muscle Atrophy (Location and Measurements)
Right upper extremity (atrophy location/measurements provided)	Checkbox	Check this box if the Veteran has muscle atrophy affecting the right upper extremity and you will specify the measurement location and record the normal-side and atrophied-side measurements. Fill only if '4A. Muscle atrophy - Yes (Right elbow)', '4B. Atrophy due to claimed condition - Yes (Right elbow)' is 'Yes' (all fields). Depends on: 4A. Muscle atrophy - Yes (Right elbow), 4B. Atrophy due to claimed condition - Yes (Right elbow)
Measurement Location (Right Upper Extremity)	Text	Enter the specific anatomic location where the right upper extremity circumference was measured (e.g., a stated distance above or below the elbow). Fill only if '4A. Muscle atrophy - Yes (Right elbow)', '4B. Atrophy due to claimed condition - Yes (Right elbow)' is 'Yes' (all fields). Depends on: 4A. Muscle atrophy - Yes (Right elbow), 4B. Atrophy due to claimed condition - Yes (Right elbow)
Circumference of Normal Side (cm)	Number	Enter the circumference measurement of the normal (unaffected) side at the specified location. Fill only if '4A. Muscle atrophy - Yes (Right elbow)', '4B. Atrophy due to claimed condition - Yes (Right elbow)' is 'Yes' (all fields). Depends on: 4A. Muscle atrophy - Yes (Right elbow), 4B. Atrophy due to claimed condition - Yes (Right elbow)
Circumference of Atrophied Side (cm)	Number	Enter the circumference measurement of the atrophied (affected) side at the specified location. Fill only if '4A. Muscle atrophy - Yes (Right elbow)', '4B. Atrophy due to claimed condition - Yes (Right elbow)' is 'Yes' (all fields). Depends on: 4A. Muscle atrophy - Yes (Right elbow), 4B. Atrophy due to claimed condition - Yes (Right elbow)
Right Elbow Muscle Atrophy (Presence, Relation to Claimed Condition, Rationale)
4A. Muscle atrophy - Yes (Right elbow)	Radiobutton	Check this box if the Veteran has muscle atrophy in the right elbow.
4A. Muscle atrophy - No (Right elbow)	Radiobutton	Check this box if the Veteran does not have muscle atrophy in the right elbow.
4B. Atrophy due to claimed condition - Yes (Right elbow)	Radiobutton	If right-elbow muscle atrophy is present, check this box if it is due to the claimed condition listed in the diagnosis section.
4B. Atrophy due to claimed condition - No (Right elbow)	Radiobutton	If right-elbow muscle atrophy is present, check this box if it is not due to the claimed condition listed in the diagnosis section (and provide a rationale).
Right Elbow Muscle Atrophy Rationale (If Not Due to Claimed Condition)	Text	Provide the medical rationale explaining why any right elbow muscle atrophy is not due to the claimed condition listed in the diagnosis section. Fill only if '4B. Atrophy due to claimed condition - No (Right elbow)' is 'No'. Depends on: 4B. Atrophy due to claimed condition - No (Right elbow)
Right Elbow Muscle Atrophy Comments
Right Elbow Muscle Atrophy Comments	Text	Enter any additional comments or notes regarding muscle atrophy findings for the right elbow.
Right Elbow Objective Evidence of Crepitus
Objective evidence of crepitus – Yes	Radiobutton	Check this box if there is objective evidence of crepitus in the right elbow.
Objective evidence of crepitus – No	Radiobutton	Check this box if there is no objective evidence of crepitus in the right elbow.
Right Elbow Outside Normal but Normal for Veteran Description
Right Elbow Normal-for-Veteran ROM Explanation	Text	Describe why the right elbow range of motion is outside the normal range but is considered normal for the Veteran (e.g., due to age, body habitus, or a non-elbow condition). Fill only if 'Abnormal or outside of normal range' is selected. Depends on: Abnormal or outside of normal range
Right Elbow Pain Evidence and Functional Impact
Evidence of pain - Yes	Radiobutton	Check this box if there is evidence of pain in the right elbow.
Evidence of pain - No	Radiobutton	Check this box if there is no evidence of pain in the right elbow.
Pain with weight-bearing	Checkbox	If there is evidence of pain, check this box when right elbow pain is present during weight-bearing. Fill only if 'Evidence of pain - Yes' is 'Yes'. Depends on: Evidence of pain - Yes
Pain with non-weightbearing	Checkbox	If there is evidence of pain, check this box when right elbow pain is present during non-weightbearing. Fill only if 'Evidence of pain - Yes' is 'Yes'. Depends on: Evidence of pain - Yes
Pain with active motion	Checkbox	If there is evidence of pain, check this box when right elbow pain occurs with active motion (the patient moves the joint). Fill only if 'Evidence of pain - Yes' is 'Yes'. Depends on: Evidence of pain - Yes
Pain with passive motion	Checkbox	If there is evidence of pain, check this box when right elbow pain occurs with passive motion (the examiner moves the joint). Fill only if 'Evidence of pain - Yes' is 'Yes'. Depends on: Evidence of pain - Yes
Pain on rest/non-movement	Checkbox	If there is evidence of pain, check this box when right elbow pain is present at rest or with no movement. Fill only if 'Evidence of pain - Yes' is 'Yes'. Depends on: Evidence of pain - Yes
Pain does not result in/cause functional loss	Checkbox	Check this box if right elbow pain is present but does not result in or cause functional loss. Fill only if 'Evidence of pain - Yes' is 'Yes'. Depends on: Evidence of pain - Yes
Pain causes functional loss	Checkbox	Check this box if right elbow pain results in or causes functional loss (and provide the description below as indicated on the form).
Right elbow pain functional loss description	Text	Describe how right elbow pain causes functional loss, including specific activities or movements affected. Fill only if 'Pain causes functional loss' is 'Yes'. Depends on: Pain causes functional loss
Right Elbow Repetitive-Use Testing Ability (3+ Repetitions)
Yes	Radiobutton	Check this box if the Veteran is able to perform right-elbow repetitive-use testing with at least three repetitions.
No	Radiobutton	Check this box if the Veteran is not able to perform right-elbow repetitive-use testing with at least three repetitions.
Right Elbow Repetitive-Use Testing Explanation	Text	Explain why the Veteran is not able to perform repetitive-use testing with at least three repetitions for the right elbow. Fill only if 'No' is 'Yes'. Depends on: No
Right Elbow ROM Contributes to Functional Loss (Yes/No)
Yes	Radiobutton	Check this box if the right elbow range of motion (ROM), when abnormal, contributes to a functional loss.
No	Radiobutton	Check this box if the right elbow range of motion (ROM), even if abnormal, does not contribute to a functional loss.
Right Elbow Unable to Test / Not Indicated Explanation
Right Elbow Unable to Test / Not Indicated Explanation	Text	Provide an explanation for why right elbow range-of-motion testing was unable to be performed or was not indicated. Fill only if 'Unable to test', 'Not indicated' is selected (any). Depends on: Unable to test, Not indicated
Right Elbow/Forearm Ankylosis Angle (Degrees)
Right Elbow/Forearm Ankylosis Angle (Degrees)	Text	Enter the angle of ankylosis for the right elbow and/or forearm, in degrees. Fill only if 'Ankylosis of right elbow/forearm - Yes' is 'Yes'. Depends on: Ankylosis of right elbow/forearm - Yes
Right Elbow/Forearm Ankylosis Present
Ankylosis of right elbow/forearm - Yes	Radiobutton	Check this box if the Veteran has ankylosis (immobility) of the right elbow and/or forearm.
Ankylosis of right elbow/forearm - No	Radiobutton	Check this box if the Veteran does not have ankylosis (immobility) of the right elbow and/or forearm.
Right Elbow/Forearm Ankylosis Severity
Favorable ankylosis (90° to 70°)	Radiobutton	Check this box if the right elbow/forearm is ankylosed in a favorable position with the joint fixed between 90 and 70 degrees. Fill only if 'Ankylosis of right elbow/forearm - Yes' is 'Yes'. Depends on: Ankylosis of right elbow/forearm - Yes
Intermediate ankylosis (>90° or 70° to 50°)	Radiobutton	Check this box if the right elbow/forearm is ankylosed at an angle of more than 90 degrees, or between 70 and 50 degrees. Fill only if 'Ankylosis of right elbow/forearm - Yes' is 'Yes'. Depends on: Ankylosis of right elbow/forearm - Yes
Unfavorable ankylosis	Radiobutton	Check this box if the right elbow/forearm ankylosis is considered unfavorable. Fill only if 'Ankylosis of right elbow/forearm - Yes' is 'Yes'. Depends on: Ankylosis of right elbow/forearm - Yes
Unfavorable: angle less than 50°	Checkbox	Check this box if the right elbow/forearm ankylosis is fixed at an angle of less than 50 degrees. Fill only if 'Unfavorable ankylosis' is 'Yes'. Depends on: Unfavorable ankylosis
Unfavorable: complete loss of supination	Checkbox	Check this box if the right elbow/forearm ankylosis results in complete loss of supination. Fill only if 'Unfavorable ankylosis' is 'Yes'. Depends on: Unfavorable ankylosis
Unfavorable: complete loss of pronation	Checkbox	Check this box if the right elbow/forearm ankylosis results in complete loss of pronation. Fill only if 'Unfavorable ankylosis' is 'Yes'. Depends on: Unfavorable ankylosis
Right Forearm Pronation Degree Endpoint
Right Forearm Pronation Endpoint (Degrees)	Text	Enter the measured endpoint value for right forearm pronation in degrees if it is different from the value recorded above. Fill only if 'Forearm pronation endpoint (80 degrees)' is different than the value recorded above. Depends on: Forearm pronation endpoint (80 degrees)
Right Forearm Pronation Endpoint Notes	Text	Provide any notes or explanation regarding the right forearm pronation degree endpoint if it differs from the value recorded above. Fill only if 'Forearm pronation endpoint (80 degrees)' is different than the value recorded above. Depends on: Forearm pronation endpoint (80 degrees)
Right Joint Condition (Damaged/Undamaged)
Damaged	Radiobutton	Check this box if the unclaimed right joint is damaged. Fill only if 'Side affected' is 'Left'. Depends on: Side affected: Left
Undamaged	Radiobutton	Check this box if the unclaimed right joint is undamaged. Fill only if 'Side affected' is 'Left'. Depends on: Side affected: Left
Right Passive ROM Limitation Endpoints (If different than above)
Right Passive ROM Flexion Limitation Endpoint (Degrees)	Text	Enter the flexion degree endpoint for the right passive range of motion limitation if it differs from the passive ROM value listed above. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Right Passive ROM Extension Limitation Endpoint (Degrees)	Text	Enter the extension degree endpoint for the right passive range of motion limitation if it differs from the passive ROM value listed above. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Right Passive ROM Forearm Supination Limitation Endpoint (Degrees)	Text	Enter the forearm supination degree endpoint for the right passive range of motion limitation if it differs from the passive ROM value listed above. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Right Passive ROM Measurements (Degrees / Same as Active ROM)
Passive ROM Flexion Endpoint (Right)	Number	Enter the measured passive flexion endpoint for the right joint in degrees. Fill only if 'Undamaged', 'Flexion — Same as active ROM' 21 is 'Yes' and 55 is 'No' (all). Depends on: Undamaged, Flexion — Same as active ROM
Flexion — Same as active ROM	Checkbox	Check this box if the passive flexion endpoint (degrees) is the same as the active ROM flexion value. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Passive ROM Extension Endpoint (Right)	Number	Enter the measured passive extension endpoint for the right joint in degrees. Fill only if 'Undamaged', 'Extension — Same as active ROM' 21 is 'Yes' and 57 is 'No' (all). Depends on: Undamaged, Extension — Same as active ROM
Extension — Same as active ROM	Checkbox	Check this box if the passive extension endpoint (degrees) is the same as the active ROM extension value. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Passive ROM Forearm Supination Endpoint (Right)	Number	Enter the measured passive forearm supination endpoint for the right joint in degrees. Fill only if 'Undamaged', 'Forearm supination — Same as active ROM' 21 is 'Yes' and 59 is 'No' (all). Depends on: Undamaged, Forearm supination — Same as active ROM
Forearm supination — Same as active ROM	Checkbox	Check this box if the passive forearm supination endpoint (degrees) is the same as the active ROM forearm supination value. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Passive ROM Forearm Pronation Endpoint (Right)	Number	Enter the measured passive forearm pronation endpoint for the right joint in degrees. Fill only if 'Undamaged', 'Forearm pronation — Same as active ROM' 21 is 'Yes' and 61 is 'No' (all). Depends on: Undamaged, Forearm pronation — Same as active ROM
Forearm pronation — Same as active ROM	Checkbox	Check this box if the passive forearm pronation endpoint (degrees) is the same as the active ROM forearm pronation value. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Right Passive ROM Pain (Select all that apply)
Flexion	Checkbox	Check this box if passive flexion range of motion of the right joint exhibited pain on examination. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Forearm supination	Checkbox	Check this box if passive forearm supination range of motion of the right joint exhibited pain on examination. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Extension	Checkbox	Check this box if passive extension range of motion of the right joint exhibited pain on examination. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Forearm pronation	Checkbox	Check this box if passive forearm pronation range of motion of the right joint exhibited pain on examination. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
SECTION 12 - FUNCTIONAL IMPACT
Yes	Radiobutton	Check this box if the diagnosed condition(s) impact the Veteran’s ability to perform any type of occupational task (e.g., standing, walking, lifting, sitting).
No	Radiobutton	Check this box if the diagnosed condition(s) do not impact the Veteran’s ability to perform any type of occupational task.
Functional Impact Description	Text	Describe how each diagnosed condition impacts the veteran’s ability to perform occupational tasks (e.g., standing, walking, lifting, sitting), providing one or more examples. Fill only if 'Yes' is 'Yes'. Depends on: Yes
SECTION 13 - REMARKS
Remarks	Text	Enter any additional remarks or explanations, and identify the section(s) of the form to which each remark applies when appropriate. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'Yes'. Depends on: No current diagnosis for any claimed condition
Section 8A - Other Pertinent Physical Findings (Yes/No and Summary)
Yes	Radiobutton	Check this box if the Veteran has any other pertinent physical findings, complications, conditions, signs, and/or symptoms related to the diagnosed conditions.
No	Radiobutton	Check this box if the Veteran does not have any other pertinent physical findings, complications, conditions, signs, and/or symptoms related to the diagnosed conditions.
Other Pertinent Physical Findings Summary	Text	Provide a brief summary describing any other pertinent physical findings, complications, conditions, signs, and/or symptoms related to the diagnosed conditions. Fill only if 'Yes' is selected. Depends on: Yes
Section 8B - Scars or Disfigurement Related to Conditions (Yes/No)
Yes	Radiobutton	Check this box if the Veteran has any scars or other skin disfigurement related to any of the diagnosed conditions or their treatment.
No	Radiobutton	Check this box if the Veteran does not have any scars or other skin disfigurement related to any of the diagnosed conditions or their treatment.
Supination and Pronation Impairment Indicated
Supination and pronation, impairment of	Checkbox	Check this box if the Veteran has an impairment of forearm supination and/or pronation that should be documented in this section. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Supination/Pronation - Hand Fixed in Full Pronation (Laterality)
Loss of (bone fusion): hand fixed in full pronation	Checkbox	Check this box if the Veteran has loss of supination/pronation due to bone fusion with the hand fixed in full pronation. Fill only if 'Supination and pronation, impairment of' is 'Yes'. Depends on: Supination and pronation, impairment of
Right (hand fixed in full pronation)	Radiobutton	Check this box if the hand fixed in full pronation condition applies to the right side only. Fill only if 'Loss of (bone fusion): hand fixed in full pronation' is 'Yes'. Depends on: Loss of (bone fusion): hand fixed in full pronation
Left (hand fixed in full pronation)	Radiobutton	Check this box if the hand fixed in full pronation condition applies to the left side only. Fill only if 'Loss of (bone fusion): hand fixed in full pronation' is 'Yes'. Depends on: Loss of (bone fusion): hand fixed in full pronation
Both (hands fixed in full pronation)	Radiobutton	Check this box if the hand fixed in full pronation condition applies to both sides. Fill only if 'Loss of (bone fusion): hand fixed in full pronation' is 'Yes'. Depends on: Loss of (bone fusion): hand fixed in full pronation
Supination/Pronation - Hand Fixed in Hyperpronation (Laterality)
Loss of (bone fusion): hand fixed in hyperpronation	Checkbox	Check this box if the Veteran has loss of bone fusion resulting in the hand being fixed in hyperpronation. Fill only if 'Supination and pronation, impairment of' is 'Yes'. Depends on: Supination and pronation, impairment of
Hyperpronation (hand fixed) - Right	Radiobutton	Check this box if the hand fixed in hyperpronation condition affects the right side only. Fill only if 'Loss of (bone fusion): hand fixed in hyperpronation' is 'Yes'. Depends on: Loss of (bone fusion): hand fixed in hyperpronation
Hyperpronation (hand fixed) - Left	Radiobutton	Check this box if the hand fixed in hyperpronation condition affects the left side only. Fill only if 'Loss of (bone fusion): hand fixed in hyperpronation' is 'Yes'. Depends on: Loss of (bone fusion): hand fixed in hyperpronation
Hyperpronation (hand fixed) - Both	Radiobutton	Check this box if the hand fixed in hyperpronation condition affects both sides. Fill only if 'Loss of (bone fusion): hand fixed in hyperpronation' is 'Yes'. Depends on: Loss of (bone fusion): hand fixed in hyperpronation
Supination/Pronation - Hand Fixed in Supination (Laterality)
Loss of (bone fusion): hand fixed in supination	Checkbox	Check this box if the Veteran has loss of supination/pronation due to bone fusion with the hand fixed in supination. Fill only if 'Supination and pronation, impairment of' is 'Yes'. Depends on: Supination and pronation, impairment of
Right	Radiobutton	Check this box if the condition "hand fixed in supination" affects the right side only. Fill only if 'Loss of (bone fusion): hand fixed in supination' is 'Yes'. Depends on: Loss of (bone fusion): hand fixed in supination
Left	Radiobutton	Check this box if the condition "hand fixed in supination" affects the left side only. Fill only if 'Loss of (bone fusion): hand fixed in supination' is 'Yes'. Depends on: Loss of (bone fusion): hand fixed in supination
Both	Radiobutton	Check this box if the condition "hand fixed in supination" affects both sides. Fill only if 'Loss of (bone fusion): hand fixed in supination' is 'Yes'. Depends on: Loss of (bone fusion): hand fixed in supination
Supination/Pronation - Hand Fixed Near Middle of Arc or Moderate Pronation (Laterality)
Loss of (bone fusion): hand fixed near the middle of the arc or moderate pronation	Checkbox	Check this box if the Veteran has loss of (bone fusion) with the hand fixed near the middle of the arc or in moderate pronation. Fill only if 'Supination and pronation, impairment of' is 'Yes'. Depends on: Supination and pronation, impairment of
Right	Radiobutton	Check this box if the condition (hand fixed near the middle of the arc or moderate pronation) affects the right side only. Fill only if 'Loss of (bone fusion): hand fixed near the middle of the arc or moderate pronation' is 'Yes'. Depends on: Loss of (bone fusion): hand fixed near the middle of the arc or moderate pronation
Left	Radiobutton	Check this box if the condition (hand fixed near the middle of the arc or moderate pronation) affects the left side only. Fill only if 'Loss of (bone fusion): hand fixed near the middle of the arc or moderate pronation' is 'Yes'. Depends on: Loss of (bone fusion): hand fixed near the middle of the arc or moderate pronation
Both	Radiobutton	Check this box if the condition (hand fixed near the middle of the arc or moderate pronation) affects both sides. Fill only if 'Loss of (bone fusion): hand fixed near the middle of the arc or moderate pronation' is 'Yes'. Depends on: Loss of (bone fusion): hand fixed near the middle of the arc or moderate pronation
Supination/Pronation - Limitation of Pronation Beyond Last Quarter of Arc; Hand Does Not Approach Full Pronation (Laterality)
Limitation of pronation beyond last quarter of arc; hand does not approach full pronation	Checkbox	Check this box if pronation is limited beyond the last quarter of the arc and the hand does not approach full pronation. Fill only if 'Supination and pronation, impairment of' is 'Yes'. Depends on: Supination and pronation, impairment of
Right	Radiobutton	Check this box if the limitation of pronation described applies to the right side. Fill only if 'Limitation of pronation beyond last quarter of arc; hand does not approach full pronation' is 'Yes'. Depends on: Limitation of pronation beyond last quarter of arc; hand does not approach full pronation
Left	Radiobutton	Check this box if the limitation of pronation described applies to the left side. Fill only if 'Limitation of pronation beyond last quarter of arc; hand does not approach full pronation' is 'Yes'. Depends on: Limitation of pronation beyond last quarter of arc; hand does not approach full pronation
Both	Radiobutton	Check this box if the limitation of pronation described applies to both sides. Fill only if 'Limitation of pronation beyond last quarter of arc; hand does not approach full pronation' is 'Yes'. Depends on: Limitation of pronation beyond last quarter of arc; hand does not approach full pronation
Supination/Pronation - Limitation of Pronation Beyond Middle of Arc (Laterality)
Limitation of pronation (motion lost beyond middle of arc)	Checkbox	Check this box if the veteran has limitation of pronation such that motion is lost beyond the middle of the arc. Fill only if 'Supination and pronation, impairment of' is 'Yes'. Depends on: Supination and pronation, impairment of
Right	Radiobutton	Check this box if the limitation of pronation (motion lost beyond the middle of the arc) affects the right side only. Fill only if 'Limitation of pronation (motion lost beyond middle of arc)' is 'Yes'. Depends on: Limitation of pronation (motion lost beyond middle of arc)
Left	Radiobutton	Check this box if the limitation of pronation (motion lost beyond the middle of the arc) affects the left side only. Fill only if 'Limitation of pronation (motion lost beyond middle of arc)' is 'Yes'. Depends on: Limitation of pronation (motion lost beyond middle of arc)
Both	Radiobutton	Check this box if the limitation of pronation (motion lost beyond the middle of the arc) affects both sides. Fill only if 'Limitation of pronation (motion lost beyond middle of arc)' is 'Yes'. Depends on: Limitation of pronation (motion lost beyond middle of arc)
Supination/Pronation - Limitation of Supination: 30 Degrees or Less (Laterality)
Limitation of supination: 30 degrees or less	Checkbox	Check this box if the Veteran has limitation of forearm supination to 30 degrees or less. Fill only if 'Supination and pronation, impairment of' is 'Yes'. Depends on: Supination and pronation, impairment of
Right	Radiobutton	Check this box if the limitation of supination to 30 degrees or less affects the right side only. Fill only if 'Limitation of supination: 30 degrees or less' is 'Yes'. Depends on: Limitation of supination: 30 degrees or less
Left	Radiobutton	Check this box if the limitation of supination to 30 degrees or less affects the left side only. Fill only if 'Limitation of supination: 30 degrees or less' is 'Yes'. Depends on: Limitation of supination: 30 degrees or less
Both	Radiobutton	Check this box if the limitation of supination to 30 degrees or less affects both sides. Fill only if 'Limitation of supination: 30 degrees or less' is 'Yes'. Depends on: Limitation of supination: 30 degrees or less
Ulna - Malunion with Bad Alignment (Laterality)
Malunion of ulna, with bad alignment	Checkbox	Check this box if the Veteran has a malunion of the ulna with bad alignment. Fill only if 'Ulna, impairment of' is 'Yes'. Depends on: Ulna, impairment of
Right	Radiobutton	Check this box if the ulna malunion with bad alignment affects the right side only. Fill only if 'Malunion of ulna, with bad alignment' is 'Yes'. Depends on: Malunion of ulna, with bad alignment
Left	Radiobutton	Check this box if the ulna malunion with bad alignment affects the left side only. Fill only if 'Malunion of ulna, with bad alignment' is 'Yes'. Depends on: Malunion of ulna, with bad alignment
Both	Radiobutton	Check this box if the ulna malunion with bad alignment affects both sides. Fill only if 'Malunion of ulna, with bad alignment' is 'Yes'. Depends on: Malunion of ulna, with bad alignment
Ulna - Nonunion Lower Half (Laterality)
Nonunion in lower half	Checkbox	Check this box if the Veteran has a nonunion in the lower half of the ulna. Fill only if 'Ulna, impairment of' is 'Yes'. Depends on: Ulna, impairment of
Right	Radiobutton	Check this box if the ulna nonunion in the lower half affects the right side only. Fill only if 'Nonunion in lower half' is 'Yes'. Depends on: Nonunion in lower half
Left	Radiobutton	Check this box if the ulna nonunion in the lower half affects the left side only. Fill only if 'Nonunion in lower half' is 'Yes'. Depends on: Nonunion in lower half
Both	Radiobutton	Check this box if the ulna nonunion in the lower half affects both the right and left sides. Fill only if 'Nonunion in lower half' is 'Yes'. Depends on: Nonunion in lower half
Ulna - Nonunion Upper Half with Loss of Bone Substance and Marked Deformity (Laterality)
Nonunion in upper half with false movement (with loss of bone substance and marked deformity)	Checkbox	Check this box if the Veteran has a nonunion in the upper half of the ulna with false movement, with loss of bone substance (1 inch/2.5 cm or more) and marked deformity. Fill only if 'Ulna, impairment of' is 'Yes'. Depends on: Ulna, impairment of
Laterality: Right	Radiobutton	Check this box if the nonunion in the upper half of the ulna (with loss of bone substance and marked deformity) affects the right side only. Fill only if 'Nonunion in upper half with false movement (with loss of bone substance and marked deformity)' is 'Yes'. Depends on: Nonunion in upper half with false movement (with loss of bone substance and marked deformity)
Laterality: Left	Radiobutton	Check this box if the nonunion in the upper half of the ulna (with loss of bone substance and marked deformity) affects the left side only. Fill only if 'Nonunion in upper half with false movement (with loss of bone substance and marked deformity)' is 'Yes'. Depends on: Nonunion in upper half with false movement (with loss of bone substance and marked deformity)
Laterality: Both	Radiobutton	Check this box if the nonunion in the upper half of the ulna (with loss of bone substance and marked deformity) affects both the right and left sides. Fill only if 'Nonunion in upper half with false movement (with loss of bone substance and marked deformity)' is 'Yes'. Depends on: Nonunion in upper half with false movement (with loss of bone substance and marked deformity)
Ulna - Nonunion Upper Half without Loss of Bone Substance or Deformity (Laterality)
Nonunion in upper half with false movement (without loss of bone substance or deformity)	Checkbox	Check this box if the Veteran has nonunion of the ulna in the upper half with false movement and there is no loss of bone substance and no deformity. Fill only if 'Ulna, impairment of' is 'Yes'. Depends on: Ulna, impairment of
Right	Radiobutton	Check this box if this ulna condition applies to the right side only. Fill only if 'Nonunion in upper half with false movement (without loss of bone substance or deformity)' is 'Yes'. Depends on: Nonunion in upper half with false movement (without loss of bone substance or deformity)
Left	Radiobutton	Check this box if this ulna condition applies to the left side only. Fill only if 'Nonunion in upper half with false movement (without loss of bone substance or deformity)' is 'Yes'. Depends on: Nonunion in upper half with false movement (without loss of bone substance or deformity)
Both	Radiobutton	Check this box if this ulna condition applies to both the right and left sides. Fill only if 'Nonunion in upper half with false movement (without loss of bone substance or deformity)' is 'Yes'. Depends on: Nonunion in upper half with false movement (without loss of bone substance or deformity)
Ulna Impairment Indicated
Ulna, impairment of	Checkbox	Check this box if the Veteran has an impairment of the ulna that applies to this evaluation. Fill only if 'Yes' is 'Yes'. Depends on: Yes
VA Healthcare Provider Status
VA Healthcare provider - Yes	Radiobutton	Check this box if you are a VA Healthcare provider.
VA Healthcare provider - No	Radiobutton	Check this box if you are not a VA Healthcare provider.
Veteran Regularly Seen as Patient in Clinic
Yes	Radiobutton	Check this box if the Veteran is regularly seen as a patient in your clinic.
No	Radiobutton	Check this box if the Veteran is not regularly seen as a patient in your clinic.
Veteran Uses Assistive Devices (Yes/No)
Yes	Radiobutton	Check this box if the Veteran uses any assistive devices.
No	Radiobutton	Check this box if the Veteran does not use any assistive devices.

Elbow and Forearm Conditions Disability Benefits Questionnaire Instructions