This form contains 739 fields organized into 184 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
10A Amputation Equivalence and Affected Extremities
10A - Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran	Radiobutton	Check this box if the Veteran's elbow and/or forearm function is so diminished that amputation with a prosthesis would provide function equal to or better than the current limb.
10A - No	Radiobutton	Check this box if the Veteran does not have functional impairment of the elbow/forearm such that amputation with prosthesis would equally serve the Veteran.
10A - Right upper	Checkbox	Check this box if the amputation-equivalent loss of function described in 10A applies to the Veteran's right upper extremity. Fill only if '10A - Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran' is 'Yes'. Depends on: 10A - Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran
10A - Left upper	Checkbox	Check this box if the amputation-equivalent loss of function described in 10A applies to the Veteran's left upper extremity. Fill only if '10A - Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran' is 'Yes'. Depends on: 10A - Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran
10B Loss of Function Summary
10B Loss of Function Summary	Text	For each extremity checked, briefly identify the condition causing the loss of function, describe the remaining effective function lost, and provide specific examples of how this loss affects use of the extremity. Fill only if '10A - Right upper', '10A - Left upper' is 'Yes' on any fields selection. Depends on: 10A - Right upper, 10A - Left upper
11A Imaging Performed - Yes/No
11A Imaging Performed - Yes	Radiobutton	Check this box if imaging studies have been performed in conjunction with this examination.
11A Imaging Performed - No	Radiobutton	Check this box if no imaging studies have been performed in conjunction with this examination.
11B Arthritis Documented and Side
11B Arthritis Documented - Yes	Radiobutton	Check this box if degenerative (osteoarthritis) or post‑traumatic arthritis has been documented. Fill only if '11A Imaging Performed - Yes' is 'Yes'. Depends on: 11A Imaging Performed - Yes
11B Arthritis Documented - No	Radiobutton	Check this box if degenerative or post‑traumatic arthritis has not been documented. Fill only if '11A Imaging Performed - Yes' is 'Yes'. Depends on: 11A Imaging Performed - Yes
11B Indicate Side - Right	Radiobutton	If arthritis is documented, check this box when the condition involves the right elbow/forearm. Fill only if '11B Arthritis Documented - Yes' is 'Yes'. Depends on: 11B Arthritis Documented - Yes
11B Indicate Side - Left	Radiobutton	If arthritis is documented, check this box when the condition involves the left elbow/forearm. Fill only if '11B Arthritis Documented - Yes' is 'Yes'. Depends on: 11B Arthritis Documented - Yes
11B Indicate Side - Both	Radiobutton	If arthritis is documented, check this box when the condition involves both elbows/forearms. Fill only if '11B Arthritis Documented - Yes' is 'Yes'. Depends on: 11B Arthritis Documented - Yes
11C Test or Procedure Summary
11C - Test or Procedure Summary	Text	Enter a brief summary describing the type of test or procedure, the date it was performed, and the test results or findings relevant to the claimed condition. Fill only if '11A Have imaging studies been performed in conjunction with this examination?' is 'Yes'. Depends on: 11A Imaging Performed - Yes
11D Other Diagnostic Findings (Yes/No and Details)
11D Other Diagnostic Findings - Yes	Radiobutton	Check this box if there are one or more other significant diagnostic test findings or results related to the claimed condition(s)/diagnosis(es) that were reviewed in conjunction with this exam.
11D Other Diagnostic Findings - No	Radiobutton	Check this box if there are no other significant diagnostic test findings or results related to the claimed condition(s)/diagnosis(es) reviewed in conjunction with this exam.
11D – Test/Procedure, Date and Results (brief summary)	Text	Provide a brief summary listing the type of diagnostic test or procedure, the date performed, and the key results or findings related to the claimed condition(s). Fill only if '11D Other Diagnostic Findings - Yes' is 'Yes'. Depends on: 11D Other Diagnostic Findings - Yes
11E Relationship of Abnormal Findings to Diagnosed Conditions
11E Relationship of Abnormal Findings to Diagnosed Conditions	Text	Describe how any abnormal test results relate to the diagnosed condition(s), explaining whether and how the findings support, contradict, or are unrelated to each diagnosis and include brief context or examples as needed. Fill only if 'Section 11 diagnostic test results' are other-than-normal. Depends on: 11B Arthritis Documented - Yes
12A Functional Impact (Yes/No and Description)
12A Yes	Radiobutton	Check this box if the diagnosed condition(s) do impact the Veteran's ability to perform any type of occupational task (e.g., standing, walking, lifting, sitting, etc.).
12A No	Radiobutton	Check this box if the diagnosed condition(s) do not impact the Veteran's ability to perform any type of occupational task.
12A Functional Impact — Description of Impact	Text	Describe how each diagnosed condition affects the Veteran’s ability to perform any type of occupational task (for example standing, walking, lifting, sitting), giving specific examples of limitations, frequency, severity, and any activities that are restricted or require assistance. Fill only if '12A Yes' is 'Yes'. Depends on: 12A Yes
13A Remarks
13A Remarks	Text	Enter any remarks or additional information related to the form; when applicable, identify the section or question number the remark pertains to. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above.' is 'Yes'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
14A Examiner signature and 14B Examiner printed name
14A Examiner signature	Text	Enter the examiner's handwritten or electronic signature to certify the accuracy and completeness of the information on this form.
14B Examiner printed name and title	Text	Enter the examiner's full printed name followed by their professional title (for example, MD, DO, DDS, DMD, Ph.D., Psy.D., NP, PA-C).
14C Examiner area of practice and 14D Date signed
14C. Examiner area of practice/specialty	Text	Enter the examiner's medical area of practice or specialty (for example: Cardiology, Orthopedics, Psychiatry, General Practice).
14D. Date signed	Date	Enter the date on which the examiner signed this certification.
14E Examiner phone/fax, 14F NPI number, and 14G Medical license and state
14E Examiner phone/fax numbers	Text	Enter the examiner's contact phone number and fax number (as a single string) for follow-up communication.
14F National Provider Identifier (NPI) number	Number	Enter the examiner's National Provider Identifier (NPI) number.
14G Medical license number and state	Text	Enter the examiner's medical license number followed by the issuing state (e.g., number and two-letter state abbreviation).
14H Examiner address
14H Examiner's address	Text	Enter the examiner's full mailing address (street address and any suite or unit), followed by city, state/province, postal code, and country as applicable.
2D Conditions (if yes) - Text
2D — Specified condition(s)	Text	Enter the specific condition(s) related to the complaint of painful motion (list diagnoses or details) as they apply to this question. Fill only if '2D Yes - related to claimed condition' is 'Yes'. Depends on: 2D Yes - related to claimed condition
2D Extension - Check and Side
2D Extension	Checkbox	Check this box if the patient has complaints of painful motion on extension (item 2D). Fill only if '2D Painful motion - Yes' is 'Yes'. Depends on: 2D Painful motion - Yes
2D Extension - Right	Radiobutton	Check this box if '2D Extension' is checked and the painful motion on extension is on the right side. Fill only if '2D Extension' is 'Yes'. Depends on: 2D Extension
2D Extension - Left	Radiobutton	Check this box if '2D Extension' is checked and the painful motion on extension is on the left side. Fill only if '2D Extension' is 'Yes'. Depends on: 2D Extension
2D Extension - Both	Radiobutton	Check this box if '2D Extension' is checked and the painful motion on extension occurs on both sides. Fill only if '2D Extension' is 'Yes'. Depends on: 2D Extension
2D Flexion - Check and Side
2D Flexion	Checkbox	Check this box if there are complaints of painful motion on flexion. Fill only if '2D Painful motion - Yes' is 'Yes'. Depends on: 2D Painful motion - Yes
2D Flexion - Right	Radiobutton	Check this box if the flexion complaint (Flexion must be checked) is present on the right side. Fill only if '2D Flexion' is 'Yes'. Depends on: 2D Flexion
2D Flexion - Left	Radiobutton	Check this box if the flexion complaint (Flexion must be checked) is present on the left side. Fill only if '2D Flexion' is 'Yes'. Depends on: 2D Flexion
2D Flexion - Both	Radiobutton	Check this box if the flexion complaint (Flexion must be checked) is present on both sides. Fill only if '2D Flexion' is 'Yes'. Depends on: 2D Flexion
2D If no, describe attribution - Text
2D – Attribution Description (If No)	Text	If you answered No to whether the painful motion is related to the claimed condition(s), describe in detail what the pain is attributed to (cause, contributing factors, history or events) in this box. Fill only if '2D No - not related to claimed condition' is 'Yes'. Depends on: 2D No - not related to claimed condition
2D Painful motion (flexion/extension) - Main Yes/No
2D Painful motion - Yes	Radiobutton	Check this box if the patient has complaints of painful motion on flexion and/or extension.
2D Painful motion - No	Radiobutton	Check this box if the patient has no complaints of painful motion on flexion and/or extension.
2D Related to claimed condition - Yes/No
2D Yes - related to claimed condition	Radiobutton	Check this box when the complaint of painful motion is related to the claimed condition(s) identified in the diagnosis section. Fill only if '2D Painful motion - Yes' is 'Yes'. Depends on: 2D Painful motion - Yes
2D No - not related to claimed condition	Radiobutton	Check this box when the complaint of painful motion is not related to the claimed condition(s) identified in the diagnosis section. Fill only if '2D Painful motion - Yes' is 'Yes'. Depends on: 2D Painful motion - Yes
2E Conditions (if yes) - Text
2E If yes, specify condition(s)	Text	Enter the specific condition(s) or diagnoses related to the complaint of painful forearm supination and/or pronation. Fill only if '2E Yes (complaint related to claimed condition)' is 'Yes'. Depends on: 2E Yes (complaint related to claimed condition)
2E Forearm pronation - Check and Side
2E Forearm pronation	Checkbox	Check this box when the patient reports painful motion during forearm pronation. Fill only if '2E Yes' is 'Yes'. Depends on: 2E Yes
2E Forearm pronation - Right	Radiobutton	Check this when Forearm pronation is selected and the painful motion affects the right side. Fill only if '2E Forearm pronation' is 'Yes'. Depends on: 2E Forearm pronation
2E Forearm pronation - Left	Radiobutton	Check this when Forearm pronation is selected and the painful motion affects the left side. Fill only if '2E Forearm pronation' is 'Yes'. Depends on: 2E Forearm pronation
2E Forearm pronation - Both	Radiobutton	Check this when Forearm pronation is selected and the painful motion affects both sides. Fill only if '2E Forearm pronation' is 'Yes'. Depends on: 2E Forearm pronation
2E Forearm supination - Check and Side
2E Forearm supination	Checkbox	Check this box if the patient has complaints of painful motion during forearm supination (select when supination is a reported complaint). Fill only if '2E Yes' is 'Yes'. Depends on: 2E Yes
2E Forearm supination - Right	Radiobutton	Check this option to indicate the forearm supination complaint affects the right side (use when the supination box is checked and the right side is involved). Fill only if '2E Forearm supination' is 'Yes'. Depends on: 2E Forearm supination
2E Forearm supination - Left	Radiobutton	Check this option to indicate the forearm supination complaint affects the left side (use when the supination box is checked and the left side is involved). Fill only if '2E Forearm supination' is 'Yes'. Depends on: 2E Forearm supination
2E Forearm supination - Both	Radiobutton	Check this option to indicate the forearm supination complaint affects both sides (use when the supination box is checked and both sides are involved). Fill only if '2E Forearm supination' is 'Yes'. Depends on: 2E Forearm supination
2E If no, describe attribution - Text
2E - If no, describe what it is attributed to	Text	Provide a brief description of what the painful forearm supination/pronation motion is attributed to when you answered 'No' (e.g., cause, event, condition, or contributing factor). Fill only if '2E No (complaint not related to claimed condition)' is 'Yes'. Depends on: 2E No (complaint not related to claimed condition)
2E Painful motion (supination/pronation) - Main Yes/No
2E Yes	Radiobutton	Check this box if the patient has complaints of painful motion on forearm supination and/or pronation.
2E No	Radiobutton	Check this box if the patient does not have complaints of painful motion on forearm supination and/or pronation.
2E Related to claimed condition - Yes/No
2E Yes (complaint related to claimed condition)	Radiobutton	Check this box if the complaint of painful forearm supination and/or pronation is related to the claimed condition(s) identified in the diagnosis section. Fill only if '2E Yes' is 'Yes'. Depends on: 2E Yes
2E No (complaint not related to claimed condition)	Radiobutton	Check this box if the complaint of painful forearm supination and/or pronation is not related to the claimed condition(s) identified in the diagnosis section. Fill only if '2E Yes' is 'Yes'. Depends on: 2E Yes
6A - Flail/joint question (Yes/No)
6A - Yes	Radiobutton	Check this box if the Veteran has a flail joint, joint fracture, ununited fracture, malaligned fracture, or impairment of supination or pronation.
6A - 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 details about the veteran's other impairments of the elbow and forearm (Section 6), including clarifications, descriptions of symptoms, dates, treatments, or any information not captured elsewhere on this page.
8C Comments
8C Comments	Text	Enter any additional comments, explanations, or clarifying information related to section 8; provide details that supplement or clarify previous answers.
9A Assistive Device Use - Yes/No
9A Yes	Radiobutton	Check this box if the Veteran uses one or more assistive devices.
9A No	Radiobutton	Check this box if the Veteran does not use any assistive devices.
9B Assistive Devices - Condition, Side, and Device
9B Condition, Side, and Assistive Device	Text	Describe each medical condition that requires an assistive device, indicate the body side involved (e.g., left, right, bilateral), and identify the specific assistive device used for that condition; include one entry per line if there are multiple conditions. Fill only if '9A Yes' is 'Yes'. Depends on: 9A Yes
Additional diagnoses (free text)
Additional diagnosis (elbow/forearm)	Text	Enter any additional diagnoses that pertain to the elbow or forearm using the same format as above (diagnosis name and side/location details); provide each diagnosis as a short descriptive text.
Assistive Device Row 1 (Brace) - Frequency
Row 1 - Brace	Checkbox	Check this box if the Veteran uses a brace as an assistive device. Fill only if '9A Yes' is 'Yes'. Depends on: 9A Yes
Row 1 - Brace — Occasional	Radiobutton	Check this box if the brace is used occasionally. Fill only if '9A Yes' is 'Yes'. Depends on: 9A Yes
Row 1 - Brace — Regular	Radiobutton	Check this box if the brace is used regularly. Fill only if '9A Yes' is 'Yes'. Depends on: 9A Yes
Row 1 - Brace — Constant	Radiobutton	Check this box if the brace is used constantly. Fill only if '9A Yes' is 'Yes'. Depends on: 9A Yes
Assistive Device Row 2 (Other) - Description and Frequency
Assistive Device Row 2 - Other	Checkbox	Check this box when the Veteran uses an assistive device not listed (write the device name on the adjacent line). Fill only if '9A Yes' is 'Yes'. Depends on: 9A Yes
Assistive Device Row 2 — Other (description)	Text	Enter the name or brief description of the other assistive device used (provide enough detail to identify the device). Fill only if '9A Yes' is 'Yes'. Depends on: 9A Yes
Assistive Device Row 2 - Frequency: Occasional	Radiobutton	Check this box when the 'Other' assistive device is used only occasionally. Fill only if '9A Yes' is 'Yes'. Depends on: 9A Yes
Assistive Device Row 2 - Frequency: Regular	Radiobutton	Check this box when the 'Other' assistive device is used on a regular basis. Fill only if '9A Yes' is 'Yes'. Depends on: 9A Yes
Assistive Device Row 2 - Frequency: Constant	Radiobutton	Check this box when the 'Other' assistive device is used constantly. Fill only if '9A Yes' is 'Yes'. Depends on: 9A Yes
Clinic Patient Status (Yes/No)
Is the Veteran regularly seen as a patient in your clinic? — Yes	Radiobutton	Check this box when the veteran is regularly seen as a patient in your clinic (answer = Yes).
Is the Veteran regularly seen as a patient in your clinic? — No	Radiobutton	Check this box when the veteran is not regularly seen as a patient in your clinic (answer = No).
Comments (1C)
1C Comments	Text	Enter any additional comments or notes related to the veteran's elbow or forearm condition, including clarifications, context, or information not captured elsewhere on the form. Fill only if '1B. Select diagnoses associated with the claimed condition(s)' indicates there is no diagnosis, the diagnosis is different from a previous diagnosis, or there is a diagnosis of a complication due to the claimed condition. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above, Row 1 - Olecranon bursitis, Row 2 - Tricep tendinitis, Row 3 - Lateral epicondylitis (diagnosis), Row 4 - Medial epicondylitis, Row 5 - Instability (medial/posterolateral rotatory), Row 6 - Dislocation, elbow, Row 7 - Osteoarthritis, elbow, Row 8 - Total elbow arthroplasty (diagnosis), Row 9 - Ankylosis of elbow joint, Row 10 - Degenerative arthritis, other than post-traumatic, Row 11 - Arthritis, gonorrheal, Row 12 - Arthritis, pneumococcal (Diagnosis), Row 13 - Arthritis, streptococcic (diagnosis), Row 14 - Arthritis, syphilitic, Row 15 - Arthritis, rheumatoid (multi-joint), Row 16 - Arthritis, post-traumatic (diagnosis present), Row 17 - Arthritis, typhoid (Diagnosis), Row 18 - Other specified forms of arthropathy (excluding gout), Row 19 - Osteoporosis, residuals of, Row 20 - Osteomalacia, residuals of, Row 21 - Bones, neoplasm, benign, Row 22 - Osteitis deformans, Row 23 - Gout (Diagnosis), Row 24 - Bursitis, Row 25 - Myositis, Row 26 - Heterotopic ossification, Row 27 - Tendinopathy (select one if known), Row 28 - Tendinitis, Row 29 - Tendinosis (condition), Row 30 - Tenosynovitis
Crepitus and localized tenderness - left column
Objective evidence of crepitus — Yes	Radiobutton	Check this box if objective crepitus was observed on examination of the joint (i.e., audible or palpable crepitus is present).
Objective evidence of crepitus — No	Radiobutton	Check this box if no objective crepitus was observed on examination of the joint.
Objective evidence of localized tenderness or pain on palpation — Yes	Radiobutton	Check this box if there is objective localized tenderness or pain on palpation of the joint or associated soft tissue.
Objective evidence of localized tenderness or pain on palpation — No	Radiobutton	Check this box if there is no objective localized tenderness or pain on palpation of the joint or associated soft tissue.
Localized tenderness explanation (left)	Text	Describe any objective localized tenderness or pain on palpation of the left joint or associated soft tissue, including specific location, severity, and how it relates to the diagnosed condition. Fill only if 'Objective evidence of localized tenderness or pain on palpation — Yes' is 'Yes'. Depends on: Objective evidence of localized tenderness or pain on palpation — Yes
Crepitus and localized tenderness - right column
Objective evidence of crepitus — Yes	Radiobutton	Check this box when objective crepitus was observed on examination of the right-side joint.
Objective evidence of crepitus — No	Radiobutton	Check this box when no objective crepitus was observed on examination of the right-side joint.
Localized tenderness/pain on palpation — Yes	Radiobutton	Check this box when localized tenderness or pain is present on palpation of the right joint or associated soft tissue.
Localized tenderness/pain on palpation — No	Radiobutton	Check this box when there is no localized tenderness or pain on palpation of the right joint or associated soft tissue.
Right - localized tenderness/pain explanation	Text	If there is objective evidence of localized tenderness or pain on palpation of the right joint or associated soft tissue, describe the finding including precise location, severity, character, and its relationship to the condition. Fill only if 'Localized tenderness/pain on palpation — Yes' is 'Yes'. Depends on: Localized tenderness/pain on palpation — Yes
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 is ambidextrous (uses both hands equally as their dominant hand).
Evidence of pain and characteristics - left column
Yes	Radiobutton	Check this box when there is evidence of pain on the left side.
No	Radiobutton	Check this box when there is no evidence of pain on the left side.
Weight-bearing	Checkbox	Check this box when the pain occurs or is present during weight-bearing activities. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Non-weightbearing	Checkbox	Check this box when the pain occurs or is present during non-weightbearing activities. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Active motion	Checkbox	Check this box when the pain is produced or reported during active motion. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Passive motion	Checkbox	Check this box when the pain is produced or reported during passive motion. Fill only if 'Yes' is 'Yes'. Depends on: Yes
On rest/non-movement	Checkbox	Check this box when the pain occurs 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 when the pain does not result in or cause any functional loss. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Causes functional loss (if checked, describe below)	Checkbox	Check this box when the pain causes functional loss, and provide a description of the loss in the space below. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Causes functional loss — description (left)	Text	Describe how the pain causes functional loss for the left side, giving details of limitations, activities affected, and examples of impaired function. Fill only if 'Causes functional loss (if checked, describe below)' is 'Yes'. Depends on: Causes functional loss (if checked, describe below)
Evidence of pain and characteristics - right column
Is there evidence of pain? — Yes	Radiobutton	Check this box if there is evidence of pain on the right side.
Is there evidence of pain? — No	Radiobutton	Check this box if there is no evidence of pain on the right side.
Weight-bearing	Checkbox	Check this box if the right-sided pain occurs or is provoked during weight-bearing. Fill only if 'Is there evidence of pain? — Yes' is 'Yes'. Depends on: Is there evidence of pain? — Yes
Non-weightbearing	Checkbox	Check this box if the right-sided pain occurs or is provoked when non-weightbearing. Fill only if 'Is there evidence of pain? — Yes' is 'Yes'. Depends on: Is there evidence of pain? — Yes
Active motion	Checkbox	Check this box if the right-sided pain is present during active motion. Fill only if 'Is there evidence of pain? — Yes' is 'Yes'. Depends on: Is there evidence of pain? — Yes
Passive motion	Checkbox	Check this box if the right-sided pain is present during passive motion. Fill only if 'Is there evidence of pain? — Yes' is 'Yes'. Depends on: Is there evidence of pain? — Yes
On rest/non-movement	Checkbox	Check this box if the right-sided pain occurs at rest or without movement. Fill only if 'Is there evidence of pain? — Yes' is 'Yes'. Depends on: Is there evidence of pain? — Yes
Does not result in/cause functional loss	Checkbox	Check this box if the right-sided pain does not result in or cause any functional loss. Fill only if 'Is there evidence of pain? — Yes' is 'Yes'. Depends on: Is there evidence of pain? — Yes
Causes functional loss (if checked, describe below)	Checkbox	Check this box if the right-sided pain causes functional loss, and describe the loss in the space provided below. Fill only if 'Is there evidence of pain? — Yes' is 'Yes'. Depends on: Is there evidence of pain? — Yes
Right column — Causes functional loss description	Text	Enter a clear description of the functional loss caused by the condition in the right-column section, giving specifics about limitations, activities affected, onset, duration, and severity. Fill only if 'Causes functional loss (if checked, describe below)' is 'Yes'. Depends on: Causes functional loss (if checked, describe below)
Evidence Reviewed
No records were reviewed	Radiobutton	Check this box when no supporting records (e.g., service treatment records, VA treatment records, private treatment records) were reviewed for this examination.
Records reviewed	Radiobutton	Check this box when one or more supporting records were reviewed for this examination (and then list the evidence reviewed and date range in the space provided).
Evidence reviewed — details	Text	Enter a detailed list of the evidence reviewed (for example: service treatment records, VA treatment records, private treatment records), including the source of each item and the date range for each record. Fill only if 'Records reviewed' is 'Yes'. Depends on: Records reviewed
Examination In-Person and Method
Examined in person - Yes	Radiobutton	Check this box if the Veteran was examined in person for this evaluation.
Examined in person - No	Radiobutton	Check this box if the Veteran was not examined in person (the exam was performed remotely, by record review, or by another non‑in‑person method).
Examination method (if not in-person)	Text	Describe how the examination was conducted when it was not performed in person, including the modality (for example: telephone, video/telehealth, chart review), and any brief relevant details about the encounter. Fill only if 'Examined in person - No' is 'Yes'. Depends on: Examined in person - No
Flail joint
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'. Depends on: 6A - Yes
Flail joint - Right	Radiobutton	Check this box when the Veteran's flail joint affects the right side. Fill only if 'Flail joint' is 'Yes'. Depends on: Flail joint
Flail joint - Left	Radiobutton	Check this box when the Veteran's flail joint affects the left side. Fill only if 'Flail joint' is 'Yes'. Depends on: Flail joint
Flail joint - Both	Radiobutton	Check this box when the Veteran's flail joint affects both sides. Fill only if 'Flail joint' is 'Yes'. Depends on: Flail joint
Forearm pronation degree endpoint - left column
Left forearm pronation endpoint (degrees)	Text	Enter the measured forearm pronation angle at the endpoint for the left side as a numeric value in degrees. Fill only if 'Forearm pronation endpoint (80 degrees)' for this elbow is different than the main endpoint measurement recorded above. Depends on: Left Forearm pronation degree endpoint (if different than above)
Left forearm pronation endpoint details / notes	Text	Provide any notes, observations, contextual details or a brief description of the left pronation endpoint (e.g., patient position, restrictions, or sketch description).
Forearm pronation degree endpoint - right column
Right forearm pronation degree (header box)	Number	Enter the right-side forearm pronation endpoint degree measurement to record an alternate or brief value for the right column. Fill only if 'Forearm pronation endpoint (80 degrees)' for this elbow is different than the main endpoint measurement recorded above. Depends on: Right Forearm pronation degree endpoint
Right forearm pronation degree (main entry)	Number	Enter the right-side forearm pronation endpoint degree measurement for the right column (use this field for the primary detailed value). Fill only if 'Forearm pronation endpoint (80 degrees)' for this elbow is different than the main endpoint measurement recorded above. Depends on: Right Forearm pronation degree endpoint
Joint fracture - Row 1 (Joint fracture main)
Row 1 - Joint fracture	Checkbox	Check this box to indicate the Veteran has a joint fracture (the main condition checkbox for Row 1). Fill only if '6A - Yes' is 'Yes'. Depends on: 6A - Yes
Row 1 - Right	Radiobutton	Check this box if the Veteran's joint fracture affects the right side. Fill only if 'Row 1 - Joint fracture' is 'Yes'. Depends on: Row 1 - Joint fracture
Row 1 - Left	Radiobutton	Check this box if the Veteran's joint fracture affects the left side. Fill only if 'Row 1 - Joint fracture' is 'Yes'. Depends on: Row 1 - Joint fracture
Row 1 - Both	Radiobutton	Check this box if the Veteran's joint fracture affects both sides. Fill only if 'Row 1 - Joint fracture' is 'Yes'. Depends on: Row 1 - Joint fracture
Joint fracture - Row 2 (With marked cubitus varus deformity)
Row 2 - With marked cubitus varus deformity	Checkbox	Check this box when the Veteran's joint fracture includes a marked cubitus varus deformity. Fill only if '6A - Yes' is 'Yes'. Depends on: 6A - Yes
Row 2 - Right	Radiobutton	Check this box to indicate the marked cubitus varus deformity affects the right side only. Fill only if 'Row 2 - With marked cubitus varus deformity' is 'Yes'. Depends on: Row 2 - With marked cubitus varus deformity
Row 2 - Left	Radiobutton	Check this box to indicate the marked cubitus varus deformity affects the left side only. Fill only if 'Row 2 - With marked cubitus varus deformity' is 'Yes'. Depends on: Row 2 - With marked cubitus varus deformity
Row 2 - Both	Radiobutton	Check this box to indicate the marked cubitus varus deformity affects both sides. Fill only if 'Row 2 - With marked cubitus varus deformity' is 'Yes'. Depends on: Row 2 - With marked cubitus varus deformity
Joint fracture - Row 3 (With marked cubitus valgus deformity)
Row 3 - With marked cubitus valgus deformity	Checkbox	Check this box when the veteran has a marked cubitus valgus deformity associated with the joint fracture condition (row 3). Fill only if '6A - Yes' is 'Yes'. Depends on: 6A - Yes
Row 3 - With marked cubitus valgus deformity (Right)	Radiobutton	Check this box to indicate the marked cubitus valgus deformity is present on the right side. Fill only if 'Row 3 - With marked cubitus valgus deformity' is 'Yes'. Depends on: Row 3 - With marked cubitus valgus deformity
Row 3 - With marked cubitus valgus deformity (Left)	Radiobutton	Check this box to indicate the marked cubitus valgus deformity is present on the left side. Fill only if 'Row 3 - With marked cubitus valgus deformity' is 'Yes'. Depends on: Row 3 - With marked cubitus valgus deformity
Row 3 - With marked cubitus valgus deformity (Both)	Radiobutton	Check this box to indicate the marked cubitus valgus deformity is present on both sides. Fill only if 'Row 3 - With marked cubitus valgus deformity' is 'Yes'. Depends on: Row 3 - With marked cubitus valgus deformity
Joint fracture - Row 4 (With ununited fracture of head of radius)
Row 4 - With ununited fracture of head of radius	Checkbox	Check this box if the Veteran has an ununited (nonunion) fracture of the head of the radius. Fill only if '6A - Yes' is 'Yes'. Depends on: 6A - Yes
Row 4 - With ununited fracture of head of radius, Right	Radiobutton	Check this box if the ununited fracture of the head of the radius affects the right side (select in conjunction with the Row 4 condition). Fill only if 'Row 4 - With ununited fracture of head of radius' is 'Yes'. Depends on: Row 4 - With ununited fracture of head of radius
Row 4 - 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 (select in conjunction with the Row 4 condition). Fill only if 'Row 4 - With ununited fracture of head of radius' is 'Yes'. Depends on: Row 4 - With ununited fracture of head of radius
Row 4 - With ununited fracture of head of radius, Both	Radiobutton	Check this box if the ununited fracture of the head of the radius affects both sides (select in conjunction with the Row 4 condition). Fill only if 'Row 4 - With ununited fracture of head of radius' is 'Yes'. Depends on: Row 4 - With ununited fracture of head of radius
Left Active ROM - Degree endpoints attributable to factors
Left Flexion degree endpoint (if different than above)	Text	Enter the left flexion endpoint in degrees that is specifically attributable to pain, weakness, fatigue, incoordination, or other identified factors (only if different from the flexion value recorded above).
Left Extension degree endpoint (if different than above)	Text	Enter the left extension endpoint in degrees that is specifically attributable to pain, weakness, fatigue, incoordination, or other identified factors (only if different from the extension value recorded above).
Left Forearm supination degree endpoint (if different than above)	Text	Enter the left forearm supination endpoint in degrees that is specifically attributable to pain, weakness, fatigue, incoordination, or other identified factors (only if different from the supination value recorded above).
Left Forearm pronation degree endpoint (if different than above)	Text	Enter the left forearm pronation endpoint in degrees that is specifically attributable to pain, weakness, fatigue, incoordination, or other identified factors (only if different from the pronation value recorded above).
Left Active ROM - Notes/Description
Left Active ROM - Notes / Description	Text	Enter any additional notes, observations, or a descriptive summary about the left joint's active range of motion, including findings, contextual details, or explanations for any atypical measurements.
Left Active ROM - Pain exhibited (select all that apply)
Left Flexion	Checkbox	Check this box if the patient exhibited pain during active left flexion of the joint on examination.
Left Forearm Supination	Checkbox	Check this box if the patient exhibited pain during active left forearm supination on examination.
Left Extension	Checkbox	Check this box if the patient exhibited pain during active left extension of the joint on examination.
Left Forearm Pronation	Checkbox	Check this box if the patient exhibited pain during active left forearm pronation on examination.
Left Active ROM - Row 1 (Flexion endpoint)
Row 1 - Flexion endpoint (145 degrees)	Checkbox	Check this box when recording the left active range of motion to indicate the flexion endpoint (145 degrees) was measured or observed during testing.
Left Flexion endpoint (Row 1)	Number	Enter the measured left flexion endpoint value for Row 1 of the active range of motion assessment.
Left Active ROM - Row 2 (Extension endpoint)
Row 2 - Extension endpoint (0 degrees)	Checkbox	Check this box when recording the left joint's active range of motion for the extension endpoint (expected 0 degrees) — i.e., when the examiner is measuring/ documenting the left extension endpoint.
Row 2 — Left Extension endpoint (degrees)	Text	Enter the measured left active range of motion at the extension endpoint in degrees (the numeric degree value observed during testing).
Left Active ROM - Row 3 (Forearm supination endpoint)
Left Row 3 - Forearm supination endpoint (85 degrees)	Checkbox	Check this box when performing left active range of motion testing and you are recording or confirming the forearm supination endpoint (nominally 85 degrees) for the left side.
Left Active ROM Row 3 — Forearm supination endpoint (degrees)	Number	Enter the measured active forearm supination endpoint for the left side in degrees.
Left Active ROM - Row 4 (Forearm pronation endpoint)
Row 4 - Forearm pronation endpoint (80 degrees)	Checkbox	Check this box when performing the left Active Range of Motion exam to indicate the forearm pronation endpoint (80 degrees) was assessed/recorded.
Row 4 - Left Forearm pronation endpoint (degrees)	Text	Enter the measured active range of motion for the left forearm pronation endpoint as a numeric degree value (e.g., 80).
Left Elbow - Additional contributing factors to disability (check all that apply)
None	Checkbox	Check this box if there are no additional contributing factors 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. Fill only if 'None' is 'No'. Depends on: None
Interference with standing	Checkbox	Check this box if the left elbow condition interferes with the veteran's ability to stand. Fill only if 'None' is 'No'. Depends on: None
Swelling	Checkbox	Check this box if swelling of the left elbow is an additional contributing factor to the disability. Fill only if 'None' is 'No'. Depends on: None
Disturbance of locomotion	Checkbox	Check this box if the left elbow condition contributes to disturbance of locomotion (affecting gait or walking). Fill only if 'None' is 'No'. Depends on: None
Deformity	Checkbox	Check this box if deformity of the left elbow contributes to the disability. Fill only if 'None' is 'No'. Depends on: None
Less movement than normal	Checkbox	Check this box if the left elbow shows less movement than normal that contributes to the disability. Fill only if 'None' is 'No'. Depends on: None
More movement than normal	Checkbox	Check this box if the left elbow shows more movement than normal (hypermobility) that contributes to the disability. Fill only if 'None' is 'No'. Depends on: None
Weakened movement	Checkbox	Check this box if weakened movement of the left elbow is an additional contributing factor to the disability. Fill only if 'None' is 'No'. Depends on: None
Atrophy of disuse	Checkbox	Check this box if atrophy from disuse of muscles around the left elbow contributes to the disability. Fill only if 'None' is 'No'. Depends on: None
Instability of station	Checkbox	Check this box if instability of station (difficulty maintaining balance/stance) related to the left elbow contributes to the disability. Fill only if 'None' is 'No'. Depends on: None
Other, describe	Checkbox	Check this box if there are other additional contributing factors to the left elbow disability not listed here, and describe them in the space provided. Fill only if 'None' is 'No'. Depends on: None
Left elbow — Describe additional contributing factors	Text	Provide a clear, specific description of any additional factors that contribute to the disability of the left elbow (for example swelling, deformity, instability, interference with sitting/standing, atrophy, or other problems), including details and how they affect function. Fill only if 'Interference with sitting', 'Interference with standing', 'Swelling', 'Disturbance of locomotion', 'Deformity', 'Less movement than normal', 'More movement than normal', 'Weakened movement', 'Atrophy of disuse', 'Instability of station', 'Other, describe' is 'Yes' for any fields. Depends on: Interference with sitting, Interference with standing, Swelling, Disturbance of locomotion, Deformity, Less movement than normal, More movement than normal, Weakened movement, Atrophy of disuse, Instability of station, Other, describe
Left elbow - Additional loss after three repetitions
Yes	Radiobutton	Check this box if there is additional loss of function or range of motion after three repetitions.
No	Radiobutton	Check this box if there is no additional loss of function or range of motion after three repetitions.
Flexion endpoint (after 3 repetitions)	Number	Enter the measured left elbow flexion endpoint in degrees after completing three repetitions. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Extension endpoint (after 3 repetitions)	Number	Enter the measured left elbow extension endpoint in degrees after completing three repetitions. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Supination endpoint (after 3 repetitions)	Number	Enter the measured left elbow supination endpoint in degrees after completing three repetitions. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Pronation endpoint (after 3 repetitions)	Number	Enter the measured left elbow pronation endpoint in degrees after completing three repetitions. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Pain	Checkbox	Check this box if pain is a factor causing the functional loss observed after the three repetitions. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Fatigability	Checkbox	Check this box if fatigability (becoming easily fatigued) contributes to the functional loss after the three repetitions. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Weakness	Checkbox	Check this box if muscle weakness contributes to the functional loss after the three repetitions. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Lack of endurance	Checkbox	Check this box if lack of endurance is a contributing factor to the functional loss after the three repetitions. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Incoordination	Checkbox	Check this box if incoordination (difficulty coordinating movements) contributes to the functional loss after the three repetitions. Fill only if 'Yes' is 'Yes'. Depends on: Yes
N/A	Checkbox	Check this box if none of the listed factors apply to the functional loss after the three repetitions. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other (specify)	Checkbox	Check this box if another factor not listed causes the functional loss after the three repetitions, and specify the factor on the provided line. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other factor (specify)	Text	Provide a brief description of any other factor(s) that cause this functional loss after completing three repetitions. Fill only if 'Yes', 'Other (specify)' is 'Yes' for all fields. Depends on: Yes, Other (specify)
Left elbow - Arthroscopic or other elbow surgery
Left elbow - Arthroscopic or other elbow surgery	Checkbox	Check this box if the Veteran has had arthroscopic or any other type of surgery on the left elbow.
Left elbow - Type of arthroscopic/other surgery	Text	Enter the name or brief description of the arthroscopic or other surgical procedure performed on the left elbow. Fill only if 'Left elbow - Arthroscopic or other elbow surgery' is 'Yes'. Depends on: Left elbow - Arthroscopic or other elbow surgery
Left elbow - Date of arthroscopic/other surgery	Date	Enter the date when the arthroscopic or other elbow surgery on the left side was performed. Fill only if 'Left elbow - Arthroscopic or other elbow surgery' is 'Yes'. Depends on: Left elbow - Arthroscopic or other elbow surgery
Left elbow - Residuals from arthroscopic/other surgery	Text	Describe any residual symptoms, limitations, complications, or findings that remain following the left elbow arthroscopic or other surgery. Fill only if 'Left elbow - Arthroscopic or other elbow surgery' is 'Yes'. Depends on: Left elbow - Arthroscopic or other elbow surgery
Left Elbow - Can testing be performed selection
Left elbow — Can testing be performed? Yes	Radiobutton	Check this box when the examiner was able to perform the ROM/testing on the left elbow (testing could be performed).
Left elbow — Can testing be performed? No	Radiobutton	Check this box when the examiner was NOT able to perform the ROM/testing on the left elbow (testing could not be performed) and provide an explanation in the adjacent text field.
Left Elbow - Evidence citation and discussion
Left elbow — Evidence citation and discussion	Text	Provide a detailed, case-specific citation and discussion of all procurable evidence related to the left elbow (including the Veteran’s own statements, lay testimony, and relevant medical records), explaining how the evidence supports your findings and noting any limitations or reasons if an estimate cannot be provided.
Left Elbow - Examination conducted during flare-up (Yes/No)
Left elbow - Is the examination being conducted during a flare-up? — Yes	Radiobutton	Check this box when the left elbow exam is being performed while the veteran is currently experiencing a flare-up.
Left elbow - Is the examination being conducted during a flare-up? — No	Radiobutton	Check this box when the left elbow exam is being performed and the veteran is not currently experiencing a flare-up.
Left Elbow - Factors causing functional loss (check all that apply)
Pain	Checkbox	Check this box if pain in the left elbow causes or contributes to the functional loss during flare-ups. Fill only if 'Left elbow - Procured evidence suggests pain, fatigability: Yes' is 'Yes'. Depends on: Left elbow - Procured evidence suggests pain, fatigability: Yes
Fatigability	Checkbox	Check this box if fatigability (easy tiring) of the left elbow limits functional ability during flare-ups. Fill only if 'Left elbow - Procured evidence suggests pain, fatigability: Yes' is 'Yes'. Depends on: Left elbow - Procured evidence suggests pain, fatigability: Yes
Weakness	Checkbox	Check this box if weakness in the left elbow causes or contributes to the functional loss during flare-ups. Fill only if 'Left elbow - Procured evidence suggests pain, fatigability: Yes' is 'Yes'. Depends on: Left elbow - Procured evidence suggests pain, fatigability: Yes
Lack of endurance	Checkbox	Check this box if lack of endurance of the left elbow limits its functional ability during flare-ups. Fill only if 'Left elbow - Procured evidence suggests pain, fatigability: Yes' is 'Yes'. Depends on: Left elbow - Procured evidence suggests pain, fatigability: Yes
Incoordination	Checkbox	Check this box if incoordination (difficulty with coordinated movements) of the left elbow causes functional loss during flare-ups. Fill only if 'Left elbow - Procured evidence suggests pain, fatigability: Yes' is 'Yes'. Depends on: Left elbow - Procured evidence suggests pain, fatigability: Yes
N/A	Checkbox	Check this box if the listed factors are not applicable to the left elbow or none of the factors apply. Fill only if 'Left elbow - Procured evidence suggests pain, fatigability: Yes' is 'Yes'. Depends on: Left elbow - Procured evidence suggests pain, fatigability: Yes
Other (specify)	Checkbox	Check this box if another factor not listed causes functional loss in the left elbow, and write the specific factor on the provided line. Fill only if 'Left elbow - Procured evidence suggests pain, fatigability: Yes' is 'Yes'. Depends on: Left elbow - Procured evidence suggests pain, fatigability: Yes
Left Elbow — Other (specify)	Text	Provide a brief description of any other factor(s) (not listed) that cause functional loss of the left elbow during flare-ups. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Left Elbow - If ROM contributes explanation
Left elbow — ROM contribution explanation	Text	Enter a clear, detailed explanation of how the left elbow’s range of motion (ROM) abnormalities contribute to functional loss, including specific activities affected, when the limitation occurs, severity, and any patterns or examples that illustrate the loss of function. Fill only if 'Left elbow - ROM contributes to functional loss: Yes' is 'Yes'. Depends on: Left elbow - ROM contributes to functional loss: Yes
Left Elbow - If testing cannot be performed explanation
Left elbow — If testing cannot be performed, explanation	Text	Provide a clear explanation why range-of-motion testing for the left elbow could not be performed, including relevant medical contraindications, patient pain or risk of further injury, and any observed limitations or circumstances preventing testing. Fill only if 'Left elbow — Can testing be performed? No' is 'Yes'. Depends on: Left elbow — Can testing be performed? No
Left Elbow - If unable to test or not indicated explanation
Left elbow — If unable to test or not indicated, explain	Text	Provide a brief explanation why the left elbow range-of-motion could not be tested or was not indicated, including relevant details such as circumstances, timing, contributing factors, and any observed or reported functional limitations. Fill only if 'Left elbow - Unable to test', 'Left elbow - Not indicated' is 'Yes' for any fields selection. Depends on: Left elbow - Unable to test, Left elbow - Not indicated
Left Elbow - Initial ROM selection
Left elbow - All normal	Checkbox	Check this box if the left elbow's initial range of motion measurement was within normal limits.
Left elbow - Abnormal or outside of normal range	Checkbox	Check this box if the left elbow's initial range of motion measurement was abnormal or outside the normal range.
Left elbow - Unable to test	Checkbox	Check this box if the examiner was unable to perform initial range of motion testing on the left elbow.
Left elbow - Not indicated	Checkbox	Check this box if initial range of motion testing for the left elbow was not indicated or not applicable.
Left elbow - No surgery
Left elbow - No surgery	Checkbox	Check this box if the Veteran has not had any surgical procedures performed on the left elbow.
Left Elbow - Procured evidence suggests pain/fatigability (Yes/No)
Left elbow - Procured evidence suggests pain, fatigability: Yes	Radiobutton	Check this box if procured evidence (including lay testimony) indicates that the veteran has pain, fatigability, weakness, lack of endurance, or incoordination in the left elbow that significantly limits functional ability with flare-ups.
Left elbow - Procured evidence suggests pain, fatigability: No	Radiobutton	Check this box if procured evidence (including lay testimony) does not indicate that the veteran has pain, fatigability, weakness, lack of endurance, or incoordination in the left elbow that significantly limits functional ability with flare-ups.
Left Elbow - Range of motion endpoints during flare-ups (flexion/extension/supination/pronation)
Left elbow flexion endpoint (flare-up)	Number	Estimated left elbow flexion endpoint during a flare-up based on examination findings and relevant lay statements.
Left elbow extension endpoint (flare-up)	Number	Estimated left elbow extension endpoint during a flare-up based on examination findings and relevant lay statements.
Left forearm supination endpoint (flare-up)	Number	Estimated left forearm supination endpoint during a flare-up based on examination findings and relevant lay statements.
Left forearm pronation endpoint (flare-up)	Number	Estimated left forearm pronation endpoint during a flare-up based on examination findings and relevant lay statements.
Left elbow - Repeated use over time
Left elbow - Examined immediately after repeated use: Yes	Radiobutton	Check this box if the Veteran is being examined immediately after repeated use over time of the left elbow.
Left elbow - Examined immediately after repeated use: No	Radiobutton	Check this box if the Veteran is not being examined immediately after repeated use over time of the left elbow.
Left elbow - Procured evidence suggests limiting symptoms: Yes	Radiobutton	Check this box if statements or other procured evidence indicate pain, fatigability, weakness, lack of endurance, or incoordination that significantly limit functional ability with repeated use over time.
Left elbow - Procured evidence suggests limiting symptoms: No	Radiobutton	Check this box if procured evidence does not indicate pain, fatigability, weakness, lack of endurance, or incoordination that significantly limit functional ability with repeated use over time.
Left elbow - Pain	Checkbox	Check this box if pain is a factor that causes the functional loss of the left elbow with repeated use over time. Fill only if 'Left elbow - Procured evidence suggests limiting symptoms: Yes' is 'Yes'. Depends on: Left elbow - Procured evidence suggests limiting symptoms: Yes
Left elbow - Fatigability	Checkbox	Check this box if fatigability is a factor that causes the functional loss of the left elbow with repeated use over time. Fill only if 'Left elbow - Procured evidence suggests limiting symptoms: Yes' is 'Yes'. Depends on: Left elbow - Procured evidence suggests limiting symptoms: Yes
Left elbow - Weakness	Checkbox	Check this box if weakness is a factor that causes the functional loss of the left elbow with repeated use over time. Fill only if 'Left elbow - Procured evidence suggests limiting symptoms: Yes' is 'Yes'. Depends on: Left elbow - Procured evidence suggests limiting symptoms: Yes
Left elbow - Lack of endurance	Checkbox	Check this box if lack of endurance is a factor that causes the functional loss of the left elbow with repeated use over time. Fill only if 'Left elbow - Procured evidence suggests limiting symptoms: Yes' is 'Yes'. Depends on: Left elbow - Procured evidence suggests limiting symptoms: Yes
Left elbow - Incoordination	Checkbox	Check this box if incoordination is a factor that causes the functional loss of the left elbow with repeated use over time. Fill only if 'Left elbow - Procured evidence suggests limiting symptoms: Yes' is 'Yes'. Depends on: Left elbow - Procured evidence suggests limiting symptoms: Yes
Left elbow - N/A	Checkbox	Check this box if none of the listed factors apply or the factors are not applicable to the left elbow's functional loss with repeated use over time. Fill only if 'Left elbow - Procured evidence suggests limiting symptoms: Yes' is 'Yes'. Depends on: Left elbow - Procured evidence suggests limiting symptoms: Yes
Left elbow - Other (specify)	Checkbox	Check this box if another factor (not listed) causes the left elbow's functional loss with repeated use over time, and specify the factor in the provided space. Fill only if 'Left elbow - Procured evidence suggests limiting symptoms: Yes' is 'Yes'. Depends on: Left elbow - Procured evidence suggests limiting symptoms: Yes
Left elbow - Other (specify)	Text	If you checked “Other” as a factor causing functional loss, briefly specify the other cause(s) of functional loss for the left elbow immediately after repeated use over time. Fill only if 'Left elbow - Procured evidence suggests limiting symptoms: Yes', 'Left elbow - Other (specify)' is 'Yes' for all fields. Depends on: Left elbow - Procured evidence suggests limiting symptoms: Yes, Left elbow - Other (specify)
Left elbow - Flexion endpoint (degrees)	Text	Enter the estimated flexion endpoint in degrees for the left elbow immediately after repeated use over time. Fill only if 'Left elbow - Procured evidence suggests limiting symptoms: Yes' is 'Yes'. Depends on: Left elbow - Procured evidence suggests limiting symptoms: Yes
Left elbow - Extension endpoint (degrees)	Text	Enter the estimated extension endpoint in degrees for the left elbow immediately after repeated use over time. Fill only if 'Left elbow - Procured evidence suggests limiting symptoms: Yes' is 'Yes'. Depends on: Left elbow - Procured evidence suggests limiting symptoms: Yes
Left elbow - Forearm supination endpoint (degrees)	Text	Enter the estimated forearm supination endpoint in degrees (left) immediately after repeated use over time. Fill only if 'Left elbow - Procured evidence suggests limiting symptoms: Yes' is 'Yes'. Depends on: Left elbow - Procured evidence suggests limiting symptoms: Yes
Left elbow - Forearm pronation endpoint (degrees)	Text	Enter the estimated forearm pronation endpoint in degrees (left) immediately after repeated use over time. Fill only if 'Left elbow - Procured evidence suggests limiting symptoms: Yes' is 'Yes'. Depends on: Left elbow - Procured evidence suggests limiting symptoms: Yes
Left elbow - Cite and discuss evidence	Text	Provide specific citations and a discussion of the evidence (Veteran statements, examination findings, medical records, and other procurable evidence) used to support the estimated range of motion and functional loss for the left elbow after repeated use over time. Fill only if 'Left elbow - Procured evidence suggests limiting symptoms: Yes' is 'Yes'. Depends on: Left elbow - Procured evidence suggests limiting symptoms: Yes
Left Elbow - ROM contributes to functional loss selection
Left elbow - ROM contributes to functional loss: Yes	Radiobutton	Check this box when the examiner determines that the left elbow's abnormal range of motion itself contributes to a functional loss. Fill only if 'Left elbow - Abnormal or outside of normal range' is 'Yes'. Depends on: Left elbow - Abnormal or outside of normal range
Left elbow - ROM contributes to functional loss: No	Radiobutton	Check this box when the examiner determines that the left elbow's range of motion does not contribute to a functional loss. Fill only if 'Left elbow - Abnormal or outside of normal range' is 'Yes'. Depends on: Left elbow - Abnormal or outside of normal range
Left Elbow - ROM outside normal description
Left elbow ROM outside normal — description	Text	Describe how the left elbow range of motion is outside the normal range but is normal for the Veteran (for reasons other than an elbow condition), including relevant details such as age, body habitus, neurologic disease, severity, duration, and any limiting activities. Fill only if 'Left elbow - Abnormal or outside of normal range' is 'Yes'. Depends on: Left elbow - Abnormal or outside of normal range
Left elbow - Total elbow joint replacement
Total elbow joint replacement	Checkbox	Check this box to indicate that the Veteran had a total elbow joint replacement on the left elbow.
Left total elbow replacement — Date of surgery	Date	Enter the date when the left total elbow joint replacement surgery was performed. Fill only if 'Total elbow joint replacement' is 'Yes'. Depends on: Total elbow joint replacement
None	Checkbox	Check this box if there are no residuals following the left total elbow joint replacement. Fill only if 'Total elbow joint replacement' is 'Yes'. Depends on: Total elbow joint replacement
Intermediate degrees of residual weakness, pain, or limitation of motion	Checkbox	Check this box if the left elbow has intermediate degrees of residual weakness, pain, or limitation of motion after the surgery. Fill only if 'Total elbow joint replacement' is 'Yes'. Depends on: Total elbow joint replacement
Chronic residuals consisting of severe painful motion or weakness	Checkbox	Check this box if there are chronic residuals consisting of severe painful motion or weakness in the left elbow following the surgery. Fill only if 'Total elbow joint replacement' is 'Yes'. Depends on: Total elbow joint replacement
Other, describe:	Checkbox	Check this box if there are other residuals not listed and provide a description in the space provided. Fill only if 'Total elbow joint replacement' is 'Yes'. Depends on: Total elbow joint replacement
Left total elbow replacement — Other residuals, describe	Text	Provide a brief description of any other residual problems or complications from the left total elbow joint replacement not listed above. Fill only if 'Other, describe:' is 'Yes'. Depends on: Other, describe:
Left Passive ROM - Degree endpoints attributable to factors
Flexion degree endpoint (attributable)	Text	Enter the degree measurement of elbow flexion (in degrees) that is specifically attributable to the identified factors, or enter 'N/A' if not applicable.
Extension degree endpoint (attributable)	Text	Enter the degree measurement of elbow extension (in degrees) that is specifically attributable to the identified factors, or enter 'N/A' if not applicable.
Forearm supination degree endpoint (attributable)	Text	Enter the degree measurement of forearm supination (in degrees) that is specifically attributable to the identified factors, or enter 'N/A' if not applicable.
Left Passive ROM - Pain exhibited (select all that apply)
Left Passive ROM - Flexion	Checkbox	Check this box if passive range-of-motion testing of the left joint produced pain during flexion.
Left Passive ROM - Forearm supination	Checkbox	Check this box if passive range-of-motion testing of the left joint produced pain during forearm supination.
Left Passive ROM - Extension	Checkbox	Check this box if passive range-of-motion testing of the left joint produced pain during extension.
Left Passive ROM - Forearm pronation	Checkbox	Check this box if passive range-of-motion testing of the left joint produced pain during forearm pronation.
Left Passive ROM - Row 1 (Flexion endpoint)
Left Passive ROM - Row 1 Flexion endpoint (degrees)	Number	Enter the measured passive flexion endpoint in degrees for the left joint (Row 1).
Row 1 - Same as active ROM (Flexion endpoint)	Checkbox	Check this box when the left passive flexion endpoint (Row 1) is the same as the left active flexion range of motion and you want to record the passive value as 'same as active ROM'.
Left Passive ROM - Row 2 (Extension endpoint)
Row 2 — Left Passive Extension endpoint (degrees)	Text	Enter the left passive extension endpoint measurement for Row 2 as a degrees value (numeric degrees, e.g., 0 or 10).
Row 2 - Extension endpoint (Same as active ROM)	Checkbox	Check this box when the passive Extension endpoint measurement is the same as the recorded active Range of Motion (ROM) for the Extension endpoint.
Left Passive ROM - Row 3 (Forearm supination endpoint)
Left Passive Forearm Supination Endpoint	Number	Enter the measured degrees of passive forearm supination (left side) at the endpoint observed during the examination.
Row 3 - Forearm supination endpoint (Left Passive ROM) — Same as active ROM	Checkbox	Check this box when the left forearm passive supination endpoint is the same as the active range of motion value (i.e., passive ROM equals active ROM) for Row 3.
Left Passive ROM - Row 4 (Forearm pronation endpoint)
Left Passive ROM Row 4 - Forearm pronation endpoint	Number	Enter the measured passive forearm pronation endpoint for the left side (row 4) as a numeric value in degrees.
Row 4 (Forearm pronation endpoint) - Same as active ROM	Checkbox	Check this box when the passive range-of-motion measurement for the left forearm pronation endpoint (Row 4) is the same as the recorded active ROM; i.e., no separate passive value needs to be entered.
Left Unclaimed Joint - Condition (Damaged/Undamaged)
Damaged	Radiobutton	Check this box if the left unclaimed joint is damaged.
Undamaged	Radiobutton	Check this box if the left unclaimed joint is undamaged (if checked, proceed to perform range of motion testing and record ROM values).
Listed Claimed Conditions (Diagnosis)
Listed Claimed Condition 1	Text	Enter the medical condition(s) the Veteran is claiming for this questionnaire (diagnosis name(s) and relevant details such as affected body part and side), separated by commas if multiple.
No current diagnosis checkbox
The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above	Checkbox	Check this box when, after the current evaluation and record review, the clinician determines there is no current diagnosis associated with any of the claimed condition(s) listed on the form (explain findings and reasons in the Remarks section).
Observed repetitive-use ROM - left elbow
Left elbow — Able to perform repetitive-use testing (Yes)	Radiobutton	Check this box when the veteran is able to perform the left-elbow repetitive-use test with at least three repetitions.
Left elbow — Able to perform repetitive-use testing (No)	Radiobutton	Check this box when the veteran is NOT able to perform the left-elbow repetitive-use test with at least three repetitions.
Left elbow — explanation for inability to perform repetitive-use testing	Text	If the veteran is unable to perform repetitive-use testing of the left elbow with at least three repetitions, provide a brief explanation including what prevents testing, the limiting motions or symptoms, and any relevant circumstances or observations. Fill only if 'Left elbow — Able to perform repetitive-use testing (No)' is 'Yes'. Depends on: Left elbow — Able to perform repetitive-use testing (No)
Observed repetitive-use ROM - right elbow
Right elbow - Yes	Radiobutton	Check this box when the veteran is able to perform repetitive-use testing of the right elbow with at least three repetitions.
Right elbow - No	Radiobutton	Check this box when the veteran is NOT able to perform repetitive-use testing of the right elbow with at least three repetitions.
3B Right elbow — If no, please explain (repetitive-use testing)	Text	Describe why the veteran is unable to perform repetitive-use testing of the right elbow with at least three repetitions, including specific limitations, pain or symptoms provoked, loss of range of motion, activity or positions that reproduce the problem, and any timing or severity details. Fill only if 'Right elbow - No' is 'Yes'. Depends on: Right elbow - No
Other (specify) checkbox
Other (specify) — Side (Right / Left / Both)	Checkbox	Check the appropriate side option (Right, Left, or Both) when entering an 'Other diagnosis' to indicate which side of the body the diagnosis applies to.
Other diagnosis #1 (text + laterality/severity)
Other diagnosis #1 — Diagnosis	Text	Enter the name or brief description of the first additional diagnosis (for example, the specific elbow or forearm condition).
Other diagnosis #1 - Right	Radiobutton	Check this box if the other diagnosis #1 applies to the patient's right side.
Other diagnosis #1 - Left	Radiobutton	Check this box if the other diagnosis #1 applies to the patient's left side.
Other diagnosis #1 - Both	Radiobutton	Check this box if the other diagnosis #1 applies to both the patient's right and left sides.
Other diagnosis #1 — Bilateral/overall modifier	Text	If the diagnosis applies to both sides or requires an overall severity/modifier, enter that severity, grade, or modifier here; leave blank if not applicable.
Other diagnosis #1 — Right side modifier	Text	Enter the severity, grade, measurement, or side-specific modifier that applies to the right side for this diagnosis; leave blank if not applicable.
Other diagnosis #1 — Left side modifier	Text	Enter the severity, grade, measurement, or side-specific modifier that applies to the left side for this diagnosis; leave blank if not applicable.
Other diagnosis #2 (text + laterality/severity)
Other diagnosis #2 - Description	Text	Enter the full name or brief description of the second additional diagnosis related to the elbow or forearm.
Other diagnosis #2 - Right	Radiobutton	Check this box when the second 'Other diagnosis' applies to the patient's right side (right elbow/forearm).
Other diagnosis #2 - Left	Radiobutton	Check this box when the second 'Other diagnosis' applies to the patient's left side (left elbow/forearm).
Other diagnosis #2 - Both	Radiobutton	Check this box when the second 'Other diagnosis' applies to both the patient's right and left sides.
Other diagnosis #2 - Both side details	Text	If the diagnosis affects both sides, enter the relevant details for bilateral involvement such as severity, grade, or qualifiers.
Other diagnosis #2 - Right side details	Text	Provide details for the right-side involvement of this diagnosis, for example severity, measurements, or short qualifiers.
Other diagnosis #2 - Left side details	Text	Provide details for the left-side involvement of this diagnosis, for example severity, measurements, or short qualifiers.
Patient Identification
Patient/Veteran Name	Text	Enter the full name of the patient or veteran as it appears on official records.
Patient/Veteran Social Security Number	Text	Enter the patient or veteran's Social Security Number used to identify their records.
Date of Examination	Date	Enter the date when the examination was conducted for this questionnaire.
Radius - Header
Radius, impairment of	Checkbox	Check this box when the Veteran has an impairment of the radius (i.e., any nonunion, malunion, false joint, or other listed radius condition) to indicate the section applies.
Radius - Row 1 (Nonunion in lower half with loss of bone substance)
Row 1 - Nonunion in lower half, with false movement: with loss of bone substance (1 inch (2.5 cm) or more) and marked deformity	Checkbox	Check this box when the veteran has a nonunion in the lower half of the radius with false movement that includes loss of bone substance of 1 inch (2.5 cm) or more and marked deformity. Fill only if '6A - Yes' is 'Yes'. Depends on: 6A - Yes
Row 1 - Right	Radiobutton	Check this when the Row 1 nonunion condition applies to the right radius. Fill only if 'Row 1 - Nonunion in lower half, with false movement: with loss of bone substance (1 inch (2.5 cm) or more) and marked deformity' is 'Yes'. Depends on: Row 1 - Nonunion in lower half, with false movement: with loss of bone substance (1 inch (2.5 cm) or more) and marked deformity
Row 1 - Left	Radiobutton	Check this when the Row 1 nonunion condition applies to the left radius. Fill only if 'Row 1 - Nonunion in lower half, with false movement: with loss of bone substance (1 inch (2.5 cm) or more) and marked deformity' is 'Yes'. Depends on: Row 1 - Nonunion in lower half, with false movement: with loss of bone substance (1 inch (2.5 cm) or more) and marked deformity
Row 1 - Both	Radiobutton	Check this when the Row 1 nonunion condition applies to both the right and left radii. Fill only if 'Row 1 - Nonunion in lower half, with false movement: with loss of bone substance (1 inch (2.5 cm) or more) and marked deformity' is 'Yes'. Depends on: Row 1 - Nonunion in lower half, with false movement: with loss of bone substance (1 inch (2.5 cm) or more) and marked deformity
Radius - Row 2 (Nonunion in lower half without loss of bone substance)
Row 2 - Nonunion in lower half, with false movement: without loss of bone substance or deformity	Checkbox	Check this box when the veteran has a nonunion of the radius in the lower half with false movement but without loss of bone substance or deformity. Fill only if '6A - Yes' is 'Yes'. Depends on: 6A - Yes
Row 2 - Right	Radiobutton	Check this box when the above nonunion condition applies to the right radius. Fill only if 'Row 2 - Nonunion in lower half, with false movement: without loss of bone substance or deformity' is 'Yes'. Depends on: Row 2 - Nonunion in lower half, with false movement: without loss of bone substance or deformity
Row 2 - Left	Radiobutton	Check this box when the above nonunion condition applies to the left radius. Fill only if 'Row 2 - Nonunion in lower half, with false movement: without loss of bone substance or deformity' is 'Yes'. Depends on: Row 2 - Nonunion in lower half, with false movement: without loss of bone substance or deformity
Row 2 - Both	Radiobutton	Check this box when the above nonunion condition applies to both radii. Fill only if 'Row 2 - Nonunion in lower half, with false movement: without loss of bone substance or deformity' is 'Yes'. Depends on: Row 2 - Nonunion in lower half, with false movement: without loss of bone substance or deformity
Radius - Row 3 (Nonunion in upper half)
Row 3 — Radius: Nonunion in upper half	Checkbox	Check this box when the Veteran has a nonunion in the upper half of the radius (then indicate laterality). Fill only if '6A - Yes' is 'Yes'. Depends on: 6A - Yes
Row 3 — Right (Nonunion in upper half, Radius)	Radiobutton	Select this option when the nonunion in the upper half of the radius affects the right side. Fill only if 'Row 3 — Radius: Nonunion in upper half' is 'Yes'. Depends on: Row 3 — Radius: Nonunion in upper half
Row 3 — Left (Nonunion in upper half, Radius)	Radiobutton	Select this option when the nonunion in the upper half of the radius affects the left side. Fill only if 'Row 3 — Radius: Nonunion in upper half' is 'Yes'. Depends on: Row 3 — Radius: Nonunion in upper half
Row 3 — Both (Nonunion in upper half, Radius)	Radiobutton	Select this option when the nonunion in the upper half of the radius affects both sides. Fill only if 'Row 3 — Radius: Nonunion in upper half' is 'Yes'. Depends on: Row 3 — Radius: Nonunion in upper half
Radius - Row 4 (Malunion of, with bad alignment)
Row 4 - Radius: Malunion of, with bad alignment	Checkbox	Check this box if the veteran has a malunion of the radius with bad alignment. Fill only if '6A - Yes' is 'Yes'. Depends on: 6A - Yes
Row 4 - Malunion of, with bad alignment — Right	Radiobutton	Check this option when the radius malunion with bad alignment affects the right side. Fill only if 'Row 4 - Radius: Malunion of, with bad alignment' is 'Yes'. Depends on: Row 4 - Radius: Malunion of, with bad alignment
Row 4 - Malunion of, with bad alignment — Left	Radiobutton	Check this option when the radius malunion with bad alignment affects the left side. Fill only if 'Row 4 - Radius: Malunion of, with bad alignment' is 'Yes'. Depends on: Row 4 - Radius: Malunion of, with bad alignment
Row 4 - Malunion of, with bad alignment — Both	Radiobutton	Check this option when the radius malunion with bad alignment affects both sides. Fill only if 'Row 4 - Radius: Malunion of, with bad alignment' is 'Yes'. Depends on: Row 4 - Radius: Malunion of, with bad alignment
Radius and ulna - nonunion with flail false joint
Radius and ulna, nonunion of, with flail false joint	Checkbox	Check this box if the veteran has a nonunion of the radius and ulna resulting in a flail (false) joint; then indicate side using the Right, Left, or Both options. Fill only if '6A - Yes' is 'Yes'. Depends on: 6A - Yes
Radius and ulna, nonunion of, with flail false joint - Right	Radiobutton	Check this box when the nonunion with flail (false) joint affects the veteran's right radius and ulna. 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 and ulna, nonunion of, with flail false joint - Left	Radiobutton	Check this box when the nonunion with flail (false) joint affects the veteran's left radius and ulna. 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 and ulna, nonunion of, with flail false joint - Both	Radiobutton	Check this box when the nonunion with flail (false) joint affects both the veteran's right and left radius and ulna. 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
Requestor - Other (describe)
Requestor - Other: please describe	Checkbox	Check this box when the person completing the questionnaire is an 'Other' requestor (not the Veteran/Claimant or a listed third party); provide a description of who the requestor is in the adjacent text box.
Requestor - Other (describe)	Text	Enter a brief description naming or identifying the other person, organization, or reason requesting completion of this questionnaire (used when 'Other' is selected). Fill only if 'Requestor - Other: please describe' is 'Yes'. Depends on: Requestor - Other: please describe
Requestor - Third Party
Third party (please list name(s) of organization(s) or individual(s))	Checkbox	Check this box when the Disability Benefits Questionnaire is being completed at the request of a third party, and list the name(s) of the organization(s) or individual(s) in the adjacent space.
Third Party Name(s)	Text	Enter the name(s) of the third party organization(s) or individual(s) requesting completion of this questionnaire (list multiple names separated by commas). Fill only if 'Third party (please list name(s) of organization(s) or individual(s))' is 'Yes'. Depends on: Third party (please list name(s) of organization(s) or individual(s))
Requestor - Veteran/Claimant
Veteran/Claimant	Checkbox	Check this box when the veteran or claimant is the person completing this Disability Benefits Questionnaire (i.e., the requestor is the veteran/claimant).
Right Active ROM - Degree endpoints attributable to factors
Right Flexion degree endpoint	Number	Enter the degree value for the right flexion endpoint when it is different from the previously recorded flexion ROM.
Right Extension degree endpoint	Number	Enter the degree value for the right extension endpoint when it is different from the previously recorded extension ROM.
Right Forearm supination degree endpoint	Number	Enter the degree value for the right forearm supination endpoint when it is different from the previously recorded supination ROM.
Right Forearm pronation degree endpoint	Number	Enter the degree value for the right forearm pronation endpoint when it is different from the previously recorded pronation ROM.
Right Active ROM - Notes/Description
Right Active ROM — Notes/Description	Text	Enter detailed notes describing the right joint's active range of motion findings, including any pain or limitations observed, degree endpoints if different from the listed values, and any factors (pain, weakness, fatigue, incoordination, etc.) that explain the limitation.
Right Active ROM - Pain exhibited (select all that apply)
Right Active ROM - Flexion	Checkbox	Check this box if pain was exhibited during active flexion of the right joint on examination.
Right Active ROM - Forearm supination	Checkbox	Check this box if pain was exhibited during active forearm supination of the right side on examination.
Right Active ROM - Extension	Checkbox	Check this box if pain was exhibited during active extension of the right joint on examination.
Right Active ROM - Forearm pronation	Checkbox	Check this box if pain was exhibited during active forearm pronation of the right side on examination.
Right Active ROM - Row 1 (Flexion endpoint)
Right Active ROM - Row 1: Flexion endpoint (145 degrees)	Checkbox	Check this box when you are recording the right joint's active flexion endpoint (up to 145 degrees) as part of the Active Range of Motion (ROM) testing.
Right Active ROM - Row 1: Flexion endpoint (degrees)	Text	Enter the measured flexion endpoint for the right joint in degrees (e.g., the active range of motion flexion value).
Right Active ROM - Row 2 (Extension endpoint)
Right Active ROM - Row 2: Extension endpoint (0 degrees)	Checkbox	Check this box when you performed and are recording the patient's right-side active range of motion for the extension endpoint (0 degrees), then enter the measured degrees.
Right ROM Row 2 - Extension endpoint (degrees)	Text	Enter the measured degrees of right-side extension endpoint for Active Range of Motion (Row 2); provide the numeric value in degrees (e.g., 0, 5, 10).
Right Active ROM - Row 3 (Forearm supination endpoint)
Row 3 - Forearm supination endpoint (85 degrees)	Checkbox	Check this box when you have performed right active range of motion testing and are recording or confirming the forearm supination endpoint (85 degrees) for the patient.
Right Active ROM — Row 3: Forearm supination endpoint (degrees)	Text	Enter the measured active range of motion at the right forearm supination endpoint in degrees as recorded during the exam.
Right Active ROM - Row 4 (Forearm pronation endpoint)
Right Forearm pronation endpoint (80 degrees) - Row 4	Checkbox	Check this box when you have performed and are recording the active right forearm pronation endpoint (80 degrees) measurement on this exam.
Row 4 — Right Forearm Pronation Endpoint (degrees)	Text	Enter the measured endpoint of active right forearm pronation in degrees (numeric value representing the angle at the pronation endpoint).
Right Elbow - Additional contributing factors to disability (check all that apply)
None	Checkbox	Check this box if there are no additional contributing factors to disability for the right elbow.
Interference with sitting	Checkbox	Check this box if the right elbow condition interferes with the Veteran's ability to sit. Fill only if 'None' is 'No'. Depends on: None
Interference with standing	Checkbox	Check this box if the right elbow condition interferes with the Veteran's ability to stand. Fill only if 'None' is 'No'. Depends on: None
Swelling	Checkbox	Check this box if swelling of the right elbow contributes to the disability. Fill only if 'None' is 'No'. Depends on: None
Disturbance of locomotion	Checkbox	Check this box if the right elbow condition causes a disturbance of locomotion or affects gait/movement. Fill only if 'None' is 'No'. Depends on: None
Deformity	Checkbox	Check this box if a deformity of the right elbow contributes to the disability. Fill only if 'None' is 'No'. Depends on: None
Less movement than normal	Checkbox	Check this box if the right elbow shows less movement than normal (reduced range of motion) that contributes to the disability. Fill only if 'None' is 'No'. Depends on: None
More movement than normal	Checkbox	Check this box if the right elbow shows more movement than normal (excessive motion/instability) that contributes to the disability. Fill only if 'None' is 'No'. Depends on: None
Weakened movement	Checkbox	Check this box if weakened movement of the right elbow (reduced strength) contributes to the disability. Fill only if 'None' is 'No'. Depends on: None
Atrophy of disuse	Checkbox	Check this box if muscle atrophy from disuse around the right elbow contributes to the disability. Fill only if 'None' is 'No'. Depends on: None
Instability of station	Checkbox	Check this box if instability of station (difficulty maintaining posture or balance related to the right elbow) contributes to the disability. Fill only if 'None' is 'No'. Depends on: None
Other, describe	Checkbox	Check this box if there are other contributing factors for the right elbow not listed here, and describe them in the provided text field. Fill only if 'None' is 'No'. Depends on: None
Right elbow — Additional contributing factors (description)	Text	Describe any additional contributing factors of disability for the right elbow that apply (provide specific details, duration, severity, and how each factor affects function), referencing the checkboxes selected above. Fill only if 'Interference with sitting', 'Interference with standing', 'Swelling', 'Disturbance of locomotion', 'Deformity', 'Less movement than normal', 'More movement than normal', 'Weakened movement', 'Atrophy of disuse', 'Instability of station', 'Other, describe' is 'Yes' for any fields. Depends on: Interference with sitting, Interference with standing, Swelling, Disturbance of locomotion, Deformity, Less movement than normal, More movement than normal, Weakened movement, Atrophy of disuse, Instability of station, Other, describe
Right elbow - Additional loss after three repetitions
Yes — additional loss after three repetitions	Radiobutton	Check this box if there is additional loss of function or range of motion in the right elbow after completing three repetitions.
No — no additional loss after three repetitions	Radiobutton	Check this box if there is no additional loss of function or range of motion in the right elbow after completing three repetitions.
Flexion endpoint (degrees)	Text	Enter the right elbow flexion endpoint in degrees measured after three repetitions (numeric value, e.g., 145). Fill only if 'Yes — additional loss after three repetitions' is 'Yes'. Depends on: Yes — additional loss after three repetitions
Extension endpoint (degrees)	Text	Enter the right elbow extension endpoint in degrees measured after three repetitions (numeric value; 0 indicates full extension). Fill only if 'Yes — additional loss after three repetitions' is 'Yes'. Depends on: Yes — additional loss after three repetitions
Supination endpoint (degrees)	Text	Enter the right elbow supination endpoint in degrees measured after three repetitions (numeric value, e.g., 85). Fill only if 'Yes — additional loss after three repetitions' is 'Yes'. Depends on: Yes — additional loss after three repetitions
Pronation endpoint (degrees)	Text	Enter the right elbow pronation endpoint in degrees measured after three repetitions (numeric value, e.g., 80). Fill only if 'Yes — additional loss after three repetitions' is 'Yes'. Depends on: Yes — additional loss after three repetitions
Pain	Checkbox	Check this box if pain is a factor causing the functional loss observed after the three repetitions. Fill only if 'Yes — additional loss after three repetitions' is 'Yes'. Depends on: Yes — additional loss after three repetitions
Fatigability	Checkbox	Check this box if fatigability (increased tiredness or exhaustion) is a factor causing the functional loss after the three repetitions. Fill only if 'Yes — additional loss after three repetitions' is 'Yes'. Depends on: Yes — additional loss after three repetitions
Weakness	Checkbox	Check this box if muscle weakness is a factor causing the functional loss after the three repetitions. Fill only if 'Yes — additional loss after three repetitions' is 'Yes'. Depends on: Yes — additional loss after three repetitions
Lack of endurance	Checkbox	Check this box if lack of endurance (inability to sustain activity) is a factor causing the functional loss after the three repetitions. Fill only if 'Yes — additional loss after three repetitions' is 'Yes'. Depends on: Yes — additional loss after three repetitions
Incoordination	Checkbox	Check this box if incoordination is a factor causing the functional loss after the three repetitions. Fill only if 'Yes — additional loss after three repetitions' is 'Yes'. Depends on: Yes — additional loss after three repetitions
N/A	Checkbox	Check this box if the question or the listed factors are not applicable to the right elbow assessment after the three repetitions. Fill only if 'Yes — additional loss after three repetitions' is 'Yes'. Depends on: Yes — additional loss after three repetitions
Other (specify)	Checkbox	Check this box if some other factor(s) not listed are causing the functional loss after the three repetitions, and write the specific factor(s) on the provided line. Fill only if 'Yes — additional loss after three repetitions' is 'Yes'. Depends on: Yes — additional loss after three repetitions
Other (specify)	Text	Provide any other factors or a brief text description of additional loss or contributing issues noted after three repetitions. Fill only if 'Yes — additional loss after three repetitions', 'Other (specify)' is 'Yes' for all fields. Depends on: Yes — additional loss after three repetitions, Other (specify)
Right elbow - Arthroscopic or other elbow surgery
Arthroscopic or other elbow surgery (Right elbow)	Checkbox	Check this box if the veteran had arthroscopic or any other elbow surgery on the right elbow (then provide type of surgery, date of surgery, and describe any residuals).
Right elbow - Type of arthroscopic/other surgery	Text	Enter the name or brief description of the arthroscopic or other elbow surgery performed on the right elbow. Fill only if 'Arthroscopic or other elbow surgery (Right elbow)' is 'Yes'. Depends on: Arthroscopic or other elbow surgery (Right elbow)
Right elbow - Date of arthroscopic/other surgery	Date	Enter the date when the arthroscopic or other elbow surgery was performed on the right elbow. Fill only if 'Arthroscopic or other elbow surgery (Right elbow)' is 'Yes'. Depends on: Arthroscopic or other elbow surgery (Right elbow)
Right elbow - Residuals from arthroscopic/other surgery	Text	Describe any residual conditions, symptoms, or limitations remaining after the arthroscopic or other elbow surgery on the right side. Fill only if 'Arthroscopic or other elbow surgery (Right elbow)' is 'Yes'. Depends on: Arthroscopic or other elbow surgery (Right elbow)
Right Elbow - Can testing be performed selection
Right Elbow - Can testing be performed? Yes	Radiobutton	Check this box when testing of the right elbow can be performed (i.e., the examiner was able to perform the required range-of-motion and functional tests).
Right Elbow - Can testing be performed? No	Radiobutton	Check this box when testing of the right elbow cannot be performed (i.e., testing was not done or is medically/physically contraindicated) and an explanation will be provided in the adjacent text box.
Right Elbow - Evidence citation and discussion
3D Right Elbow – Evidence citation and discussion	Text	Enter specific citations and a discussion of the procured evidence for the right elbow (including lay statements, medical records, and other sources) that support your conclusions about flare-ups and functional loss; be specific to the case and base statements on all procurable evidence.
Right Elbow - Examination conducted during flare-up (Yes/No)
Right elbow – Is the examination being conducted during a flare-up? Yes	Radiobutton	Check this box when the right elbow examination is being performed while the veteran is currently experiencing a flare-up.
Right elbow – Is the examination being conducted during a flare-up? No	Radiobutton	Check this box when the right elbow examination is being performed and the veteran is not currently experiencing a flare-up.
Right Elbow - Factors causing functional loss (check all that apply)
Right elbow - Pain	Checkbox	Check this box if pain is a factor causing the functional loss of the right elbow. Fill only if 'Does procured evidence suggest pain, fatigability, etc. — Yes' is 'Yes'. Depends on: Does procured evidence suggest pain, fatigability, etc. — Yes
Right elbow - Fatigability	Checkbox	Check this box if fatigability (easily tiredness with use) is a factor causing the functional loss of the right elbow. Fill only if 'Does procured evidence suggest pain, fatigability, etc. — Yes' is 'Yes'. Depends on: Does procured evidence suggest pain, fatigability, etc. — Yes
Right elbow - Weakness	Checkbox	Check this box if weakness is a factor causing the functional loss of the right elbow. Fill only if 'Does procured evidence suggest pain, fatigability, etc. — Yes' is 'Yes'. Depends on: Does procured evidence suggest pain, fatigability, etc. — Yes
Right elbow - Lack of endurance	Checkbox	Check this box if lack of endurance (reduced ability to sustain activity) is a factor causing the functional loss of the right elbow. Fill only if 'Does procured evidence suggest pain, fatigability, etc. — Yes' is 'Yes'. Depends on: Does procured evidence suggest pain, fatigability, etc. — Yes
Right elbow - Incoordination	Checkbox	Check this box if incoordination (poor coordination or control) is a factor causing the functional loss of the right elbow. Fill only if 'Does procured evidence suggest pain, fatigability, etc. — Yes' is 'Yes'. Depends on: Does procured evidence suggest pain, fatigability, etc. — Yes
Right elbow - N/A	Checkbox	Check this box if none of the listed factors apply or the question is not applicable to the right elbow. Fill only if 'Does procured evidence suggest pain, fatigability, etc. — Yes' is 'Yes'. Depends on: Does procured evidence suggest pain, fatigability, etc. — Yes
Right elbow - Other (specify)	Checkbox	Check this box if another factor not listed causes the functional loss of the right elbow, and provide the specific factor on the line provided. Fill only if 'Does procured evidence suggest pain, fatigability, etc. — Yes' is 'Yes'. Depends on: Does procured evidence suggest pain, fatigability, etc. — Yes
Right elbow — Other (specify)	Text	Enter any other factor(s) causing functional loss of the right elbow not listed in the checkboxes (describe the factor briefly). Fill only if 'Right elbow - Other (specify)' is 'Yes'. Depends on: Right elbow - Other (specify)
Right Elbow - If ROM contributes explanation
Right elbow — ROM contribution explanation	Text	Describe clearly how the right elbow's range of motion contributes to the claimant's functional loss, including specific limitations, activities affected, severity, frequency, any effect during flare-ups or repetitive use, and any relevant context or examples. Fill only if 'Right elbow — ROM contributes to functional loss: Yes' is 'Yes'. Depends on: Right elbow — ROM contributes to functional loss: Yes
Right Elbow - If testing cannot be performed explanation
Right Elbow — If testing cannot be performed: Explanation	Text	Provide a clear, detailed explanation of why range-of-motion testing could not be performed on the right elbow, including relevant factors (for example: severe pain, risk of further injury, medical contraindication, patient refusal, or other limiting circumstances) and any observations about the joint that support this explanation. Fill only if 'Right Elbow - Can testing be performed? No' is 'Yes'. Depends on: Right Elbow - Can testing be performed? No
Right Elbow - If unable to test or not indicated explanation
Right Elbow – Explanation if unable to test or not indicated	Text	Provide a clear, detailed explanation describing why the right elbow range-of-motion could not be tested or why testing was not indicated, including relevant circumstances, limitations, timing, and any observed symptoms. Fill only if 'Right elbow - Unable to test', 'Right elbow - Not indicated' is 'Yes' for any fields selection. Depends on: Right elbow - Unable to test, Right elbow - Not indicated
Right Elbow - Initial ROM selection
Right elbow - All Normal	Checkbox	Check this box if the right elbow's initial measured range of motion is within normal limits (no restriction) on the exam.
Right elbow - Abnormal or outside of normal range	Checkbox	Check this box if the right elbow's initial measured range of motion is abnormal or falls outside the normal range on testing.
Right elbow - Unable to test	Checkbox	Check this box if the examiner was unable to perform or obtain initial range of motion measurements for the right elbow.
Right elbow - Not indicated	Checkbox	Check this box if initial range of motion measurement for the right elbow was not indicated or is not applicable.
Right elbow - No surgery
Right elbow - No surgery	Checkbox	Check this box if the veteran did not have any surgical procedures performed on the right elbow.
Right Elbow - Procured evidence suggests pain/fatigability (Yes/No)
Does procured evidence suggest pain, fatigability, etc. — Yes	Radiobutton	Check this box when procured evidence (statements from the Veteran) indicates pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability with flare-ups for the right elbow.
Does procured evidence suggest pain, fatigability, etc. — No	Radiobutton	Check this box when procured evidence (statements from the Veteran) does not indicate pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability with flare-ups for the right elbow.
Right Elbow - Range of motion endpoints during flare-ups (flexion/extension/supination/pronation)
Right elbow flexion endpoint (flare-up)	Text	Enter the estimated elbow flexion endpoint during a flare-up in degrees based on procured evidence and the Veteran’s statements.
Right elbow extension endpoint (flare-up)	Text	Enter the estimated elbow extension endpoint during a flare-up in degrees (0° indicates full extension) based on procured evidence and the Veteran’s statements.
Right forearm supination endpoint (flare-up)	Text	Enter the estimated forearm supination endpoint during a flare-up in degrees (reference full supination ≈85°) based on procured evidence and the Veteran’s statements.
Right forearm pronation endpoint (flare-up)	Text	Enter the estimated forearm pronation endpoint during a flare-up in degrees (reference full pronation ≈80°) based on procured evidence and the Veteran’s statements.
Right elbow - Repeated use over time
Right elbow — Examined immediately after repeated use: Yes	Radiobutton	Check this box if the veteran is being examined immediately after repeated use over time for the right elbow.
Right elbow — Examined immediately after repeated use: No	Radiobutton	Check this box if the veteran is not being examined immediately after repeated use over time for the right elbow.
Right elbow — Procured evidence suggests limiting symptoms: Yes	Radiobutton	Check this box if procured evidence (for example, the veteran's statements) suggests pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability with repeated use over time.
Right elbow — Procured evidence suggests limiting symptoms: No	Radiobutton	Check this box if procured evidence does not suggest limiting symptoms that significantly affect functional ability with repeated use over time.
Right elbow — Pain	Checkbox	Check this box if pain is a factor that causes functional loss of the right elbow with repeated use over time. Fill only if 'Right elbow — Procured evidence suggests limiting symptoms: Yes' is 'Yes'. Depends on: Right elbow — Procured evidence suggests limiting symptoms: Yes
Right elbow — Fatigability	Checkbox	Check this box if fatigability is a factor that causes functional loss of the right elbow with repeated use over time. Fill only if 'Right elbow — Procured evidence suggests limiting symptoms: Yes' is 'Yes'. Depends on: Right elbow — Procured evidence suggests limiting symptoms: Yes
Right elbow — Weakness	Checkbox	Check this box if weakness is a factor that causes functional loss of the right elbow with repeated use over time. Fill only if 'Right elbow — Procured evidence suggests limiting symptoms: Yes' is 'Yes'. Depends on: Right elbow — Procured evidence suggests limiting symptoms: Yes
Right elbow — Lack of endurance	Checkbox	Check this box if lack of endurance is a factor that causes functional loss of the right elbow with repeated use over time. Fill only if 'Right elbow — Procured evidence suggests limiting symptoms: Yes' is 'Yes'. Depends on: Right elbow — Procured evidence suggests limiting symptoms: Yes
Right elbow — Incoordination	Checkbox	Check this box if incoordination is a factor that causes functional loss of the right elbow with repeated use over time. Fill only if 'Right elbow — Procured evidence suggests limiting symptoms: Yes' is 'Yes'. Depends on: Right elbow — Procured evidence suggests limiting symptoms: Yes
Right elbow — N/A	Checkbox	Check this box if the 'not applicable' option best describes the factors causing functional loss for the right elbow (i.e., none of the listed factors apply). Fill only if 'Right elbow — Procured evidence suggests limiting symptoms: Yes' is 'Yes'. Depends on: Right elbow — Procured evidence suggests limiting symptoms: Yes
Right elbow — Other (specify)	Checkbox	Check this box if another factor not listed contributes to functional loss of the right elbow with repeated use over time, and specify that factor in the adjacent text field. Fill only if 'Right elbow — Procured evidence suggests limiting symptoms: Yes' is 'Yes'. Depends on: Right elbow — Procured evidence suggests limiting symptoms: Yes
Right elbow - Other factor (specify)	Text	If you checked 'Other,' briefly specify any additional factor(s) that cause functional loss of the right elbow after repeated use over time. Fill only if 'Right elbow — Procured evidence suggests limiting symptoms: Yes', 'Right elbow — Other (specify)' is 'Yes' for all fields. Depends on: Right elbow — Procured evidence suggests limiting symptoms: Yes, Right elbow — Other (specify)
Right elbow - Flexion endpoint (after repeated use)	Number	Provide the examiner's estimated flexion endpoint for the right elbow immediately after repeated use, based on examination findings and other relevant evidence. Fill only if 'Right elbow — Procured evidence suggests limiting symptoms: Yes' is 'Yes'. Depends on: Right elbow — Procured evidence suggests limiting symptoms: Yes
Right elbow - Extension endpoint (after repeated use)	Number	Provide the examiner's estimated extension endpoint for the right elbow immediately after repeated use, based on examination findings and other relevant evidence. Fill only if 'Right elbow — Procured evidence suggests limiting symptoms: Yes' is 'Yes'. Depends on: Right elbow — Procured evidence suggests limiting symptoms: Yes
Right elbow - Forearm supination endpoint (after repeated use)	Number	Provide the examiner's estimated forearm supination endpoint for the right elbow immediately after repeated use, based on examination findings and other relevant evidence. Fill only if 'Right elbow — Procured evidence suggests limiting symptoms: Yes' is 'Yes'. Depends on: Right elbow — Procured evidence suggests limiting symptoms: Yes
Right elbow - Forearm pronation endpoint (after repeated use)	Number	Provide the examiner's estimated forearm pronation endpoint for the right elbow immediately after repeated use, based on examination findings and other relevant evidence. Fill only if 'Right elbow — Procured evidence suggests limiting symptoms: Yes' is 'Yes'. Depends on: Right elbow — Procured evidence suggests limiting symptoms: Yes
Right elbow - Evidence and discussion	Text	Cite and discuss all procurable, case-specific evidence that supports the estimated range of motion for the right elbow after repeated use, and explain any limitations or reasons an estimate cannot be provided. Fill only if 'Right elbow — Procured evidence suggests limiting symptoms: Yes' is 'Yes'. Depends on: Right elbow — Procured evidence suggests limiting symptoms: Yes
Right Elbow - ROM contributes to functional loss selection
Right elbow — ROM contributes to functional loss: Yes	Radiobutton	Check this box when the right elbow's abnormal range of motion itself contributes to a functional loss. Fill only if 'Right elbow - Abnormal or outside of normal range' is 'Yes'. Depends on: Right elbow - Abnormal or outside of normal range
Right elbow — ROM contributes to functional loss: No	Radiobutton	Check this box when the right elbow's range of motion is abnormal but does not itself contribute to a functional loss. Fill only if 'Right elbow - Abnormal or outside of normal range' is 'Yes'. Depends on: Right elbow - Abnormal or outside of normal range
Right Elbow - ROM outside normal description
Right elbow — ROM outside normal description	Text	Describe why the right elbow range of motion is outside the normal range but considered normal for the Veteran (for example age, body habitus, neurologic disease, or other non-elbow causes), including any measured degrees or specifics about the limitation if available. Fill only if 'Right elbow - Abnormal or outside of normal range' is 'Yes'. Depends on: Right elbow - Abnormal or outside of normal range
Right elbow - Total elbow joint replacement
Total elbow joint replacement	Checkbox	Check this box if the veteran had a total elbow joint replacement of the right elbow.
Date of right total elbow joint replacement	Date	Enter the date the Veteran underwent the right total elbow joint replacement. Fill only if 'Total elbow joint replacement' is 'Yes'. Depends on: Total elbow joint replacement
Residuals - None	Checkbox	Check this box if there are no residuals following the right total elbow joint replacement. Fill only if 'Total elbow joint replacement' is 'Yes'. 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 has intermediate residual weakness, pain, or limitation of motion after the total elbow joint replacement. Fill only if 'Total elbow joint replacement' is 'Yes'. Depends on: Total elbow joint replacement
Residuals - Chronic residuals consisting of severe painful motion or weakness	Checkbox	Check this box if the right elbow has chronic residuals consisting of severe painful motion or weakness following the total elbow joint replacement. Fill only if 'Total elbow joint replacement' is 'Yes'. Depends on: Total elbow joint replacement
Residuals - Other, describe	Checkbox	Check this box if there are other residuals not listed for the right elbow after the total elbow joint replacement and provide a description in the space provided. Fill only if 'Total elbow joint replacement' is 'Yes'. Depends on: Total elbow joint replacement
Right total elbow joint replacement details	Text	Provide any additional details about the right total elbow joint replacement such as surgical notes, complications, implants used, or other relevant narrative information. Fill only if 'Residuals - Other, describe' is 'Yes'. Depends on: Residuals - Other, describe
Right Passive ROM - Degree endpoints attributable to factors
Flexion degree endpoint (attributable to factors)	Text	Enter the degree value for the passive flexion endpoint that is specifically attributable to the listed factors (use the numeric degree as entered on the form).
Extension degree endpoint (attributable to factors)	Text	Enter the degree value for the passive extension endpoint that is specifically attributable to the listed factors (use the numeric degree as entered on the form).
Forearm supination degree endpoint (attributable to factors)	Text	Enter the degree value for the passive forearm supination endpoint that is specifically attributable to the listed factors (use the numeric degree as entered on the form).
Right Passive ROM - Pain exhibited (select all that apply)
Right Passive ROM - Flexion	Checkbox	Check this box if passive range-of-motion testing on the right side exhibited pain during flexion.
Right Passive ROM - Forearm supination	Checkbox	Check this box if passive range-of-motion testing on the right side exhibited pain during forearm supination.
Right Passive ROM - Extension	Checkbox	Check this box if passive range-of-motion testing on the right side exhibited pain during extension.
Right Passive ROM - Forearm pronation	Checkbox	Check this box if passive range-of-motion testing on the right side exhibited pain during forearm pronation.
Right Passive ROM - Row 1 (Flexion endpoint)
Right Passive ROM Row 1 - Flexion endpoint (degrees)	Number	Enter the measured passive flexion endpoint for the right joint (Row 1) in degrees.
Row 1 (Flexion endpoint) - Same as active ROM	Checkbox	Check this box when the passive flexion endpoint measurement is the same as the recorded active range of motion (no separate passive value to record).
Right Passive ROM - Row 2 (Extension endpoint)
Right Passive ROM Row 2 — Extension endpoint (degrees)	Text	Enter the measured passive extension endpoint for the right side (row 2) in degrees.
Row 2 (Extension endpoint) — Same as active ROM	Checkbox	Check this box when the passive extension endpoint measurement is the same as the previously recorded active ROM measurement for the right side extension endpoint.
Right Passive ROM - Row 3 (Forearm supination endpoint)
Row 3 — Right Passive Forearm Supination Endpoint (degrees)	Text	Enter the measured passive forearm supination endpoint for the right side in degrees (numeric degree value) as recorded during the passive ROM test for Row 3.
Right Passive ROM - Row 3 (Forearm supination endpoint) - Same as active ROM	Checkbox	Check this box when the passive range-of-motion measurement for the right forearm supination endpoint (row 3, 85 degrees) is the same as the recorded active ROM value.
Right Passive ROM - Row 4 (Forearm pronation endpoint)
Row 4 — Forearm pronation endpoint (passive) degrees	Number	Enter the measured passive forearm pronation endpoint for the right side in degrees for Row 4.
Row 4 - Forearm pronation endpoint (Same as active ROM)	Checkbox	Check this box when the passive forearm pronation endpoint (Row 4, 80 degrees) is the same as the active range of motion and no separate passive ROM value is being recorded.
Right Unclaimed Joint - Condition (Damaged/Undamaged)
Right Unclaimed Joint - Damaged	Radiobutton	Check this box when the right unclaimed joint is damaged.
Right Unclaimed Joint - Undamaged	Radiobutton	Check this box when the right unclaimed joint is not damaged; if checked, perform range of motion (ROM) testing and record the ROM values.
Row 1 - Olecranon bursitis
Row 1 - Olecranon bursitis	Checkbox	Check this box when the clinician determined olecranon bursitis is a current diagnosis for the claimed condition during this evaluation. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 1 - Olecranon bursitis: Right	Radiobutton	Check this box when the olecranon bursitis affects the right side. Fill only if 'Row 1 - Olecranon bursitis' is 'Yes'. Depends on: Row 1 - Olecranon bursitis
Row 1 - Olecranon bursitis: Left	Radiobutton	Check this box when the olecranon bursitis affects the left side. Fill only if 'Row 1 - Olecranon bursitis' is 'Yes'. Depends on: Row 1 - Olecranon bursitis
Row 1 - Olecranon bursitis: Both	Radiobutton	Check this box when the olecranon bursitis affects both sides. Fill only if 'Row 1 - Olecranon bursitis' is 'Yes'. Depends on: Row 1 - Olecranon bursitis
Row 1 - ICD code (Olecranon bursitis)	Text	Enter the ICD diagnostic code corresponding to the Olecranon bursitis diagnosis (letters, numbers and punctuation as required by the code). Fill only if 'Row 1 - Olecranon bursitis' is 'Yes'. Depends on: Row 1 - Olecranon bursitis
Row 1 - Date of diagnosis (Right)	Date	Enter the date when the right-sided Olecranon bursitis was diagnosed. Fill only if 'Row 1 - Olecranon bursitis' is 'Yes'. Depends on: Row 1 - Olecranon bursitis
Row 1 - Date of diagnosis (Left)	Date	Enter the date when the left-sided Olecranon bursitis was diagnosed. Fill only if 'Row 1 - Olecranon bursitis' is 'Yes'. Depends on: Row 1 - Olecranon bursitis
Row 10 - Degenerative arthritis, other than post-traumatic
Row 10 - Degenerative arthritis, other than post-traumatic	Checkbox	Check this box when the veteran has a current diagnosis of degenerative arthritis (other than post‑traumatic) associated with the claimed condition(s). Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 10 - Degenerative arthritis, other than post-traumatic — Right	Radiobutton	Check this box when the degenerative arthritis affects the right side. Fill only if 'Row 10 - Degenerative arthritis, other than post-traumatic' is 'Yes'. Depends on: Row 10 - Degenerative arthritis, other than post-traumatic
Row 10 - Degenerative arthritis, other than post-traumatic — Left	Radiobutton	Check this box when the degenerative arthritis affects the left side. Fill only if 'Row 10 - Degenerative arthritis, other than post-traumatic' is 'Yes'. Depends on: Row 10 - Degenerative arthritis, other than post-traumatic
Row 10 - Degenerative arthritis, other than post-traumatic — Both	Radiobutton	Check this box when the degenerative arthritis affects both sides (bilateral). Fill only if 'Row 10 - Degenerative arthritis, other than post-traumatic' is 'Yes'. Depends on: Row 10 - Degenerative arthritis, other than post-traumatic
Row 10 - ICD code	Text	Enter the ICD diagnosis code that corresponds to 'Degenerative arthritis, other than post‑traumatic' for this row. Fill only if 'Row 10 - Degenerative arthritis, other than post-traumatic' is 'Yes'. Depends on: Row 10 - Degenerative arthritis, other than post-traumatic
Row 10 - Date of diagnosis (Right)	Date	Enter the date the diagnosis was made for the right side of the body related to this condition. Fill only if 'Row 10 - Degenerative arthritis, other than post-traumatic' is 'Yes'. Depends on: Row 10 - Degenerative arthritis, other than post-traumatic
Row 10 - Date of diagnosis (Left)	Date	Enter the date the diagnosis was made for the left side of the body related to this condition. Fill only if 'Row 10 - Degenerative arthritis, other than post-traumatic' is 'Yes'. Depends on: Row 10 - Degenerative arthritis, other than post-traumatic
Row 11 - Arthritis, gonorrheal
Row 11 - Arthritis, gonorrheal	Checkbox	Check this box if the Veteran has a current diagnosis of arthritis, gonorrheal (gonococcal) associated with the claimed condition(s). Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 11 - Arthritis, gonorrheal - Right	Radiobutton	Check this box if the arthritis, gonorrheal diagnosis affects the right side. Fill only if 'Row 11 - Arthritis, gonorrheal' is 'Yes'. Depends on: Row 11 - Arthritis, gonorrheal
Row 11 - Arthritis, gonorrheal - Left	Radiobutton	Check this box if the arthritis, gonorrheal diagnosis affects the left side. Fill only if 'Row 11 - Arthritis, gonorrheal' is 'Yes'. Depends on: Row 11 - Arthritis, gonorrheal
Row 11 - Arthritis, gonorrheal - Both	Radiobutton	Check this box if the arthritis, gonorrheal diagnosis affects both sides. Fill only if 'Row 11 - Arthritis, gonorrheal' is 'Yes'. Depends on: Row 11 - Arthritis, gonorrheal
Row 11 - ICD code (Arthritis, gonorrheal)	Text	Enter the ICD diagnostic code that corresponds to the diagnosis of arthritis, gonorrheal for this condition. Fill only if 'Row 11 - Arthritis, gonorrheal' is 'Yes'. Depends on: Row 11 - Arthritis, gonorrheal
Row 11 - Date of diagnosis, Right (Arthritis, gonorrheal)	Date	Provide the date the arthritis, gonorrheal diagnosis was made for the right side. Fill only if 'Row 11 - Arthritis, gonorrheal' is 'Yes'. Depends on: Row 11 - Arthritis, gonorrheal
Row 11 - Date of diagnosis, Left (Arthritis, gonorrheal)	Date	Provide the date the arthritis, gonorrheal diagnosis was made for the left side. Fill only if 'Row 11 - Arthritis, gonorrheal' is 'Yes'. Depends on: Row 11 - Arthritis, gonorrheal
Row 12 - Arthritis, pneumococcal
Row 12 - Arthritis, pneumococcal (Diagnosis)	Checkbox	Check this box if the veteran has a current diagnosis of pneumococcal arthritis associated with the claimed condition(s). Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 12 - Arthritis, pneumococcal — Side affected: Right	Radiobutton	Check this box if the pneumococcal arthritis affects the right side. Fill only if 'Row 12 - Arthritis, pneumococcal (Diagnosis)' is 'Yes'. Depends on: Row 12 - Arthritis, pneumococcal (Diagnosis)
Row 12 - Arthritis, pneumococcal — Side affected: Left	Radiobutton	Check this box if the pneumococcal arthritis affects the left side. Fill only if 'Row 12 - Arthritis, pneumococcal (Diagnosis)' is 'Yes'. Depends on: Row 12 - Arthritis, pneumococcal (Diagnosis)
Row 12 - Arthritis, pneumococcal — Side affected: Both	Radiobutton	Check this box if the pneumococcal arthritis affects both sides. Fill only if 'Row 12 - Arthritis, pneumococcal (Diagnosis)' is 'Yes'. Depends on: Row 12 - Arthritis, pneumococcal (Diagnosis)
Row 12 - Arthritis, pneumococcal ICD code	Text	Enter the ICD diagnostic code that corresponds to the arthritis, pneumococcal diagnosis for this row. Fill only if 'Row 12 - Arthritis, pneumococcal (Diagnosis)' is 'Yes'. Depends on: Row 12 - Arthritis, pneumococcal (Diagnosis)
Row 12 - Arthritis, pneumococcal Date of diagnosis (Right)	Date	Enter the date when the arthritis, pneumococcal diagnosis was made for the right side. Fill only if 'Row 12 - Arthritis, pneumococcal (Diagnosis)' is 'Yes'. Depends on: Row 12 - Arthritis, pneumococcal (Diagnosis)
Row 12 - Arthritis, pneumococcal Date of diagnosis (Left)	Date	Enter the date when the arthritis, pneumococcal diagnosis was made for the left side. Fill only if 'Row 12 - Arthritis, pneumococcal (Diagnosis)' is 'Yes'. Depends on: Row 12 - Arthritis, pneumococcal (Diagnosis)
Row 13 - Arthritis, streptococcic
Row 13 - Arthritis, streptococcic (diagnosis)	Checkbox	Check this box when the veteran has a current diagnosis of 'Arthritis, streptococcic' determined during this evaluation. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 13 - Arthritis, streptococcic — Right	Radiobutton	Check this when the arthritis affects the right side (right elbow); choose only one side option (Right, Left, or Both). Fill only if 'Row 13 - Arthritis, streptococcic (diagnosis)' is 'Yes'. Depends on: Row 13 - Arthritis, streptococcic (diagnosis)
Row 13 - Arthritis, streptococcic — Left	Radiobutton	Check this when the arthritis affects the left side (left elbow); choose only one side option (Right, Left, or Both). Fill only if 'Row 13 - Arthritis, streptococcic (diagnosis)' is 'Yes'. Depends on: Row 13 - Arthritis, streptococcic (diagnosis)
Row 13 - Arthritis, streptococcic — Both	Radiobutton	Check this when the arthritis affects both sides (both elbows); choose only one side option (Right, Left, or Both). Fill only if 'Row 13 - Arthritis, streptococcic (diagnosis)' is 'Yes'. Depends on: Row 13 - Arthritis, streptococcic (diagnosis)
Row 13 ICD code	Text	Enter the ICD diagnostic code (e.g., ICD-10 code) that corresponds to the diagnosis 'Arthritis, streptococcic' for this row. Fill only if 'Row 13 - Arthritis, streptococcic (diagnosis)' is 'Yes'. Depends on: Row 13 - Arthritis, streptococcic (diagnosis)
Row 13 Date of diagnosis — Right	Date	Enter the date the diagnosis was made for the right side for 'Arthritis, streptococcic'. Fill only if 'Row 13 - Arthritis, streptococcic (diagnosis)' is 'Yes'. Depends on: Row 13 - Arthritis, streptococcic (diagnosis)
Row 13 Date of diagnosis — Left	Date	Enter the date the diagnosis was made for the left side for 'Arthritis, streptococcic'. Fill only if 'Row 13 - Arthritis, streptococcic (diagnosis)' is 'Yes'. Depends on: Row 13 - Arthritis, streptococcic (diagnosis)
Row 14 - Arthritis, syphilitic
Row 14 - Arthritis, syphilitic	Checkbox	Check this box if the clinician has determined a diagnosis of syphilitic arthritis associated with the claimed condition(s). Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 14 - Side affected: Right	Radiobutton	Check this if the syphilitic arthritis affects the veteran's right side (select only if the diagnosis box is checked). Fill only if 'Row 14 - Arthritis, syphilitic' is 'Yes'. Depends on: Row 14 - Arthritis, syphilitic
Row 14 - Side affected: Left	Radiobutton	Check this if the syphilitic arthritis affects the veteran's left side (select only if the diagnosis box is checked). Fill only if 'Row 14 - Arthritis, syphilitic' is 'Yes'. Depends on: Row 14 - Arthritis, syphilitic
Row 14 - Side affected: Both	Radiobutton	Check this if the syphilitic arthritis affects both sides (select only if the diagnosis box is checked). Fill only if 'Row 14 - Arthritis, syphilitic' is 'Yes'. Depends on: Row 14 - Arthritis, syphilitic
Row 14 - Arthritis, syphilitic: ICD code	Text	Enter the ICD diagnosis code that corresponds to the syphilitic arthritis diagnosis for this row. Fill only if 'Row 14 - Arthritis, syphilitic' is 'Yes'. Depends on: Row 14 - Arthritis, syphilitic
Row 14 - Arthritis, syphilitic: Date of diagnosis (Right)	Date	Provide the date when the right-side syphilitic arthritis was diagnosed for this condition. Fill only if 'Row 14 - Arthritis, syphilitic' is 'Yes'. Depends on: Row 14 - Arthritis, syphilitic
Row 14 - Arthritis, syphilitic: Date of diagnosis (Left)	Date	Provide the date when the left-side syphilitic arthritis was diagnosed for this condition. Fill only if 'Row 14 - Arthritis, syphilitic' is 'Yes'. Depends on: Row 14 - Arthritis, syphilitic
Row 15 - Arthritis, rheumatoid (multi-joint)
Row 15 - Arthritis, rheumatoid (multi-joint)	Checkbox	Check this box when the clinician has determined a current diagnosis of rheumatoid (multi-joint) arthritis for the claimed condition(s). Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 15 - Arthritis, rheumatoid (multi-joint) - Right	Radiobutton	Check this box when the rheumatoid (multi-joint) arthritis affects the right side only. Fill only if 'Row 15 - Arthritis, rheumatoid (multi-joint)' is 'Yes'. Depends on: Row 15 - Arthritis, rheumatoid (multi-joint)
Row 15 - Arthritis, rheumatoid (multi-joint) - Left	Radiobutton	Check this box when the rheumatoid (multi-joint) arthritis affects the left side only. Fill only if 'Row 15 - Arthritis, rheumatoid (multi-joint)' is 'Yes'. Depends on: Row 15 - Arthritis, rheumatoid (multi-joint)
Row 15 - Arthritis, rheumatoid (multi-joint) - Both	Radiobutton	Check this box when the rheumatoid (multi-joint) arthritis affects both sides. Fill only if 'Row 15 - Arthritis, rheumatoid (multi-joint)' is 'Yes'. Depends on: Row 15 - Arthritis, rheumatoid (multi-joint)
Row 15 - Rheumatoid arthritis ICD code	Text	Enter the ICD diagnostic code that corresponds to the rheumatoid (multi-joint) arthritis diagnosis for this row. Fill only if 'Row 15 - Arthritis, rheumatoid (multi-joint)' is 'Yes'. Depends on: Row 15 - Arthritis, rheumatoid (multi-joint)
Row 15 - Date of diagnosis (Right)	Date	Enter the date the rheumatoid (multi-joint) arthritis was diagnosed for the right side. Fill only if 'Row 15 - Arthritis, rheumatoid (multi-joint)' is 'Yes'. Depends on: Row 15 - Arthritis, rheumatoid (multi-joint)
Row 15 - Date of diagnosis (Left)	Date	Enter the date the rheumatoid (multi-joint) arthritis was diagnosed for the left side. Fill only if 'Row 15 - Arthritis, rheumatoid (multi-joint)' is 'Yes'. Depends on: Row 15 - Arthritis, rheumatoid (multi-joint)
Row 16 - Arthritis, post-traumatic
Row 16 - Arthritis, post-traumatic (diagnosis present)	Checkbox	Check this box when the clinician has determined that the Veteran has a current diagnosis of post‑traumatic arthritis for the listed anatomic area. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 16 - Arthritis, post-traumatic — Right	Radiobutton	Check this box when the Veteran's post‑traumatic arthritis affects the right side (use only if the diagnosis box is checked). Fill only if 'Row 16 - Arthritis, post-traumatic (diagnosis present)' is 'Yes'. Depends on: Row 16 - Arthritis, post-traumatic (diagnosis present)
Row 16 - Arthritis, post-traumatic — Left	Radiobutton	Check this box when the Veteran's post‑traumatic arthritis affects the left side (use only if the diagnosis box is checked). Fill only if 'Row 16 - Arthritis, post-traumatic (diagnosis present)' is 'Yes'. Depends on: Row 16 - Arthritis, post-traumatic (diagnosis present)
Row 16 - Arthritis, post-traumatic — Both	Radiobutton	Check this box when the Veteran's post‑traumatic arthritis affects both sides (use only if the diagnosis box is checked). Fill only if 'Row 16 - Arthritis, post-traumatic (diagnosis present)' is 'Yes'. Depends on: Row 16 - Arthritis, post-traumatic (diagnosis present)
Row 16 - ICD code (Arthritis, post‑traumatic)	Text	Enter the ICD diagnosis code (alphanumeric) that corresponds to the post‑traumatic arthritis diagnosis for this line item. Fill only if 'Row 16 - Arthritis, post-traumatic (diagnosis present)' is 'Yes'. Depends on: Row 16 - Arthritis, post-traumatic (diagnosis present)
Row 16 - Date of diagnosis (Right)	Date	Enter the date the post‑traumatic arthritis was diagnosed for the right side. Fill only if 'Row 16 - Arthritis, post-traumatic (diagnosis present)' is 'Yes'. Depends on: Row 16 - Arthritis, post-traumatic (diagnosis present)
Row 16 - Date of diagnosis (Left)	Date	Enter the date the post‑traumatic arthritis was diagnosed for the left side. Fill only if 'Row 16 - Arthritis, post-traumatic (diagnosis present)' is 'Yes'. Depends on: Row 16 - Arthritis, post-traumatic (diagnosis present)
Row 17 - Arthritis, typhoid
Row 17 - Arthritis, typhoid (Diagnosis)	Checkbox	Check this box when the veteran has a diagnosis of 'Arthritis, typhoid' associated with the claimed condition. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 17 - Arthritis, typhoid (Right)	Radiobutton	Check this box when the 'Arthritis, typhoid' diagnosis affects the right side. Fill only if 'Row 17 - Arthritis, typhoid (Diagnosis)' is 'Yes'. Depends on: Row 17 - Arthritis, typhoid (Diagnosis)
Row 17 - Arthritis, typhoid (Left)	Radiobutton	Check this box when the 'Arthritis, typhoid' diagnosis affects the left side. Fill only if 'Row 17 - Arthritis, typhoid (Diagnosis)' is 'Yes'. Depends on: Row 17 - Arthritis, typhoid (Diagnosis)
Row 17 - Arthritis, typhoid (Both)	Radiobutton	Check this box when the 'Arthritis, typhoid' diagnosis affects both sides. Fill only if 'Row 17 - Arthritis, typhoid (Diagnosis)' is 'Yes'. Depends on: Row 17 - Arthritis, typhoid (Diagnosis)
Row 17 - Arthritis, typhoid: ICD code	Text	Enter the ICD diagnostic code that corresponds to the arthritis, typhoid condition listed on this row. Fill only if 'Row 17 - Arthritis, typhoid (Diagnosis)' is 'Yes'. Depends on: Row 17 - Arthritis, typhoid (Diagnosis)
Row 17 - Arthritis, typhoid: Date of diagnosis (Right)	Date	Enter the date the arthritis, typhoid diagnosis was made for the right side. Fill only if 'Row 17 - Arthritis, typhoid (Diagnosis)' is 'Yes'. Depends on: Row 17 - Arthritis, typhoid (Diagnosis)
Row 17 - Arthritis, typhoid: Date of diagnosis (Left)	Date	Enter the date the arthritis, typhoid diagnosis was made for the left side. Fill only if 'Row 17 - Arthritis, typhoid (Diagnosis)' is 'Yes'. Depends on: Row 17 - Arthritis, typhoid (Diagnosis)
Row 18 - Other specified forms of arthropathy (excluding gout)
Row 18 - Other specified forms of arthropathy (excluding gout)	Checkbox	Check this box when the clinician has determined the veteran has a diagnosis of other specified forms of arthropathy (excluding gout) associated with the claimed condition(s). Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 18 - Other specified forms of arthropathy (excluding gout) — Right	Radiobutton	Check this box if the diagnosis in Row 18 affects the right side. Fill only if 'Row 18 - Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Row 18 - Other specified forms of arthropathy (excluding gout)
Row 18 - Other specified forms of arthropathy (excluding gout) — Left	Radiobutton	Check this box if the diagnosis in Row 18 affects the left side. Fill only if 'Row 18 - Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Row 18 - Other specified forms of arthropathy (excluding gout)
Row 18 - Other specified forms of arthropathy (excluding gout) — Both	Radiobutton	Check this box if the diagnosis in Row 18 affects both sides. Fill only if 'Row 18 - Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Row 18 - Other specified forms of arthropathy (excluding gout)
Row 18 - ICD code	Text	Enter the ICD diagnosis code that corresponds to the specified other form of arthropathy for this row. Fill only if 'Row 18 - Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Row 18 - Other specified forms of arthropathy (excluding gout)
Row 18 - Date of diagnosis (Right)	Date	Enter the date the condition was diagnosed for the right side. Fill only if 'Row 18 - Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Row 18 - Other specified forms of arthropathy (excluding gout)
Row 18 - Date of diagnosis (Left)	Date	Enter the date the condition was diagnosed for the left side. Fill only if 'Row 18 - Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Row 18 - Other specified forms of arthropathy (excluding gout)
Row 18 - Specify other form of arthropathy	Text	Provide the specific name or description of the other specified form of arthropathy (excluding gout). Fill only if 'Row 18 - Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Row 18 - Other specified forms of arthropathy (excluding gout)
Row 19 - Osteoporosis, residuals of
Row 19 - Osteoporosis, residuals of	Checkbox	Check this box if the Veteran has a diagnosis of "Osteoporosis, residuals of" associated with the claimed condition. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 19 - Osteoporosis, residuals of — Right	Radiobutton	Check this box if the diagnosis affects the right side only. Fill only if 'Row 19 - Osteoporosis, residuals of' is 'Yes'. Depends on: Row 19 - Osteoporosis, residuals of
Row 19 - Osteoporosis, residuals of — Left	Radiobutton	Check this box if the diagnosis affects the left side only. Fill only if 'Row 19 - Osteoporosis, residuals of' is 'Yes'. Depends on: Row 19 - Osteoporosis, residuals of
Row 19 - Osteoporosis, residuals of — Both	Radiobutton	Check this box if the diagnosis affects both the right and left sides. Fill only if 'Row 19 - Osteoporosis, residuals of' is 'Yes'. Depends on: Row 19 - Osteoporosis, residuals of
Row 19 - Osteoporosis, residuals of: ICD code	Text	Enter the ICD diagnosis code that corresponds to the residuals of osteoporosis for this condition row. Fill only if 'Row 19 - Osteoporosis, residuals of' is 'Yes'. Depends on: Row 19 - Osteoporosis, residuals of
Row 19 - Osteoporosis, residuals of: Date of diagnosis (Right)	Date	Provide the date of diagnosis for the right side related to residuals of osteoporosis for this condition row. Fill only if 'Row 19 - Osteoporosis, residuals of' is 'Yes'. Depends on: Row 19 - Osteoporosis, residuals of
Row 19 - Osteoporosis, residuals of: Date of diagnosis (Left)	Date	Provide the date of diagnosis for the left side related to residuals of osteoporosis for this condition row. Fill only if 'Row 19 - Osteoporosis, residuals of' is 'Yes'. Depends on: Row 19 - Osteoporosis, residuals of
Row 2 - Tricep tendinitis
Row 2 - Tricep tendinitis	Checkbox	Check this box if the veteran has a current diagnosis of tricep tendinitis associated with the claimed condition(s). Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 2 - Tricep tendinitis: Right	Radiobutton	Check this box if the tricep tendinitis affects the right side. Fill only if 'Row 2 - Tricep tendinitis' is 'Yes'. Depends on: Row 2 - Tricep tendinitis
Row 2 - Tricep tendinitis: Left	Radiobutton	Check this box if the tricep tendinitis affects the left side. Fill only if 'Row 2 - Tricep tendinitis' is 'Yes'. Depends on: Row 2 - Tricep tendinitis
Row 2 - Tricep tendinitis: Both	Radiobutton	Check this box if the tricep tendinitis affects both sides. Fill only if 'Row 2 - Tricep tendinitis' is 'Yes'. Depends on: Row 2 - Tricep tendinitis
Row 2 - Tricep tendinitis ICD code	Text	Enter the ICD diagnosis code assigned for tricep tendinitis for this row. Fill only if 'Row 2 - Tricep tendinitis' is 'Yes'. Depends on: Row 2 - Tricep tendinitis
Row 2 - Tricep tendinitis Date of diagnosis (Right)	Date	Provide the date when tricep tendinitis was diagnosed for the right side. Fill only if 'Row 2 - Tricep tendinitis' is 'Yes'. Depends on: Row 2 - Tricep tendinitis
Row 2 - Tricep tendinitis Date of diagnosis (Left)	Date	Provide the date when tricep tendinitis was diagnosed for the left side. Fill only if 'Row 2 - Tricep tendinitis' is 'Yes'. Depends on: Row 2 - Tricep tendinitis
Row 20 - Osteomalacia, residuals of
Row 20 - Osteomalacia, residuals of	Checkbox	Check this box when the evaluator has determined that 'Osteomalacia, residuals of' is a diagnosis associated with the claimed condition(s) during the current evaluation. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 20 - Osteomalacia, residuals of — Right	Radiobutton	Check this box to indicate the residuals of osteomalacia affect the Right side (use only when the Row 20 diagnosis is selected). Fill only if 'Row 20 - Osteomalacia, residuals of' is 'Yes'. Depends on: Row 20 - Osteomalacia, residuals of
Row 20 - Osteomalacia, residuals of — Left	Radiobutton	Check this box to indicate the residuals of osteomalacia affect the Left side (use only when the Row 20 diagnosis is selected). Fill only if 'Row 20 - Osteomalacia, residuals of' is 'Yes'. Depends on: Row 20 - Osteomalacia, residuals of
Row 20 - Osteomalacia, residuals of — Both	Radiobutton	Check this box to indicate the residuals of osteomalacia affect Both sides (use only when the Row 20 diagnosis is selected). Fill only if 'Row 20 - Osteomalacia, residuals of' is 'Yes'. Depends on: Row 20 - Osteomalacia, residuals of
Row 20 - Osteomalacia, residuals of — ICD code	Text	Enter the ICD diagnostic code that corresponds to the residuals of osteomalacia for this condition. Fill only if 'Row 20 - Osteomalacia, residuals of' is 'Yes'. Depends on: Row 20 - Osteomalacia, residuals of
Row 20 - Osteomalacia, residuals of — Date of diagnosis (Right)	Date	Enter the date of diagnosis for the right side related to residuals of osteomalacia. Fill only if 'Row 20 - Osteomalacia, residuals of' is 'Yes'. Depends on: Row 20 - Osteomalacia, residuals of
Row 20 - Osteomalacia, residuals of — Date of diagnosis (Left)	Date	Enter the date of diagnosis for the left side related to residuals of osteomalacia. Fill only if 'Row 20 - Osteomalacia, residuals of' is 'Yes'. Depends on: Row 20 - Osteomalacia, residuals of
Row 21 - Bones, neoplasm, benign
Row 21 - Bones, neoplasm, benign	Checkbox	Check this box if the veteran has a current diagnosis of benign bone neoplasm determined during this evaluation. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 21 - Bones, neoplasm, benign — Right	Radiobutton	Check this box if the benign bone neoplasm affects the right side (used together with the Row 21 diagnosis checkbox). Fill only if 'Row 21 - Bones, neoplasm, benign' is 'Yes'. Depends on: Row 21 - Bones, neoplasm, benign
Row 21 - Bones, neoplasm, benign — Left	Radiobutton	Check this box if the benign bone neoplasm affects the left side (used together with the Row 21 diagnosis checkbox). Fill only if 'Row 21 - Bones, neoplasm, benign' is 'Yes'. Depends on: Row 21 - Bones, neoplasm, benign
Row 21 - Bones, neoplasm, benign — Both	Radiobutton	Check this box if the benign bone neoplasm affects both sides (used together with the Row 21 diagnosis checkbox). Fill only if 'Row 21 - Bones, neoplasm, benign' is 'Yes'. Depends on: Row 21 - Bones, neoplasm, benign
Row 21 - Bones, neoplasm, benign: ICD code	Text	Enter the ICD diagnosis code that corresponds to the 'Bones, neoplasm, benign' condition for row 21. Fill only if 'Row 21 - Bones, neoplasm, benign' is 'Yes'. Depends on: Row 21 - Bones, neoplasm, benign
Row 21 - Bones, neoplasm, benign: Date of diagnosis (Right)	Date	Enter the date of diagnosis for the right side for the 'Bones, neoplasm, benign' condition listed in row 21. Fill only if 'Row 21 - Bones, neoplasm, benign' is 'Yes'. Depends on: Row 21 - Bones, neoplasm, benign
Row 21 - Bones, neoplasm, benign: Date of diagnosis (Left)	Date	Enter the date of diagnosis for the left side for the 'Bones, neoplasm, benign' condition listed in row 21. Fill only if 'Row 21 - Bones, neoplasm, benign' is 'Yes'. Depends on: Row 21 - Bones, neoplasm, benign
Row 22 - Osteitis deformans
Row 22 - Osteitis deformans	Checkbox	Check this box when the veteran has a current diagnosis of osteitis deformans. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 22 - Osteitis deformans — Side affected: Right	Radiobutton	Select this option when the osteitis deformans diagnosis affects the right side (use when the osteitis deformans box is checked). Fill only if 'Row 22 - Osteitis deformans' is 'Yes'. Depends on: Row 22 - Osteitis deformans
Row 22 - Osteitis deformans — Side affected: Left	Radiobutton	Select this option when the osteitis deformans diagnosis affects the left side (use when the osteitis deformans box is checked). Fill only if 'Row 22 - Osteitis deformans' is 'Yes'. Depends on: Row 22 - Osteitis deformans
Row 22 - Osteitis deformans — Side affected: Both	Radiobutton	Select this option when the osteitis deformans diagnosis affects both sides (use when the osteitis deformans box is checked). Fill only if 'Row 22 - Osteitis deformans' is 'Yes'. Depends on: Row 22 - Osteitis deformans
Row 22 - Osteitis deformans: ICD code	Text	Enter the ICD diagnosis code associated with osteitis deformans for this row (letters and numbers as appropriate). Fill only if 'Row 22 - Osteitis deformans' is 'Yes'. Depends on: Row 22 - Osteitis deformans
Row 22 - Osteitis deformans: Date of diagnosis (Right)	Date	Enter the date of diagnosis for the right side for osteitis deformans. Fill only if 'Row 22 - Osteitis deformans' is 'Yes'. Depends on: Row 22 - Osteitis deformans
Row 22 - Osteitis deformans: Date of diagnosis (Left)	Date	Enter the date of diagnosis for the left side for osteitis deformans. Fill only if 'Row 22 - Osteitis deformans' is 'Yes'. Depends on: Row 22 - Osteitis deformans
Row 23 - Gout
Row 23 - Gout (Diagnosis)	Checkbox	Check this box if the veteran has a current diagnosis of gout associated with the claimed condition. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 23 - Gout — Right	Radiobutton	Check this box to indicate the gout affects the right side (select the side that applies). Fill only if 'Row 23 - Gout (Diagnosis)' is 'Yes'. Depends on: Row 23 - Gout (Diagnosis)
Row 23 - Gout — Left	Radiobutton	Check this box to indicate the gout affects the left side (select the side that applies). Fill only if 'Row 23 - Gout (Diagnosis)' is 'Yes'. Depends on: Row 23 - Gout (Diagnosis)
Row 23 - Gout — Both	Radiobutton	Check this box to indicate the gout affects both sides (use when both right and left are affected). Fill only if 'Row 23 - Gout (Diagnosis)' is 'Yes'. Depends on: Row 23 - Gout (Diagnosis)
Row 23 - Gout ICD code	Text	Enter the ICD code that corresponds to the diagnosis of gout for this row. Fill only if 'Row 23 - Gout (Diagnosis)' is 'Yes'. Depends on: Row 23 - Gout (Diagnosis)
Row 23 - Gout Date of diagnosis (Right)	Date	Provide the date of diagnosis for gout affecting the right side. Fill only if 'Row 23 - Gout (Diagnosis)' is 'Yes'. Depends on: Row 23 - Gout (Diagnosis)
Row 23 - Gout Date of diagnosis (Left)	Date	Provide the date of diagnosis for gout affecting the left side. Fill only if 'Row 23 - Gout (Diagnosis)' is 'Yes'. Depends on: Row 23 - Gout (Diagnosis)
Row 24 - Bursitis
Row 24 - Bursitis	Checkbox	Check this box when the clinician determines the veteran has a current diagnosis of bursitis associated with the claimed condition(s). Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 24 - Bursitis — Right	Radiobutton	Check this box when bursitis affects the right side (right elbow) of the veteran. Fill only if 'Row 24 - Bursitis' is 'Yes'. Depends on: Row 24 - Bursitis
Row 24 - Bursitis — Left	Radiobutton	Check this box when bursitis affects the left side (left elbow) of the veteran. Fill only if 'Row 24 - Bursitis' is 'Yes'. Depends on: Row 24 - Bursitis
Row 24 - Bursitis — Both	Radiobutton	Check this box when bursitis affects both sides (both elbows) of the veteran. Fill only if 'Row 24 - Bursitis' is 'Yes'. Depends on: Row 24 - Bursitis
24 - Bursitis ICD code	Text	Enter the ICD diagnosis code (e.g., ICD-10) that corresponds to the bursitis condition listed on row 24. Fill only if 'Row 24 - Bursitis' is 'Yes'. Depends on: Row 24 - Bursitis
24 - Bursitis Date of diagnosis (Right)	Date	Enter the date when bursitis was diagnosed for the right side as shown for row 24. Fill only if 'Row 24 - Bursitis' is 'Yes'. Depends on: Row 24 - Bursitis
24 - Bursitis Date of diagnosis (Left)	Date	Enter the date when bursitis was diagnosed for the left side as shown for row 24. Fill only if 'Row 24 - Bursitis' is 'Yes'. Depends on: Row 24 - Bursitis
Row 25 - Myositis
Row 25 - Myositis	Checkbox	Check this box when the clinician has determined the veteran has a current diagnosis of myositis associated with the claimed condition. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 25 - Myositis — Right	Radiobutton	Check this box when the myositis affects the right side of the body (right limb/area). Fill only if 'Row 25 - Myositis' is 'Yes'. Depends on: Row 25 - Myositis
Row 25 - Myositis — Left	Radiobutton	Check this box when the myositis affects the left side of the body (left limb/area). Fill only if 'Row 25 - Myositis' is 'Yes'. Depends on: Row 25 - Myositis
Row 25 - Myositis — Both	Radiobutton	Check this box when the myositis affects both sides of the body. Fill only if 'Row 25 - Myositis' is 'Yes'. Depends on: Row 25 - Myositis
Row 25 - Myositis ICD code	Text	Enter the ICD diagnosis code that corresponds to Myositis for this claimed condition. Fill only if 'Row 25 - Myositis' is 'Yes'. Depends on: Row 25 - Myositis
Row 25 - Myositis Date of diagnosis (Right)	Date	Enter the date of diagnosis for Myositis affecting the right side. Fill only if 'Row 25 - Myositis' is 'Yes'. Depends on: Row 25 - Myositis
Row 25 - Myositis Date of diagnosis (Left)	Date	Enter the date of diagnosis for Myositis affecting the left side. Fill only if 'Row 25 - Myositis' is 'Yes'. Depends on: Row 25 - Myositis
Row 26 - Heterotopic ossification
Row 26 - Heterotopic ossification	Checkbox	Check this box when heterotopic ossification is a diagnosed condition associated with the claimed condition(s). Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 26 - Heterotopic ossification — Right	Radiobutton	Check this box when the heterotopic ossification affects the right side. Fill only if 'Row 26 - Heterotopic ossification' is 'Yes'. Depends on: Row 26 - Heterotopic ossification
Row 26 - Heterotopic ossification — Left	Radiobutton	Check this box when the heterotopic ossification affects the left side. Fill only if 'Row 26 - Heterotopic ossification' is 'Yes'. Depends on: Row 26 - Heterotopic ossification
Row 26 - Heterotopic ossification — Both	Radiobutton	Check this box when the heterotopic ossification affects both sides. Fill only if 'Row 26 - Heterotopic ossification' is 'Yes'. Depends on: Row 26 - 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'. Depends on: Row 26 - 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'. Depends on: Row 26 - Heterotopic ossification
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'. Depends on: Row 26 - Heterotopic ossification
Row 27 - Tendinopathy (select one if known)
Row 27 - Tendinopathy (select one if known)	Checkbox	Check this box to indicate that tendinopathy applies to this claimed condition (select the side below if known). Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 27 - Tendinopathy, Right	Radiobutton	Check this box when the tendinopathy affects the right side. Fill only if 'Row 27 - Tendinopathy (select one if known)' is 'Yes'. Depends on: Row 27 - Tendinopathy (select one if known)
Row 27 - Tendinopathy, Left	Radiobutton	Check this box when the tendinopathy affects the left side. Fill only if 'Row 27 - Tendinopathy (select one if known)' is 'Yes'. Depends on: Row 27 - Tendinopathy (select one if known)
Row 27 - Tendinopathy, Both	Radiobutton	Check this box when the tendinopathy affects both sides. Fill only if 'Row 27 - Tendinopathy (select one if known)' is 'Yes'. Depends on: Row 27 - Tendinopathy (select one if known)
Row 27 - Tendinopathy ICD code	Text	Enter the ICD diagnosis code that identifies the type of tendinopathy for this condition. Fill only if 'Row 27 - Tendinopathy (select one if known)' is 'Yes'. Depends on: Row 27 - Tendinopathy (select one if known)
Row 27 - Tendinopathy Date of diagnosis (Right)	Date	Enter the date when tendinopathy was diagnosed for the right side. Fill only if 'Row 27 - Tendinopathy (select one if known)' is 'Yes'. Depends on: Row 27 - Tendinopathy (select one if known)
Row 27 - Tendinopathy Date of diagnosis (Left)	Date	Enter the date when tendinopathy was diagnosed for the left side. Fill only if 'Row 27 - Tendinopathy (select one if known)' is 'Yes'. Depends on: Row 27 - Tendinopathy (select one if known)
Row 28 - Tendinitis
Row 28 - Tendinitis	Checkbox	Check this box when the clinician has diagnosed tendinitis for the claimed condition. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 28 - Tendinitis: Right	Radiobutton	Check this box when the diagnosed tendinitis affects the right side. Fill only if 'Row 28 - Tendinitis' is 'Yes'. Depends on: Row 28 - Tendinitis
Row 28 - Tendinitis: Left	Radiobutton	Check this box when the diagnosed tendinitis affects the left side. Fill only if 'Row 28 - Tendinitis' is 'Yes'. Depends on: Row 28 - Tendinitis
Row 28 - Tendinitis: Both	Radiobutton	Check this box when the diagnosed tendinitis affects both the right and left sides. Fill only if 'Row 28 - Tendinitis' is 'Yes'. Depends on: Row 28 - Tendinitis
Row 28 - Tendinitis ICD code	Text	Enter the ICD diagnosis code assigned for the tendinitis condition listed on row 28. Fill only if 'Row 28 - Tendinitis' is 'Yes'. Depends on: Row 28 - Tendinitis
Row 28 - Tendinitis Date of diagnosis (Right)	Date	Enter the date the right-side tendinitis was diagnosed for the condition listed on row 28. Fill only if 'Row 28 - Tendinitis' is 'Yes'. Depends on: Row 28 - Tendinitis
Row 28 - Tendinitis Date of diagnosis (Left)	Date	Enter the date the left-side tendinitis was diagnosed for the condition listed on row 28. Fill only if 'Row 28 - Tendinitis' is 'Yes'. Depends on: Row 28 - Tendinitis
Row 29 - Tendinosis
Row 29 - Tendinosis (condition)	Checkbox	Check this box when tendinosis is a diagnosed condition for the claimed elbow/forearm condition. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 29 - Tendinosis: Right	Radiobutton	Check this box when tendinosis affects the right side. Fill only if 'Row 29 - Tendinosis (condition)' is 'Yes'. Depends on: Row 29 - Tendinosis (condition)
Row 29 - Tendinosis: Left	Radiobutton	Check this box when tendinosis affects the left side. Fill only if 'Row 29 - Tendinosis (condition)' is 'Yes'. Depends on: Row 29 - Tendinosis (condition)
Row 29 - Tendinosis: Both	Radiobutton	Check this box when tendinosis affects both sides. Fill only if 'Row 29 - Tendinosis (condition)' is 'Yes'. Depends on: Row 29 - Tendinosis (condition)
Row 29 - Tendinosis ICD code	Text	Enter the ICD diagnosis code that corresponds to the tendinosis diagnosis for this row. Fill only if 'Row 29 - Tendinosis (condition)' is 'Yes'. Depends on: Row 29 - Tendinosis (condition)
Row 29 - Tendinosis Date of diagnosis (Right)	Date	Enter the date when tendinosis was diagnosed for the right side. Fill only if 'Row 29 - Tendinosis (condition)' is 'Yes'. Depends on: Row 29 - Tendinosis (condition)
Row 29 - Tendinosis Date of diagnosis (Left)	Date	Enter the date when tendinosis was diagnosed for the left side. Fill only if 'Row 29 - Tendinosis (condition)' is 'Yes'. Depends on: Row 29 - Tendinosis (condition)
Row 3 - Lateral epicondylitis
Row 3 - Lateral epicondylitis (diagnosis)	Checkbox	Check this box if the clinician determines the veteran currently has a diagnosis of lateral epicondylitis for the claimed condition. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 3 - Lateral epicondylitis - Right	Radiobutton	Check this box if the lateral epicondylitis affects the right side. Fill only if 'Row 3 - Lateral epicondylitis (diagnosis)' is 'Yes'. Depends on: Row 3 - Lateral epicondylitis (diagnosis)
Row 3 - Lateral epicondylitis - Left	Radiobutton	Check this box if the lateral epicondylitis affects the left side. Fill only if 'Row 3 - Lateral epicondylitis (diagnosis)' is 'Yes'. Depends on: Row 3 - Lateral epicondylitis (diagnosis)
Row 3 - Lateral epicondylitis - Both	Radiobutton	Check this box if the lateral epicondylitis affects both sides. Fill only if 'Row 3 - Lateral epicondylitis (diagnosis)' is 'Yes'. Depends on: Row 3 - Lateral epicondylitis (diagnosis)
Row 3 - Lateral epicondylitis ICD code	Text	Enter the ICD diagnosis code assigned for lateral epicondylitis for this evaluation (e.g., the applicable ICD-10 code). Fill only if 'Row 3 - Lateral epicondylitis (diagnosis)' is 'Yes'. Depends on: Row 3 - Lateral epicondylitis (diagnosis)
Row 3 - Lateral epicondylitis Date of diagnosis (Right)	Date	Provide the date the diagnosis of lateral epicondylitis was made for the right side. Fill only if 'Row 3 - Lateral epicondylitis (diagnosis)' is 'Yes'. Depends on: Row 3 - Lateral epicondylitis (diagnosis)
Row 3 - Lateral epicondylitis Date of diagnosis (Left)	Date	Provide the date the diagnosis of lateral epicondylitis was made for the left side. Fill only if 'Row 3 - Lateral epicondylitis (diagnosis)' is 'Yes'. Depends on: Row 3 - Lateral epicondylitis (diagnosis)
Row 30 - Tenosynovitis
Row 30 - Tenosynovitis	Checkbox	Check this box if tenosynovitis is a diagnosed condition associated with the claimed condition and should be recorded on this row. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 30 - Side affected: Right	Radiobutton	Select this option if the tenosynovitis affects the right side. Fill only if 'Row 30 - Tenosynovitis' is 'Yes'. Depends on: Row 30 - Tenosynovitis
Row 30 - Side affected: Left	Radiobutton	Select this option if the tenosynovitis affects the left side. Fill only if 'Row 30 - Tenosynovitis' is 'Yes'. Depends on: Row 30 - Tenosynovitis
Row 30 - Side affected: Both	Radiobutton	Select this option if the tenosynovitis affects both sides. Fill only if 'Row 30 - Tenosynovitis' is 'Yes'. Depends on: Row 30 - Tenosynovitis
Row 30 - Tenosynovitis ICD code	Text	Enter the ICD diagnosis code assigned for tenosynovitis for this condition. Fill only if 'Row 30 - Tenosynovitis' is 'Yes'. Depends on: Row 30 - Tenosynovitis
Row 30 - Tenosynovitis Date of diagnosis (Right)	Date	Enter the date the tenosynovitis diagnosis was made for the right side. Fill only if 'Row 30 - Tenosynovitis' is 'Yes'. Depends on: Row 30 - Tenosynovitis
Row 30 - Tenosynovitis Date of diagnosis (Left)	Date	Enter the date the tenosynovitis diagnosis was made for the left side. Fill only if 'Row 30 - Tenosynovitis' is 'Yes'. Depends on: Row 30 - Tenosynovitis
Row 4 - Medial epicondylitis
Row 4 - Medial epicondylitis	Checkbox	Check this box when the clinician determines the Veteran has a current diagnosis of medial epicondylitis associated with the claimed condition. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 4 - Medial epicondylitis — Right	Radiobutton	Check this box to indicate the medial epicondylitis affects the right side. Fill only if 'Row 4 - Medial epicondylitis' is 'Yes'. Depends on: Row 4 - Medial epicondylitis
Row 4 - Medial epicondylitis — Left	Radiobutton	Check this box to indicate the medial epicondylitis affects the left side. Fill only if 'Row 4 - Medial epicondylitis' is 'Yes'. Depends on: Row 4 - Medial epicondylitis
Row 4 - Medial epicondylitis — Both	Radiobutton	Check this box to indicate the medial epicondylitis affects both sides. Fill only if 'Row 4 - Medial epicondylitis' is 'Yes'. Depends on: Row 4 - Medial epicondylitis
Row 4 - Medial epicondylitis ICD code	Text	Enter the ICD diagnostic code that corresponds to the medial epicondylitis diagnosis for this row (alphanumeric code). Fill only if 'Row 4 - Medial epicondylitis' is 'Yes'. Depends on: Row 4 - Medial epicondylitis
Row 4 - Medial epicondylitis Date of diagnosis (Right)	Date	Enter the date when the medial epicondylitis diagnosis was determined for the right side. Fill only if 'Row 4 - Medial epicondylitis' is 'Yes'. Depends on: Row 4 - Medial epicondylitis
Row 4 - Medial epicondylitis Date of diagnosis (Left)	Date	Enter the date when the medial epicondylitis diagnosis was determined for the left side. Fill only if 'Row 4 - Medial epicondylitis' is 'Yes'. Depends on: Row 4 - Medial epicondylitis
Row 5 - Instability (medial/posterolateral rotatory)
Row 5 - Instability (medial/posterolateral rotatory)	Checkbox	Check this box when the clinician has determined a diagnosis of instability (medial/posterolateral rotatory) for the claimed condition.
Row 5 - Instability (medial/posterolateral rotatory) — Right	Radiobutton	Check this box to indicate the instability diagnosis applies to the right side (only use if the Row 5 diagnosis box is selected). Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 5 - Instability (medial/posterolateral rotatory) — Left	Radiobutton	Check this box to indicate the instability diagnosis applies to the left side (only use if the Row 5 diagnosis box is selected). Fill only if 'Row 5 - Instability (medial/posterolateral rotatory) — Right' is 'Yes'. Depends on: Row 5 - Instability (medial/posterolateral rotatory) — Right
Row 5 - Instability (medial/posterolateral rotatory) — Both	Radiobutton	Check this box to indicate the instability diagnosis is bilateral (affects both sides); only use if the Row 5 diagnosis box is selected. Fill only if 'Row 5 - Instability (medial/posterolateral rotatory) — Right' is 'Yes'. Depends on: Row 5 - Instability (medial/posterolateral rotatory) — Right
Row 5 - Instability (medial/posterolateral rotatory) — ICD code	Text	Enter the ICD diagnosis code(s) that correspond to the instability (medial/posterolateral rotatory) condition. Fill only if 'Row 5 - Instability (medial/posterolateral rotatory) — Right' is 'Yes'. Depends on: Row 5 - Instability (medial/posterolateral rotatory) — Right
Row 5 - Instability (medial/posterolateral rotatory) — Date of diagnosis (Right)	Date	Provide the date of diagnosis for the right side for the instability (medial/posterolateral rotatory) condition. Fill only if 'Row 5 - Instability (medial/posterolateral rotatory) — Right' is 'Yes'. Depends on: Row 5 - Instability (medial/posterolateral rotatory) — Right
Row 5 - Instability (medial/posterolateral rotatory) — Date of diagnosis (Left)	Date	Provide the date of diagnosis for the left side for the instability (medial/posterolateral rotatory) condition. Fill only if 'Row 5 - Instability (medial/posterolateral rotatory) — Right' is 'Yes'. Depends on: Row 5 - Instability (medial/posterolateral rotatory) — Right
Row 6 - Dislocation, elbow
Row 6 - Dislocation, elbow	Checkbox	Check this box when a current diagnosis of dislocation of the elbow is present for the claimed condition. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 6 - Dislocation, elbow — Right	Radiobutton	Check this box if the dislocation affects the right elbow. Fill only if 'Row 6 - Dislocation, elbow' is 'Yes'. Depends on: Row 6 - Dislocation, elbow
Row 6 - Dislocation, elbow — Left	Radiobutton	Check this box if the dislocation affects the left elbow. Fill only if 'Row 6 - Dislocation, elbow' is 'Yes'. Depends on: Row 6 - Dislocation, elbow
Row 6 - Dislocation, elbow — Both	Radiobutton	Check this box if the dislocation affects both the right and left elbows. Fill only if 'Row 6 - Dislocation, elbow' is 'Yes'. Depends on: Row 6 - Dislocation, elbow
Row 6 ICD code (Dislocation, elbow)	Text	Enter the ICD diagnostic code that corresponds to the dislocation of the elbow for this claimed condition. Fill only if 'Row 6 - Dislocation, elbow' is 'Yes'. Depends on: Row 6 - Dislocation, elbow
Row 6 Date of diagnosis — Right elbow	Date	Enter the date the right elbow dislocation was diagnosed for this evaluation. Fill only if 'Row 6 - Dislocation, elbow' is 'Yes'. Depends on: Row 6 - Dislocation, elbow
Row 6 Date of diagnosis — Left elbow	Date	Enter the date the left elbow dislocation was diagnosed for this evaluation. Fill only if 'Row 6 - Dislocation, elbow' is 'Yes'. Depends on: Row 6 - Dislocation, elbow
Row 7 - Osteoarthritis, elbow
Row 7 - Osteoarthritis, elbow	Checkbox	Check this box when the veteran has a current diagnosis of osteoarthritis of the elbow identified during this evaluation. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 7 - Osteoarthritis, elbow — Side affected: Right	Radiobutton	Check this box when the osteoarthritis affects the veteran's right elbow. Fill only if 'Row 7 - Osteoarthritis, elbow' is 'Yes'. Depends on: Row 7 - Osteoarthritis, elbow
Row 7 - Osteoarthritis, elbow — Side affected: Left	Radiobutton	Check this box when the osteoarthritis affects the veteran's left elbow. Fill only if 'Row 7 - Osteoarthritis, elbow' is 'Yes'. Depends on: Row 7 - Osteoarthritis, elbow
Row 7 - Osteoarthritis, elbow — Side affected: Both	Radiobutton	Check this box when the osteoarthritis affects both elbows. Fill only if 'Row 7 - Osteoarthritis, elbow' is 'Yes'. Depends on: Row 7 - Osteoarthritis, elbow
Row 7 ICD code (Osteoarthritis, elbow)	Text	Enter the ICD diagnosis code assigned for osteoarthritis of the elbow for this condition. Fill only if 'Row 7 - Osteoarthritis, elbow' is 'Yes'. Depends on: Row 7 - Osteoarthritis, elbow
Row 7 Date of diagnosis — Right elbow	Date	Enter the date when osteoarthritis of the right elbow was diagnosed. Fill only if 'Row 7 - Osteoarthritis, elbow' is 'Yes'. Depends on: Row 7 - Osteoarthritis, elbow
Row 7 Date of diagnosis — Left elbow	Date	Enter the date when osteoarthritis of the left elbow was diagnosed. Fill only if 'Row 7 - Osteoarthritis, elbow' is 'Yes'. Depends on: Row 7 - Osteoarthritis, elbow
Row 8 - Total elbow arthroplasty
Row 8 - Total elbow arthroplasty (diagnosis)	Checkbox	Check this box to indicate that the veteran has a current diagnosis of total elbow arthroplasty. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 8 - Total elbow arthroplasty — Right	Radiobutton	Check this when the total elbow arthroplasty affects the right elbow. Fill only if 'Row 8 - Total elbow arthroplasty (diagnosis)' is 'Yes'. Depends on: Row 8 - Total elbow arthroplasty (diagnosis)
Row 8 - Total elbow arthroplasty — Left	Radiobutton	Check this when the total elbow arthroplasty affects the left elbow. Fill only if 'Row 8 - Total elbow arthroplasty (diagnosis)' is 'Yes'. Depends on: Row 8 - Total elbow arthroplasty (diagnosis)
Row 8 - Total elbow arthroplasty — Both	Radiobutton	Check this when the total elbow arthroplasty affects both elbows (both sides). Fill only if 'Row 8 - Total elbow arthroplasty (diagnosis)' is 'Yes'. Depends on: Row 8 - Total elbow arthroplasty (diagnosis)
Row 8 - Total elbow arthroplasty: ICD code	Text	Enter the diagnosis ICD code for total elbow arthroplasty for this row (use the appropriate alphanumeric code assigned to the condition). Fill only if 'Row 8 - Total elbow arthroplasty (diagnosis)' is 'Yes'. Depends on: Row 8 - Total elbow arthroplasty (diagnosis)
Row 8 - Total elbow arthroplasty: Date of diagnosis (Right)	Date	Enter the date when the diagnosis for total elbow arthroplasty was made for the right side. Fill only if 'Row 8 - Total elbow arthroplasty (diagnosis)' is 'Yes'. Depends on: Row 8 - Total elbow arthroplasty (diagnosis)
Row 8 - Total elbow arthroplasty: Date of diagnosis (Left)	Date	Enter the date when the diagnosis for total elbow arthroplasty was made for the left side. Fill only if 'Row 8 - Total elbow arthroplasty (diagnosis)' is 'Yes'. Depends on: Row 8 - Total elbow arthroplasty (diagnosis)
Row 9 - Ankylosis of elbow joint
Row 9 - Ankylosis of elbow joint	Checkbox	Check this box when the veteran has a diagnosis of ankylosis of the elbow joint associated with the claimed condition. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'No'. Depends on: The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above
Row 9 - Ankylosis of elbow joint - Right	Radiobutton	Check this box if the ankylosis affects the veteran's right elbow. Fill only if 'Row 9 - Ankylosis of elbow joint' is 'Yes'. Depends on: Row 9 - Ankylosis of elbow joint
Row 9 - Ankylosis of elbow joint - Left	Radiobutton	Check this box if the ankylosis affects the veteran's left elbow. Fill only if 'Row 9 - Ankylosis of elbow joint' is 'Yes'. Depends on: Row 9 - Ankylosis of elbow joint
Row 9 - Ankylosis of elbow joint - Both	Radiobutton	Check this box if the ankylosis affects both elbows. Fill only if 'Row 9 - Ankylosis of elbow joint' is 'Yes'. Depends on: Row 9 - Ankylosis of elbow joint
Row 9 - Ankylosis of elbow joint: ICD code	Text	Enter the ICD diagnosis code that corresponds to ankylosis of the elbow joint for this claimed condition. Fill only if 'Row 9 - Ankylosis of elbow joint' is 'Yes'. Depends on: Row 9 - Ankylosis of elbow joint
Row 9 - Ankylosis of elbow joint: Date of diagnosis (Right)	Date	Enter the date the diagnosis of ankylosis was made for the right elbow. Fill only if 'Row 9 - Ankylosis of elbow joint' is 'Yes'. Depends on: Row 9 - Ankylosis of elbow joint
Row 9 - Ankylosis of elbow joint: Date of diagnosis (Left)	Date	Enter the date the diagnosis of ankylosis was made for the left elbow. Fill only if 'Row 9 - Ankylosis of elbow joint' is 'Yes'. Depends on: Row 9 - Ankylosis of elbow joint
Section 2A - Medical history description
2A. History (elbow/forearm) description	Text	Provide a brief summary describing the Veteran's elbow and/or forearm condition, including onset, course, and relevant details about how the condition developed and progressed.
Section 2B - Flare-ups (Yes/No + description)
Section 2B - Yes (Flare-ups)	Radiobutton	Check this box if the Veteran reports that they experience flare-ups of the elbow or forearm.
Section 2B - No (Flare-ups)	Radiobutton	Check this box if the Veteran reports that they do not experience flare-ups of the elbow or forearm.
Flare‑up description (Section 2B)	Text	Enter the Veteran’s description of elbow/forearm flare‑ups, including frequency, duration, characteristics, precipitating and alleviating factors, severity, and the extent of any functional impairment or symptoms experienced during a flare‑up. Fill only if 'Section 2B - Yes (Flare-ups)' is 'Yes'. Depends on: Section 2B - Yes (Flare-ups)
Section 2C - Functional loss (Yes/No + description)
Section 2C - Yes	Radiobutton	Check this box if the Veteran reports having any functional loss or functional impairment of the joint or extremity being evaluated on this questionnaire.
Section 2C - No	Radiobutton	Check this box if the Veteran reports no functional loss or functional impairment of the joint or extremity being evaluated on this questionnaire.
Section 2C — Functional loss or impairment description	Text	Provide the Veteran's own description of any functional loss or functional impairment of the evaluated joint or extremity, including how it limits activities, when it occurs, and any relevant details or examples. Fill only if 'Section 2C - Yes' is 'Yes'. Depends on: Section 2C - Yes
Section 4 - Left elbow Muscle Atrophy
Section 4 - 4A Left elbow: Yes	Radiobutton	Check this box if the Veteran has muscle atrophy in the left elbow.
Section 4 - 4A Left elbow: No	Radiobutton	Check this box if the Veteran does not have muscle atrophy in the left elbow.
Section 4 - 4B Left elbow: Yes	Radiobutton	Check this box if the left elbow muscle atrophy is due to the claimed condition in the diagnosis section. Fill only if 'Section 4 - 4A Left elbow: Yes' is 'Yes'. Depends on: Section 4 - 4A Left elbow: Yes
Section 4 - 4B Left elbow: No	Radiobutton	Check this box if the left elbow muscle atrophy is not due to the claimed condition in the diagnosis section. Fill only if 'Section 4 - 4A Left elbow: Yes' is 'Yes'. Depends on: Section 4 - 4A Left elbow: Yes
Section 4 Left elbow — 4B Rationale	Text	If you answered 'No' to whether the left elbow muscle atrophy is due to the claimed condition, provide the rationale explaining why it is not related. Fill only if 'Section 4 - 4B Left elbow: No' is 'No'. Depends on: Section 4 - 4B Left elbow: No
Section 4 - 4C Left upper extremity: Specify location	Checkbox	Check this box when you will provide the specific location of measurement for the left upper extremity (for example, '10 cm above or below elbow'). Fill only if 'Section 1 - Diagnosis' includes a diagnosis that causes left upper extremity muscle atrophy. Depends on: Other diagnosis #1 - Left, Other diagnosis #1 - Both, Other diagnosis #2 - Left, Other diagnosis #2 - Both, Other (specify) — Side (Right / Left / Both), Additional diagnosis (elbow/forearm)
Section 4 Left elbow — 4C Location/Details	Text	Describe the specific location of atrophy for the left upper extremity and any relevant details about measurements at maximum muscle bulk (for example, '10 cm above elbow'). Fill only if 'Section 1 - Diagnosis' includes a diagnosis that causes left upper extremity muscle atrophy. Depends on: Other diagnosis #1 - Left, Other diagnosis #1 - Both, Other diagnosis #2 - Left, Other diagnosis #2 - Both, Other (specify) — Side (Right / Left / Both), Additional diagnosis (elbow/forearm)
Section 4 Left elbow — Circumference of normal side	Number	Enter the circumference of the normal (non-atrophied) left upper extremity at the measured site in centimeters. Fill only if 'Section 1 - Diagnosis' includes a diagnosis that causes left upper extremity muscle atrophy. Depends on: Other diagnosis #1 - Left, Other diagnosis #1 - Both, Other diagnosis #2 - Left, Other diagnosis #2 - Both, Other (specify) — Side (Right / Left / Both), Additional diagnosis (elbow/forearm)
Section 4 Left elbow — Circumference of atrophied side	Number	Enter the circumference of the atrophied left upper extremity at the measured site in centimeters. Fill only if 'Section 1 - Diagnosis' includes a diagnosis that causes left upper extremity muscle atrophy. Depends on: Other diagnosis #1 - Left, Other diagnosis #1 - Both, Other diagnosis #2 - Left, Other diagnosis #2 - Both, Other (specify) — Side (Right / Left / Both), Additional diagnosis (elbow/forearm)
Section 4 Left elbow — 4D Comments	Text	Provide any additional comments or observations related to left elbow muscle atrophy.
Section 4 - Right elbow Muscle Atrophy
Section 4 (4A) Right elbow - Yes (muscle atrophy present)	Radiobutton	Check this box if the veteran has muscle atrophy in the right elbow.
Section 4 (4A) Right elbow - No (muscle atrophy not present)	Radiobutton	Check this box if the veteran does not have muscle atrophy in the right elbow.
Section 4 (4B) Right elbow - Yes (atrophy due to claimed condition)	Radiobutton	Check this box if the right elbow muscle atrophy is due to the claimed condition listed in the diagnosis section. Fill only if 'Section 4 (4A) Right elbow - Yes (muscle atrophy present)' is 'Yes'. Depends on: Section 4 (4A) Right elbow - Yes (muscle atrophy present)
Section 4 (4B) Right elbow - No (atrophy not due to claimed condition)	Radiobutton	Check this box if the right elbow muscle atrophy is not due to the claimed condition listed in the diagnosis section. Fill only if 'Section 4 (4A) Right elbow - Yes (muscle atrophy present)' is 'Yes'. Depends on: Section 4 (4A) Right elbow - Yes (muscle atrophy present)
Section 4 (4B) - Right elbow: Rationale if not due to claimed condition	Text	Provide the rationale explaining why the right elbow muscle atrophy is not attributable to the claimed condition listed in the diagnosis section. Fill only if 'Section 4 (4B) Right elbow - No (atrophy not due to claimed condition)' is 'No'. Depends on: Section 4 (4B) Right elbow - No (atrophy not due to claimed condition)
Section 4 (4C) Right upper extremity - Specify location of measurement	Checkbox	Check this box when you are providing the specific location for measurement of atrophy on the right upper extremity (e.g., '10cm above or below elbow'). Fill only if 'Section 1 - Diagnosis' includes a diagnosis that causes right upper extremity muscle atrophy. Depends on: Other diagnosis #1 - Right, Other diagnosis #1 - Both, Other diagnosis #2 - Right, Other diagnosis #2 - Both, Other (specify) — Side (Right / Left / Both), Additional diagnosis (elbow/forearm)
Section 4 (4C) - Right elbow: Specific location of measurement and atrophy description	Text	Specify the exact location on the right upper extremity where the muscle bulk measurement was taken (for example '10 cm above the elbow') and describe the atrophied area and relevant measurement context. Fill only if 'Section 1 - Diagnosis' includes a diagnosis that causes right upper extremity muscle atrophy. Depends on: Other diagnosis #1 - Right, Other diagnosis #1 - Both, Other diagnosis #2 - Right, Other diagnosis #2 - Both, Other (specify) — Side (Right / Left / Both), Additional diagnosis (elbow/forearm)
Section 4 (4C) - Right elbow: Circumference of normal side	Number	Enter the measured circumference of the normal (non-atrophied) right side at maximum muscle bulk. Fill only if 'Section 1 - Diagnosis' includes a diagnosis that causes right upper extremity muscle atrophy. Depends on: Other diagnosis #1 - Right, Other diagnosis #1 - Both, Other diagnosis #2 - Right, Other diagnosis #2 - Both, Other (specify) — Side (Right / Left / Both), Additional diagnosis (elbow/forearm)
Section 4 (4C) - Right elbow: Circumference of atrophied side	Number	Enter the measured circumference of the atrophied right side at maximum muscle bulk. Fill only if 'Section 1 - Diagnosis' includes a diagnosis that causes right upper extremity muscle atrophy. Depends on: Other diagnosis #1 - Right, Other diagnosis #1 - Both, Other diagnosis #2 - Right, Other diagnosis #2 - Both, Other (specify) — Side (Right / Left / Both), Additional diagnosis (elbow/forearm)
Section 4 (4D) - Right elbow: Comments	Text	Provide any additional comments, observations, or clarifying information related to the right elbow muscle atrophy assessment.
Section 5 - Left elbow Ankylosis
5A Left elbow - Ankylosis: Yes	Radiobutton	Check this box if there is ankylosis (immobilization) of the left elbow and/or forearm.
5A Left elbow - Ankylosis: No	Radiobutton	Check this box if there is no ankylosis of the left elbow and/or forearm.
5A Left elbow - Favorable ankylosis (angle between 90° and 70°)	Radiobutton	Check this box when the left elbow ankylosis is classified as favorable, with an angle between 90 degrees and 70 degrees. Fill only if '5A Left elbow - Ankylosis: Yes' is 'Yes'. Depends on: 5A Left elbow - Ankylosis: Yes
5A Left elbow - Intermediate ankylosis (>90° or between 70° and 50°)	Radiobutton	Check this box when the left elbow ankylosis is intermediate in severity (an angle of more than 90 degrees, or between 70 and 50 degrees). Fill only if '5A Left elbow - Ankylosis: Yes' is 'Yes'. Depends on: 5A Left elbow - Ankylosis: Yes
5A Left elbow - Unfavorable ankylosis	Radiobutton	Check this box when the left elbow ankylosis is classified as unfavorable in severity. Fill only if '5A Left elbow - Ankylosis: Yes' is 'Yes'. Depends on: 5A Left elbow - Ankylosis: Yes
5A Left elbow - At an angle of less than 50 degrees	Checkbox	Check this box when the left elbow ankylosis angle is less than 50 degrees. Fill only if '5A Left elbow - Ankylosis: Yes' is 'Yes'. Depends on: 5A Left elbow - Ankylosis: Yes
5A Left elbow - With complete loss of supination	Checkbox	Check this box when the left forearm has complete loss of supination associated with the ankylosis. Fill only if '5A Left elbow - Ankylosis: Yes' is 'Yes'. Depends on: 5A Left elbow - Ankylosis: Yes
5A Left elbow - With complete loss of pronation	Checkbox	Check this box when the left forearm has complete loss of pronation associated with the ankylosis. Fill only if '5A Left elbow - Ankylosis: Yes' is 'Yes'. Depends on: 5A Left elbow - Ankylosis: Yes
Section 5 - Left elbow: Angle of ankylosis (degrees)	Number	Enter the measured angle of ankylosis for the left elbow in degrees. Fill only if '5A Left elbow - Ankylosis: Yes' is 'Yes'. Depends on: 5A Left elbow - Ankylosis: Yes
Section 5 - Right elbow Ankylosis
Section 5 - Right elbow: 5A — Is there ankylosis? Yes	Radiobutton	Check this box if the veteran has ankylosis of the right elbow and/or forearm (answer Yes to 5A).
Section 5 - Right elbow: 5A — Is there ankylosis? No	Radiobutton	Check this box if the veteran does not have ankylosis of the right elbow and/or forearm (answer No to 5A).
Section 5 - Right elbow: Favorable ankylosis (angle between 90° and 70°)	Radiobutton	Check this box when the right elbow is ankylosed in a favorable position, fixed at an angle between 90 degrees and 70 degrees. Fill only if 'Section 5 - Right elbow: 5A — Is there ankylosis? Yes' is 'Yes'. Depends on: Section 5 - Right elbow: 5A — Is there ankylosis? Yes
Section 5 - Right elbow: Intermediate ankylosis (angle >90° or between 70° and 50°)	Radiobutton	Check this box when the right elbow is ankylosed in an intermediate position, fixed at an angle of more than 90 degrees or between 70 and 50 degrees. Fill only if 'Section 5 - Right elbow: 5A — Is there ankylosis? Yes' is 'Yes'. Depends on: Section 5 - Right elbow: 5A — Is there ankylosis? Yes
Section 5 - Right elbow: Unfavorable ankylosis	Radiobutton	Check this box when the right elbow ankylosis is considered unfavorable (use additional boxes below as applicable). Fill only if 'Section 5 - Right elbow: 5A — Is there ankylosis? Yes' is 'Yes'. Depends on: Section 5 - Right elbow: 5A — Is there ankylosis? Yes
Section 5 - Right elbow: At an angle of less than 50 degrees	Checkbox	Check this box when the right elbow ankylosis is fixed at an angle of less than 50 degrees. Fill only if 'Section 5 - Right elbow: 5A — Is there ankylosis? Yes' is 'Yes'. Depends on: Section 5 - Right elbow: 5A — Is there ankylosis? Yes
Section 5 - Right elbow: With complete loss of supination	Checkbox	Check this box when the right forearm/elbow has complete loss of supination. Fill only if 'Section 5 - Right elbow: 5A — Is there ankylosis? Yes' is 'Yes'. Depends on: Section 5 - Right elbow: 5A — Is there ankylosis? Yes
Section 5 - Right elbow: With complete loss of pronation	Checkbox	Check this box when the right forearm/elbow has complete loss of pronation. Fill only if 'Section 5 - Right elbow: 5A — Is there ankylosis? Yes' is 'Yes'. Depends on: Section 5 - Right elbow: 5A — Is there ankylosis? Yes
5B. Angle of ankylosis (Right elbow)	Text	Enter the measured angle in degrees representing the degree of ankylosis for the right elbow (e.g., 10, 90). Fill only if 'Section 5 - Right elbow: 5A — Is there ankylosis? Yes' is 'Yes'. Depends on: Section 5 - Right elbow: 5A — Is there ankylosis? Yes
Section 8A - Other pertinent physical findings (description)
8A. Other pertinent physical findings (brief summary)	Text	Enter a brief summary describing any other pertinent physical findings, complications, conditions, signs, or symptoms related to the conditions listed in the diagnosis section. Fill only if 'Section 8A - Yes' is 'Yes'. Depends on: Section 8A - Yes
Section 8A - Other pertinent physical findings (response)
Section 8A - Yes	Radiobutton	Check this box if the Veteran has any other pertinent physical findings, complications, conditions, signs, and/or symptoms related to the listed diagnoses and you will provide a brief description below.
Section 8A - No	Radiobutton	Check this box if the Veteran does not have any other pertinent physical findings, complications, conditions, signs, or symptoms related to the listed diagnoses.
Section 8B - Scars or disfigurement (response)
8B: Yes - Scars or disfigurement present	Radiobutton	Check this box if the Veteran has any scars or other disfigurement of the skin related to any of the listed conditions or their treatment.
8B: No - No scars or disfigurement	Radiobutton	Check this box if the Veteran does not have any scars or other disfigurement of the skin related to the listed conditions or their treatment.
Supination/Pronation - Header
Supination and pronation, impairment of	Checkbox	Check this box when the Veteran has an impairment of supination and/or pronation of the forearm/hand; selecting it indicates you should complete the specific loss/fixation options and side (Right/Left/Both) below.
Supination/Pronation - Row 1 (Loss of bone fusion: hand fixed in supination)
Row 1 - Loss of (bone fusion): hand fixed in supination	Checkbox	Check this box when the veteran has loss of bone fusion resulting in the hand being fixed in supination. Fill only if '6A - Yes' is 'Yes'. Depends on: 6A - Yes
Row 1 - Right (side)	Radiobutton	Check this when the Row 1 condition (hand fixed in supination) applies to the right side; only select a side option if the Row 1 condition box is checked. Fill only if 'Row 1 - Loss of (bone fusion): hand fixed in supination' is 'Yes'. Depends on: Row 1 - Loss of (bone fusion): hand fixed in supination
Row 1 - Left (side)	Radiobutton	Check this when the Row 1 condition (hand fixed in supination) applies to the left side; only select a side option if the Row 1 condition box is checked. Fill only if 'Row 1 - Loss of (bone fusion): hand fixed in supination' is 'Yes'. Depends on: Row 1 - Loss of (bone fusion): hand fixed in supination
Row 1 - Both (sides)	Radiobutton	Check this when the Row 1 condition (hand fixed in supination) applies to both sides; only select a side option if the Row 1 condition box is checked. Fill only if 'Row 1 - Loss of (bone fusion): hand fixed in supination' is 'Yes'. Depends on: Row 1 - Loss of (bone fusion): hand fixed in supination
Supination/Pronation - Row 2 (Loss of bone fusion: hand fixed in hyperpronation)
Row 2 - Loss of (bone fusion): hand fixed in hyperpronation	Checkbox	Check this box when the veteran has loss of bone fusion with the hand fixed in hyperpronation. Fill only if '6A - Yes' is 'Yes'. Depends on: 6A - Yes
Row 2 - Loss of (bone fusion): hand fixed in hyperpronation — Right	Radiobutton	Check this box when the hand-fixed-in-hyperpronation impairment affects the right side. Fill only if 'Row 2 - Loss of (bone fusion): hand fixed in hyperpronation' is 'Yes'. Depends on: Row 2 - Loss of (bone fusion): hand fixed in hyperpronation
Row 2 - Loss of (bone fusion): hand fixed in hyperpronation — Left	Radiobutton	Check this box when the hand-fixed-in-hyperpronation impairment affects the left side. Fill only if 'Row 2 - Loss of (bone fusion): hand fixed in hyperpronation' is 'Yes'. Depends on: Row 2 - Loss of (bone fusion): hand fixed in hyperpronation
Row 2 - Loss of (bone fusion): hand fixed in hyperpronation — Both	Radiobutton	Check this box when the hand-fixed-in-hyperpronation impairment affects both sides. Fill only if 'Row 2 - Loss of (bone fusion): hand fixed in hyperpronation' is 'Yes'. Depends on: Row 2 - Loss of (bone fusion): hand fixed in hyperpronation
Supination/Pronation - Row 3 (Loss of bone fusion: hand fixed in full pronation)
Row 3 - Loss of (bone fusion): hand fixed in full pronation	Checkbox	Check this box when the veteran has loss of bone fusion resulting in the hand being fixed in full pronation. Fill only if '6A - Yes' is 'Yes'. Depends on: 6A - Yes
Row 3 - Right	Radiobutton	Check this option when the loss of bone fusion with the hand fixed in full pronation affects the right hand. Fill only if 'Row 3 - Loss of (bone fusion): hand fixed in full pronation' is 'Yes'. Depends on: Row 3 - Loss of (bone fusion): hand fixed in full pronation
Row 3 - Left	Radiobutton	Check this option when the loss of bone fusion with the hand fixed in full pronation affects the left hand. Fill only if 'Row 3 - Loss of (bone fusion): hand fixed in full pronation' is 'Yes'. Depends on: Row 3 - Loss of (bone fusion): hand fixed in full pronation
Row 3 - Both	Radiobutton	Check this option when the loss of bone fusion with the hand fixed in full pronation affects both hands. Fill only if 'Row 3 - Loss of (bone fusion): hand fixed in full pronation' is 'Yes'. Depends on: Row 3 - Loss of (bone fusion): hand fixed in full pronation
Supination/Pronation - Row 4 (Loss of bone fusion: hand fixed near middle of arc or moderate pronation)
Row 4 - Loss of (bone fusion): hand fixed near the middle of the arc or moderate pronation	Checkbox	Check this box when the veteran has loss of bone fusion causing the hand to be fixed near the middle of the supination/pronation arc (moderate pronation); then indicate the side using the Right/Left/Both option. Fill only if '6A - Yes' is 'Yes'. Depends on: 6A - Yes
Row 4 - Right	Radiobutton	Select this option when the above loss of bone fusion (hand fixed near the middle of the arc/moderate pronation) affects the right side. Fill only if 'Row 4 - Loss of (bone fusion): hand fixed near the middle of the arc or moderate pronation' is 'Yes'. Depends on: Row 4 - Loss of (bone fusion): hand fixed near the middle of the arc or moderate pronation
Row 4 - Left	Radiobutton	Select this option when the above loss of bone fusion (hand fixed near the middle of the arc/moderate pronation) affects the left side. Fill only if 'Row 4 - Loss of (bone fusion): hand fixed near the middle of the arc or moderate pronation' is 'Yes'. Depends on: Row 4 - Loss of (bone fusion): hand fixed near the middle of the arc or moderate pronation
Row 4 - Both	Radiobutton	Select this option when the above loss of bone fusion (hand fixed near the middle of the arc/moderate pronation) affects both sides. Fill only if 'Row 4 - Loss of (bone fusion): hand fixed near the middle of the arc or moderate pronation' is 'Yes'. Depends on: Row 4 - Loss of (bone fusion): hand fixed near the middle of the arc or moderate pronation
Supination/Pronation - Row 5 (Limitation of pronation: motion lost beyond the middle of the arc)
Row 5 - Limitation of pronation: motion lost beyond the middle of the arc (Condition)	Checkbox	Check this box when the veteran has a limitation of pronation where motion is lost beyond the middle of the arc. Fill only if '6A - Yes' is 'Yes'. Depends on: 6A - Yes
Row 5 - Limitation of pronation: Right	Radiobutton	Check this box when the limitation of pronation (motion lost beyond the middle of the arc) affects the right side. Fill only if 'Row 5 - Limitation of pronation: motion lost beyond the middle of the arc (Condition)' is 'Yes'. Depends on: Row 5 - Limitation of pronation: motion lost beyond the middle of the arc (Condition)
Row 5 - Limitation of pronation: Left	Radiobutton	Check this box when the limitation of pronation (motion lost beyond the middle of the arc) affects the left side. Fill only if 'Row 5 - Limitation of pronation: motion lost beyond the middle of the arc (Condition)' is 'Yes'. Depends on: Row 5 - Limitation of pronation: motion lost beyond the middle of the arc (Condition)
Row 5 - Limitation of pronation: Both	Radiobutton	Check this box when the limitation of pronation (motion lost beyond the middle of the arc) affects both sides. Fill only if 'Row 5 - Limitation of pronation: motion lost beyond the middle of the arc (Condition)' is 'Yes'. Depends on: Row 5 - Limitation of pronation: motion lost beyond the middle of the arc (Condition)
Supination/Pronation - Row 6 (Limitation of pronation: motion lost beyond last quarter of arc)
Row 6 — Limitation of pronation: motion lost beyond last quarter of arc; hand does not approach full pronation	Checkbox	Check this box when the veteran has limitation of pronation in which motion is lost beyond the last quarter of the arc and the hand does not approach full pronation. Fill only if '6A - Yes' is 'Yes'. Depends on: 6A - Yes
Row 6 — Limitation of pronation (Right)	Radiobutton	Check this when the limitation of pronation described applies to the right side. Fill only if 'Row 6 — Limitation of pronation: motion lost beyond last quarter of arc; hand does not approach full pronation' is 'Yes'. Depends on: Row 6 — Limitation of pronation: motion lost beyond last quarter of arc; hand does not approach full pronation
Row 6 — Limitation of pronation (Left)	Radiobutton	Check this when the limitation of pronation described applies to the left side. Fill only if 'Row 6 — Limitation of pronation: motion lost beyond last quarter of arc; hand does not approach full pronation' is 'Yes'. Depends on: Row 6 — Limitation of pronation: motion lost beyond last quarter of arc; hand does not approach full pronation
Row 6 — Limitation of pronation (Both)	Radiobutton	Check this when the limitation of pronation described applies to both sides. Fill only if 'Row 6 — Limitation of pronation: motion lost beyond last quarter of arc; hand does not approach full pronation' is 'Yes'. Depends on: Row 6 — Limitation of pronation: motion lost beyond last quarter of arc; hand does not approach full pronation
Supination/Pronation - Row 7 (Limitation of supination: 30 degrees or less)
Row 7 - Limitation of supination: 30 degrees or less	Checkbox	Check this box to indicate the veteran has a limitation of supination measured at 30 degrees or less. Fill only if '6A - Yes' is 'Yes'. Depends on: 6A - Yes
Row 7 - Right	Radiobutton	Check this box to indicate the limitation of supination (30 degrees or less) affects the right side. Fill only if 'Row 7 - Limitation of supination: 30 degrees or less' is 'Yes'. Depends on: Row 7 - Limitation of supination: 30 degrees or less
Row 7 - Left	Radiobutton	Check this box to indicate the limitation of supination (30 degrees or less) affects the left side. Fill only if 'Row 7 - Limitation of supination: 30 degrees or less' is 'Yes'. Depends on: Row 7 - Limitation of supination: 30 degrees or less
Row 7 - Both	Radiobutton	Check this box to indicate the limitation of supination (30 degrees or less) affects both sides. Fill only if 'Row 7 - Limitation of supination: 30 degrees or less' is 'Yes'. Depends on: Row 7 - Limitation of supination: 30 degrees or less
Ulna - Header
Ulna, impairment of	Checkbox	Check this box when the Veteran has an impairment of the ulna (i.e., a diagnosed ulna injury or condition being evaluated under this section).
Ulna - Row 1 (Nonunion in upper half with loss of bone substance)
Row 1 - Nonunion in upper half with false movement, loss of bone substance (1 inch / 2.5 cm) and marked deformity	Checkbox	Check this box when the veteran has a nonunion in the upper half of the ulna with false movement, loss of bone substance of 1 inch (2.5 cm) or more, and a marked deformity. Fill only if '6A - Yes' is 'Yes'. Depends on: 6A - Yes
Row 1 - Right	Radiobutton	Check this box when the Row 1 nonunion condition applies to the right ulna. Fill only if 'Row 1 - Nonunion in upper half with false movement, loss of bone substance (1 inch / 2.5 cm) and marked deformity' is 'Yes'. Depends on: Row 1 - Nonunion in upper half with false movement, loss of bone substance (1 inch / 2.5 cm) and marked deformity
Row 1 - Left	Radiobutton	Check this box when the Row 1 nonunion condition applies to the left ulna. Fill only if 'Row 1 - Nonunion in upper half with false movement, loss of bone substance (1 inch / 2.5 cm) and marked deformity' is 'Yes'. Depends on: Row 1 - Nonunion in upper half with false movement, loss of bone substance (1 inch / 2.5 cm) and marked deformity
Row 1 - Both	Radiobutton	Check this box when the Row 1 nonunion condition applies to both ulnas. Fill only if 'Row 1 - Nonunion in upper half with false movement, loss of bone substance (1 inch / 2.5 cm) and marked deformity' is 'Yes'. Depends on: Row 1 - Nonunion in upper half with false movement, loss of bone substance (1 inch / 2.5 cm) and marked deformity
Ulna - Row 2 (Nonunion in upper half without loss of bone substance)
Row 2 - Nonunion in upper half with false movement without loss of bone substance or deformity	Checkbox	Check this box if the veteran has an ulna nonunion in the upper half with false movement but without loss of bone substance or deformity. Fill only if '6A - Yes' is 'Yes'. Depends on: 6A - Yes
Row 2 - Nonunion in upper half ... without loss of bone substance or deformity — Right	Radiobutton	Select this bubble to indicate the Row 2 nonunion affects the right ulna (use only when the Row 2 condition box is checked). Fill only if 'Row 2 - Nonunion in upper half with false movement without loss of bone substance or deformity' is 'Yes'. Depends on: Row 2 - Nonunion in upper half with false movement without loss of bone substance or deformity
Row 2 - Nonunion in upper half ... without loss of bone substance or deformity — Left	Radiobutton	Select this bubble to indicate the Row 2 nonunion affects the left ulna (use only when the Row 2 condition box is checked). Fill only if 'Row 2 - Nonunion in upper half with false movement without loss of bone substance or deformity' is 'Yes'. Depends on: Row 2 - Nonunion in upper half with false movement without loss of bone substance or deformity
Row 2 - Nonunion in upper half ... without loss of bone substance or deformity — Both	Radiobutton	Select this bubble to indicate the Row 2 nonunion affects both ulnae (use only when the Row 2 condition box is checked). Fill only if 'Row 2 - Nonunion in upper half with false movement without loss of bone substance or deformity' is 'Yes'. Depends on: Row 2 - Nonunion in upper half with false movement without loss of bone substance or deformity
Ulna - Row 3 (Nonunion in lower half)
Row 3 - Nonunion in lower half	Checkbox	Check this box if the veteran has a nonunion in the lower half of the ulna. Fill only if '6A - Yes' is 'Yes'. Depends on: 6A - Yes
Row 3 - Nonunion in lower half — Right	Radiobutton	Check this box if the nonunion in the lower half of the ulna affects the right side (select this only when the condition box is checked). Fill only if 'Row 3 - Nonunion in lower half' is 'Yes'. Depends on: Row 3 - Nonunion in lower half
Row 3 - Nonunion in lower half — Left	Radiobutton	Check this box if the nonunion in the lower half of the ulna affects the left side (select this only when the condition box is checked). Fill only if 'Row 3 - Nonunion in lower half' is 'Yes'. Depends on: Row 3 - Nonunion in lower half
Row 3 - Nonunion in lower half — Both	Radiobutton	Check this box if the nonunion in the lower half of the ulna affects both sides (select this only when the condition box is checked). Fill only if 'Row 3 - Nonunion in lower half' is 'Yes'. Depends on: Row 3 - Nonunion in lower half
Ulna - Row 4 (Malunion of, with bad alignment)
Row 4 - Malunion of, with bad alignment (Ulna) - Condition	Checkbox	Check this box when the veteran has a malunion of the ulna with bad alignment; if checked, also indicate which side is affected. Fill only if '6A - Yes' is 'Yes'. Depends on: 6A - Yes
Row 4 - Malunion of, with bad alignment (Ulna) - Right	Radiobutton	Select this when the malunion with bad alignment affects the right ulna. Fill only if 'Row 4 - Malunion of, with bad alignment (Ulna) - Condition' is 'Yes'. Depends on: Row 4 - Malunion of, with bad alignment (Ulna) - Condition
Row 4 - Malunion of, with bad alignment (Ulna) - Left	Radiobutton	Select this when the malunion with bad alignment affects the left ulna. Fill only if 'Row 4 - Malunion of, with bad alignment (Ulna) - Condition' is 'Yes'. Depends on: Row 4 - Malunion of, with bad alignment (Ulna) - Condition
Row 4 - Malunion of, with bad alignment (Ulna) - Both	Radiobutton	Select this when the malunion with bad alignment affects both ulnas. Fill only if 'Row 4 - Malunion of, with bad alignment (Ulna) - Condition' is 'Yes'. Depends on: Row 4 - Malunion of, with bad alignment (Ulna) - Condition
VA Healthcare Provider (Yes/No)
Are you a VA Healthcare provider? — Yes	Radiobutton	Check this box if the person completing this Disability Benefits Questionnaire is a VA healthcare provider.
Are you a VA Healthcare provider? — No	Radiobutton	Check this box if the person completing this Disability Benefits Questionnaire is not a VA healthcare provider.

Elbow and Forearm Conditions Disability Benefits Questionnaire Instructions