This form contains 790 fields organized into 173 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
15A Other Pertinent Physical Findings (Yes/No and Description)
Yes	Radiobutton	Check this box if the Veteran has other pertinent physical findings, complications, conditions, signs, or symptoms related to the diagnosed conditions.
No	Radiobutton	Check this box if the Veteran does not have any other pertinent physical findings, complications, conditions, signs, or symptoms related to the diagnosed conditions.
Other Pertinent Physical Findings Description	Text	Provide a brief summary describing any other pertinent physical findings, complications, conditions, signs, or symptoms related to the diagnosed conditions. Fill only if 'Yes' is 'Yes'. Depends on: Yes
15B Scars or Other Disfigurement Related to Conditions (Yes/No)
Yes	Radiobutton	Check this box if the Veteran has any scars or other skin disfigurement related to any diagnosed condition or to treatment of any diagnosed condition.
No	Radiobutton	Check this box if the Veteran does not have any scars or other skin disfigurement related to any diagnosed condition or to treatment of any diagnosed condition.
17A Functional impairment equivalent to amputation (Yes/No)
Yes	Radiobutton	Check this box if the Veteran’s foot condition(s) cause functional impairment of an extremity such that amputation with prosthesis would equally serve the Veteran.
No	Radiobutton	Check this box if the Veteran does not have functional impairment equivalent to amputation with prosthesis.
17A If Yes, extremities affected
Right lower extremity	Checkbox	Check this box if the functional impairment described in 17A applies to the Veteran’s right lower extremity. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left lower extremity	Checkbox	Check this box if the functional impairment described in 17A applies to the Veteran’s left lower extremity. Fill only if 'Yes' is 'Yes'. Depends on: Yes
17A Loss of function details and examples (brief summary)
Loss of effective function details and examples	Text	For each extremity selected in 17A, describe the condition causing the loss of function, explain the loss of effective function, and provide brief specific examples demonstrating the functional impairment. Fill only if 'Yes', 'Right lower extremity', 'Left lower extremity' is 'Yes' and any fields selection. Depends on: Yes, Right lower extremity, Left lower extremity
18A Imaging Studies Performed
Yes	Radiobutton	Check this box if imaging studies were performed in conjunction with this examination.
No	Radiobutton	Check this box if no imaging studies were performed in conjunction with this examination.
18B Arthritis Documented and Affected Foot
Yes (arthritis documented)	Radiobutton	Check this box if imaging shows degenerative or post-traumatic arthritis is documented. Fill only if 'Yes' is 'Yes'. Depends on: Yes
No (arthritis not documented)	Radiobutton	Check this box if imaging does not document degenerative or post-traumatic arthritis. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right foot	Radiobutton	Check this box if arthritis is documented and it affects the right foot. Fill only if 'Yes (arthritis documented)' is 'Yes'. Depends on: Yes (arthritis documented)
Left foot	Radiobutton	Check this box if arthritis is documented and it affects the left foot. Fill only if 'Yes (arthritis documented)' is 'Yes'. Depends on: Yes (arthritis documented)
Both feet	Radiobutton	Check this box if arthritis is documented and it affects both feet. Fill only if 'Yes (arthritis documented)' is 'Yes'. Depends on: Yes (arthritis documented)
18C Imaging/Test Details Summary
Imaging/Test Details (Type, Date, Results Summary)	Text	Enter the type of imaging study or diagnostic test/procedure performed, the date it was done, and a brief summary of the results. Fill only if 'Yes' is 'Yes'. Depends on: Yes
18D Other Significant Diagnostic Findings
Yes	Radiobutton	Check this box if there are other significant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es) that were reviewed in conjunction with this examination.
No	Radiobutton	Check this box if there are no other significant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es) that were reviewed in conjunction with this examination.
Other Significant Diagnostic Findings Summary	Text	Provide a brief summary of any other significant diagnostic test findings or results reviewed for the claimed condition(s), including the test/procedure type, the date performed, and the results. Fill only if 'Yes' is 'Yes'. Depends on: Yes
18E Relationship of Abnormal Findings to Diagnosed Conditions
Relationship of Abnormal Findings to Diagnosed Conditions	Text	Describe how any abnormal diagnostic test findings relate to the diagnosed condition(s), including which findings support or correspond to each diagnosis.
3A Pain on Use of Feet (and Accentuation/Side)
Pain on use of the feet: Yes	Radiobutton	Check this box if the Veteran has pain when using the feet. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
Pain on use of the feet: No	Radiobutton	Check this box if the Veteran does not have pain when using the feet. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
Side affected (pain on use): Right	Radiobutton	Check this box if the pain on use affects the right foot only. Fill only if 'Pain on use of the feet: Yes' is 'Yes'. Depends on: Pain on use of the feet: Yes
Side affected (pain on use): Left	Radiobutton	Check this box if the pain on use affects the left foot only. Fill only if 'Pain on use of the feet: Yes' is 'Yes'. Depends on: Pain on use of the feet: Yes
Side affected (pain on use): Both	Radiobutton	Check this box if the pain on use affects both feet. Fill only if 'Pain on use of the feet: Yes' is 'Yes'. Depends on: Pain on use of the feet: Yes
Pain accentuated on use: Yes	Radiobutton	Check this box if the Veteran’s pain increases (is accentuated) with use. Fill only if 'Pain on use of the feet: Yes' is 'Yes'. Depends on: Pain on use of the feet: Yes
Pain accentuated on use: No	Radiobutton	Check this box if the Veteran’s pain is not increased (not accentuated) with use. Fill only if 'Pain on use of the feet: Yes' is 'Yes'. Depends on: Pain on use of the feet: Yes
Side affected (pain accentuated on use): Right	Radiobutton	Check this box if pain that is accentuated on use affects the right foot only. Fill only if 'Pain accentuated on use: Yes' is 'Yes'. Depends on: Pain accentuated on use: Yes
Side affected (pain accentuated on use): Left	Radiobutton	Check this box if pain that is accentuated on use affects the left foot only. Fill only if 'Pain accentuated on use: Yes' is 'Yes'. Depends on: Pain accentuated on use: Yes
Side affected (pain accentuated on use): Both	Radiobutton	Check this box if pain that is accentuated on use affects both feet. Fill only if 'Pain accentuated on use: Yes' is 'Yes'. Depends on: Pain accentuated on use: Yes
3B Pain on Manipulation of Feet (and Accentuation/Side)
Pain on manipulation of the feet - Yes	Radiobutton	Check this box if the Veteran has pain when the feet are manipulated on examination. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
Pain on manipulation of the feet - No	Radiobutton	Check this box if the Veteran does not have pain when the feet are manipulated on examination. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
Side affected (pain on manipulation) - Right	Radiobutton	Check this box if pain on manipulation affects the right foot only. Fill only if 'Pain on manipulation of the feet - Yes' is 'Yes'. Depends on: Pain on manipulation of the feet - Yes
Side affected (pain on manipulation) - Left	Radiobutton	Check this box if pain on manipulation affects the left foot only. Fill only if 'Pain on manipulation of the feet - Yes' is 'Yes'. Depends on: Pain on manipulation of the feet - Yes
Side affected (pain on manipulation) - Both	Radiobutton	Check this box if pain on manipulation affects both feet. Fill only if 'Pain on manipulation of the feet - Yes' is 'Yes'. Depends on: Pain on manipulation of the feet - Yes
Pain accentuated on manipulation - Yes	Radiobutton	Check this box if the Veteran’s pain increases (is accentuated) with manipulation of the feet. Fill only if 'Pain on manipulation of the feet - Yes' is 'Yes'. Depends on: Pain on manipulation of the feet - Yes
Pain accentuated on manipulation - No	Radiobutton	Check this box if the Veteran’s pain is not increased (not accentuated) with manipulation of the feet. Fill only if 'Pain on manipulation of the feet - Yes' is 'Yes'. Depends on: Pain on manipulation of the feet - Yes
Side affected (accentuated pain on manipulation) - Right	Radiobutton	Check this box if the accentuated pain on manipulation affects the right foot only. Fill only if 'Pain accentuated on manipulation - Yes' is 'Yes'. Depends on: Pain accentuated on manipulation - Yes
Side affected (accentuated pain on manipulation) - Left	Radiobutton	Check this box if the accentuated pain on manipulation affects the left foot only. Fill only if 'Pain accentuated on manipulation - Yes' is 'Yes'. Depends on: Pain accentuated on manipulation - Yes
Side affected (accentuated pain on manipulation) - Both	Radiobutton	Check this box if the accentuated pain on manipulation affects both feet. Fill only if 'Pain accentuated on manipulation - Yes' is 'Yes'. Depends on: Pain accentuated on manipulation - Yes
3C Swelling on Use (and Side Affected)
Swelling on use - Yes	Radiobutton	Check this box if there is an indication of swelling when the feet are used. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
Swelling on use - No	Radiobutton	Check this box if there is no indication of swelling when the feet are used. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
Side affected - Right	Radiobutton	Check this box if swelling on use affects the right foot only. Fill only if 'Swelling on use - Yes' is 'Yes'. Depends on: Swelling on use - Yes
Side affected - Left	Radiobutton	Check this box if swelling on use affects the left foot only. Fill only if 'Swelling on use - Yes' is 'Yes'. Depends on: Swelling on use - Yes
Side affected - Both	Radiobutton	Check this box if swelling on use affects both feet. Fill only if 'Swelling on use - Yes' is 'Yes'. Depends on: Swelling on use - Yes
3D Characteristic Calluses (and Side Affected)
Yes	Radiobutton	Check this box if the Veteran has characteristic calluses. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
No	Radiobutton	Check this box if the Veteran does not have characteristic calluses. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
Right	Radiobutton	If the Veteran has characteristic calluses, check this box to indicate the right side is affected. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left	Radiobutton	If the Veteran has characteristic calluses, check this box to indicate the left side is affected. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Both	Radiobutton	If the Veteran has characteristic calluses, check this box to indicate both sides are affected. Fill only if 'Yes' is 'Yes'. Depends on: Yes
3E First Device Effects Row (Arch Supports)
Arch Supports (Complete Relief)	Checkbox	Check this box if the Veteran uses arch supports and they result in complete relief of symptoms. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
Right (Side Relieved)	Radiobutton	Check this box if arch supports provide complete relief of symptoms on the right side/foot. Fill only if 'Arch Supports (Complete Relief)' is 'Yes'. Depends on: Arch Supports (Complete Relief)
Left (Side Relieved)	Radiobutton	Check this box if arch supports provide complete relief of symptoms on the left side/foot. Fill only if 'Arch Supports (Complete Relief)' is 'Yes'. Depends on: Arch Supports (Complete Relief)
Both (Sides Relieved)	Radiobutton	Check this box if arch supports provide complete relief of symptoms on both sides/feet. Fill only if 'Arch Supports (Complete Relief)' is 'Yes'. Depends on: Arch Supports (Complete Relief)
Arch Supports (Tried But Remains Symptomatic)	Checkbox	Check this box if the Veteran has tried arch supports but remains symptomatic. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
Right (Side Not Relieved)	Radiobutton	Check this box if arch supports were tried but symptoms on the right side/foot are not relieved. Fill only if 'Arch Supports (Tried But Remains Symptomatic)' is 'Yes'. Depends on: Arch Supports (Tried But Remains Symptomatic)
Left (Side Not Relieved)	Radiobutton	Check this box if arch supports were tried but symptoms on the left side/foot are not relieved. Fill only if 'Arch Supports (Tried But Remains Symptomatic)' is 'Yes'. Depends on: Arch Supports (Tried But Remains Symptomatic)
Both (Sides Not Relieved)	Radiobutton	Check this box if arch supports were tried but symptoms on both sides/feet are not relieved. Fill only if 'Arch Supports (Tried But Remains Symptomatic)' is 'Yes'. Depends on: Arch Supports (Tried But Remains Symptomatic)
3E Second Device Effects Row (Built-up Shoes)
Built-up Shoes (Complete Relief of Symptoms)	Checkbox	Check this box if the Veteran uses built-up shoes and they provide complete relief of symptoms. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
Side Relieved – Right (Built-up Shoes)	Radiobutton	Check this box if built-up shoes provide complete relief of symptoms on the right side/foot. Fill only if 'Built-up Shoes (Complete Relief of Symptoms)' is 'Yes'. Depends on: Built-up Shoes (Complete Relief of Symptoms)
Side Relieved – Left (Built-up Shoes)	Radiobutton	Check this box if built-up shoes provide complete relief of symptoms on the left side/foot. Fill only if 'Built-up Shoes (Complete Relief of Symptoms)' is 'Yes'. Depends on: Built-up Shoes (Complete Relief of Symptoms)
Side Relieved – Both (Built-up Shoes)	Radiobutton	Check this box if built-up shoes provide complete relief of symptoms on both sides/feet. Fill only if 'Built-up Shoes (Complete Relief of Symptoms)' is 'Yes'. Depends on: Built-up Shoes (Complete Relief of Symptoms)
Built-up Shoes (Tried But Remains Symptomatic)	Checkbox	Check this box if the Veteran has tried built-up shoes but remains symptomatic. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
Side Not Relieved – Right (Built-up Shoes)	Radiobutton	Check this box if the right side/foot is not relieved by built-up shoes (Veteran remains symptomatic). Fill only if 'Built-up Shoes (Tried But Remains Symptomatic)' is 'Yes'. Depends on: Built-up Shoes (Tried But Remains Symptomatic)
Side Not Relieved – Left (Built-up Shoes)	Radiobutton	Check this box if the left side/foot is not relieved by built-up shoes (Veteran remains symptomatic). Fill only if 'Built-up Shoes (Tried But Remains Symptomatic)' is 'Yes'. Depends on: Built-up Shoes (Tried But Remains Symptomatic)
Side Not Relieved – Both (Built-up Shoes)	Radiobutton	Check this box if both sides/feet are not relieved by built-up shoes (Veteran remains symptomatic). Fill only if 'Built-up Shoes (Tried But Remains Symptomatic)' is 'Yes'. Depends on: Built-up Shoes (Tried But Remains Symptomatic)
3F Extreme Tenderness of Plantar Surfaces (Side & Improvement by Orthopedic Shoes/Appliances)
Extreme tenderness of plantar surfaces: Yes	Radiobutton	Check this box if the Veteran has extreme tenderness of the plantar surfaces on one or both feet. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
Extreme tenderness of plantar surfaces: No	Radiobutton	Check this box if the Veteran does not have extreme tenderness of the plantar surfaces on either foot. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
Side affected: Right	Radiobutton	Check this box if the extreme tenderness affects the right foot. Fill only if 'Extreme tenderness of plantar surfaces: Yes' is 'Yes'. Depends on: Extreme tenderness of plantar surfaces: Yes
Side affected: Left	Radiobutton	Check this box if the extreme tenderness affects the left foot. Fill only if 'Extreme tenderness of plantar surfaces: Yes' is 'Yes'. Depends on: Extreme tenderness of plantar surfaces: Yes
Side affected: Both	Radiobutton	Check this box if the extreme tenderness affects both feet. Fill only if 'Extreme tenderness of plantar surfaces: Yes' is 'Yes'. Depends on: Extreme tenderness of plantar surfaces: Yes
Improved by orthopedic shoes/appliances (Right): Yes	Radiobutton	Check this box if the right foot tenderness is improved by orthopedic shoes or appliances. Fill only if 'Extreme tenderness of plantar surfaces: Yes' is 'Yes'. Depends on: Extreme tenderness of plantar surfaces: Yes
Improved by orthopedic shoes/appliances (Right): No	Radiobutton	Check this box if the right foot tenderness is not improved by orthopedic shoes or appliances. Fill only if 'Extreme tenderness of plantar surfaces: Yes' is 'Yes'. Depends on: Extreme tenderness of plantar surfaces: Yes
Improved by orthopedic shoes/appliances (Right): N/A	Radiobutton	Check this box if improvement by orthopedic shoes or appliances is not applicable for the right foot (e.g., no right-foot tenderness or not assessed). Fill only if 'Extreme tenderness of plantar surfaces: Yes' is 'Yes'. Depends on: Extreme tenderness of plantar surfaces: Yes
Improved by orthopedic shoes/appliances (Left): Yes	Radiobutton	Check this box if the left foot tenderness is improved by orthopedic shoes or appliances. Fill only if 'Extreme tenderness of plantar surfaces: Yes' is 'Yes'. Depends on: Extreme tenderness of plantar surfaces: Yes
Improved by orthopedic shoes/appliances (Left): No	Radiobutton	Check this box if the left foot tenderness is not improved by orthopedic shoes or appliances. Fill only if 'Extreme tenderness of plantar surfaces: Yes' is 'Yes'. Depends on: Extreme tenderness of plantar surfaces: Yes
Improved by orthopedic shoes/appliances (Left): N/A	Radiobutton	Check this box if improvement by orthopedic shoes or appliances is not applicable for the left foot (e.g., no left-foot tenderness or not assessed). Fill only if 'Extreme tenderness of plantar surfaces: Yes' is 'Yes'. Depends on: Extreme tenderness of plantar surfaces: Yes
3G Decreased Longitudinal Arch Height on Weight-Bearing (and Side Affected)
Yes — Decreased longitudinal arch height on weight-bearing	Radiobutton	Check this box if the Veteran has decreased longitudinal arch height of one or both feet when weight-bearing. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
No — Decreased longitudinal arch height on weight-bearing	Radiobutton	Check this box if the Veteran does not have decreased longitudinal arch height of either foot when weight-bearing. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
Right — Side affected	Radiobutton	Check this box if the decreased longitudinal arch height on weight-bearing affects the right foot only. Fill only if 'Yes — Decreased longitudinal arch height on weight-bearing' is 'Yes'. Depends on: Yes — Decreased longitudinal arch height on weight-bearing
Left — Side affected	Radiobutton	Check this box if the decreased longitudinal arch height on weight-bearing affects the left foot only. Fill only if 'Yes — Decreased longitudinal arch height on weight-bearing' is 'Yes'. Depends on: Yes — Decreased longitudinal arch height on weight-bearing
Both — Side affected	Radiobutton	Check this box if the decreased longitudinal arch height on weight-bearing affects both feet. Fill only if 'Yes — Decreased longitudinal arch height on weight-bearing' is 'Yes'. Depends on: Yes — Decreased longitudinal arch height on weight-bearing
3H Marked Deformity (Pronation/Abduction/etc.) (and Side Affected)
Yes	Radiobutton	Check this box if there is objective evidence of marked deformity of one or both feet (e.g., pronation, abduction, etc.). Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
No	Radiobutton	Check this box if there is no objective evidence of marked deformity of either foot. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
Right	Radiobutton	If marked deformity is present, check this box to indicate the right foot is affected. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left	Radiobutton	If marked deformity is present, check this box to indicate the left foot is affected. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Both	Radiobutton	If marked deformity is present, check this box to indicate both feet are affected. Fill only if 'Yes' is 'Yes'. Depends on: Yes
3I Marked Pronation (Side & Improvement by Orthopedic Shoes/Appliances)
Marked pronation - Yes	Radiobutton	Check this box if there is marked pronation of one foot or both feet. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
Marked pronation - No	Radiobutton	Check this box if there is no marked pronation of either foot. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
Side affected - Right	Radiobutton	Check this box if the marked pronation affects the right foot only. Fill only if 'Marked pronation - Yes' is 'Yes'. Depends on: Marked pronation - Yes
Side affected - Left	Radiobutton	Check this box if the marked pronation affects the left foot only. Fill only if 'Marked pronation - Yes' is 'Yes'. Depends on: Marked pronation - Yes
Side affected - Both	Radiobutton	Check this box if the marked pronation affects both feet. Fill only if 'Marked pronation - Yes' is 'Yes'. Depends on: Marked pronation - Yes
Improved by orthopedic shoes/appliances (Right) - Yes	Radiobutton	Check this box if the right foot condition is improved by orthopedic shoes or appliances. Fill only if 'Marked pronation - Yes' is 'Yes'. Depends on: Marked pronation - Yes
Improved by orthopedic shoes/appliances (Right) - No	Radiobutton	Check this box if the right foot condition is not improved by orthopedic shoes or appliances. Fill only if 'Marked pronation - Yes' is 'Yes'. Depends on: Marked pronation - Yes
Improved by orthopedic shoes/appliances (Right) - N/A	Radiobutton	Check this box if improvement by orthopedic shoes or appliances is not applicable for the right foot. Fill only if 'Marked pronation - Yes' is 'Yes'. Depends on: Marked pronation - Yes
Improved by orthopedic shoes/appliances (Left) - Yes	Radiobutton	Check this box if the left foot condition is improved by orthopedic shoes or appliances. Fill only if 'Marked pronation - Yes' is 'Yes'. Depends on: Marked pronation - Yes
Improved by orthopedic shoes/appliances (Left) - No	Radiobutton	Check this box if the left foot condition is not improved by orthopedic shoes or appliances. Fill only if 'Marked pronation - Yes' is 'Yes'. Depends on: Marked pronation - Yes
Improved by orthopedic shoes/appliances (Left) - N/A	Radiobutton	Check this box if improvement by orthopedic shoes or appliances is not applicable for the left foot. Fill only if 'Marked pronation - Yes' is 'Yes'. Depends on: Marked pronation - Yes
3J Weight-Bearing Line Over/Medial to Great Toe (and Side Affected)
Yes	Radiobutton	Check this box if, for one or both feet, the weight-bearing line is over or medial to the great toe. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
No	Radiobutton	Check this box if, for neither foot, the weight-bearing line is over or medial to the great toe. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
Right	Radiobutton	Check this box if the weight-bearing line is over or medial to the great toe on the right foot. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left	Radiobutton	Check this box if the weight-bearing line is over or medial to the great toe on the left foot. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Both	Radiobutton	Check this box if the weight-bearing line is over or medial to the great toe on both feet. Fill only if 'Yes' is 'Yes'. Depends on: Yes
3K Other Lower Extremity Deformity Affecting Weight-Bearing Line (Side & Description)
Yes	Radiobutton	Check this box if the Veteran has a lower extremity deformity other than pes planus that causes alteration of the weight-bearing line. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
No	Radiobutton	Check this box if the Veteran does not have a lower extremity deformity (other than pes planus) that alters the weight-bearing line. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
Right	Radiobutton	Check this box if the deformity affecting the weight-bearing line is on the right lower extremity. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left	Radiobutton	Check this box if the deformity affecting the weight-bearing line is on the left lower extremity. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Both	Radiobutton	Check this box if the deformity affecting the weight-bearing line is present on both lower extremities. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other Lower Extremity Deformity Description	Text	Describe the lower extremity deformity (other than pes planus) that is causing alteration of the weight-bearing line, including which side is affected and relevant details. Fill only if 'Yes' is 'Yes'. Depends on: Yes
3L Inward Bowing of Achilles Tendon (and Side Affected)
Yes	Radiobutton	Check this box if the Veteran has inward bowing of the Achilles' tendon (hindfoot valgus with lateral deviation of the heel) in one or both feet. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
No	Radiobutton	Check this box if the Veteran does not have inward bowing of the Achilles' tendon in either foot. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
Right	Radiobutton	If 'Yes' is selected, check this box to indicate the inward bowing affects the right foot only. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left	Radiobutton	If 'Yes' is selected, check this box to indicate the inward bowing affects the left foot only. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Both	Radiobutton	If 'Yes' is selected, check this box to indicate the inward bowing affects both feet. Fill only if 'Yes' is 'Yes'. Depends on: Yes
3M Marked Inward Displacement/Severe Spasm of Achilles on Manipulation (Side & Improvement by Orthopedic Shoes/Appliances)
Yes	Radiobutton	Check this box if the Veteran has marked inward displacement and severe spasm of the Achilles’ tendon (rigid hindfoot) on manipulation of one or both feet. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
No	Radiobutton	Check this box if the Veteran does not have marked inward displacement and severe spasm of the Achilles’ tendon (rigid hindfoot) on manipulation of either foot. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
Right	Radiobutton	Check this box if marked inward displacement and severe spasm on manipulation affects the right foot. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left	Radiobutton	Check this box if marked inward displacement and severe spasm on manipulation affects the left foot. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Both	Radiobutton	Check this box if marked inward displacement and severe spasm on manipulation affects both feet. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right foot improved by orthopedic shoes/appliances: Yes	Radiobutton	Check this box if the right foot’s marked inward displacement and severe spasm is improved by orthopedic shoes or appliances. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right foot improved by orthopedic shoes/appliances: No	Radiobutton	Check this box if the right foot’s marked inward displacement and severe spasm is not improved by orthopedic shoes or appliances. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right foot improved by orthopedic shoes/appliances: N/A	Radiobutton	Check this box if improvement by orthopedic shoes or appliances is not applicable for the right foot (e.g., condition not present or not evaluated). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left foot improved by orthopedic shoes/appliances: Yes	Radiobutton	Check this box if the left foot’s marked inward displacement and severe spasm is improved by orthopedic shoes or appliances. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left foot improved by orthopedic shoes/appliances: No	Radiobutton	Check this box if the left foot’s marked inward displacement and severe spasm is not improved by orthopedic shoes or appliances. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left foot improved by orthopedic shoes/appliances: N/A	Radiobutton	Check this box if improvement by orthopedic shoes or appliances is not applicable for the left foot (e.g., condition not present or not evaluated). Fill only if 'Yes' is 'Yes'. Depends on: Yes
3N Comments
Comments (3N)	Text	Enter any additional comments or explanations related to the Veteran's condition and the responses provided in items 3L and 3M. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
4A Non-surgical Treatment for Plantar Fasciitis (Yes/No and Side)
Non-surgical treatment for plantar fasciitis: Yes	Radiobutton	Check this box if the Veteran has undergone any non-surgical treatment for plantar fasciitis. Fill only if 'Plantar fasciitis' is 'Yes'. Depends on: Plantar fasciitis (diagnosis)
Non-surgical treatment for plantar fasciitis: No	Radiobutton	Check this box if the Veteran has not undergone any non-surgical treatment for plantar fasciitis. Fill only if 'Plantar fasciitis' is 'Yes'. Depends on: Plantar fasciitis (diagnosis)
Side treated: Right	Radiobutton	Check this box if the non-surgical treatment was for the right foot. Fill only if 'Non-surgical treatment for plantar fasciitis: Yes' is 'Yes'. Depends on: Non-surgical treatment for plantar fasciitis: Yes
Side treated: Left	Radiobutton	Check this box if the non-surgical treatment was for the left foot. Fill only if 'Non-surgical treatment for plantar fasciitis: Yes' is 'Yes'. Depends on: Non-surgical treatment for plantar fasciitis: Yes
Side treated: Both	Radiobutton	Check this box if the non-surgical treatment was for both feet. Fill only if 'Non-surgical treatment for plantar fasciitis: Yes' is 'Yes'. Depends on: Non-surgical treatment for plantar fasciitis: Yes
4B Non-surgical Treatment Relieved Symptoms (Yes/No and Side Not Relieved)
Relieved symptoms — Yes	Radiobutton	Check this box if the Veteran’s non-surgical treatment for plantar fasciitis relieved the symptoms. Fill only if 'Non-surgical treatment for plantar fasciitis: Yes' is 'Yes'. Depends on: Non-surgical treatment for plantar fasciitis: Yes
Relieved symptoms — No	Radiobutton	Check this box if the Veteran’s non-surgical treatment for plantar fasciitis did not relieve the symptoms. Fill only if 'Non-surgical treatment for plantar fasciitis: Yes' is 'Yes'. Depends on: Non-surgical treatment for plantar fasciitis: Yes
Side not relieved — Right	Radiobutton	If symptoms were not relieved, check this box to indicate the right side was not relieved. Fill only if 'Relieved symptoms — No' is 'Yes'. Depends on: Relieved symptoms — No
Side not relieved — Left	Radiobutton	If symptoms were not relieved, check this box to indicate the left side was not relieved. Fill only if 'Relieved symptoms — No' is 'Yes'. Depends on: Relieved symptoms — No
Side not relieved — Both	Radiobutton	If symptoms were not relieved, check this box to indicate both sides were not relieved. Fill only if 'Relieved symptoms — No' is 'Yes'. Depends on: Relieved symptoms — No
4C Surgical Treatment for Plantar Fasciitis (Yes/No and Side)
Surgical treatment for plantar fasciitis: Yes	Radiobutton	Check this box if the Veteran has undergone surgical treatment for plantar fasciitis. Fill only if 'Plantar fasciitis' is 'Yes'. Depends on: Plantar fasciitis (diagnosis)
Surgical treatment for plantar fasciitis: No	Radiobutton	Check this box if the Veteran has not undergone surgical treatment for plantar fasciitis. Fill only if 'Plantar fasciitis' is 'Yes'. Depends on: Plantar fasciitis (diagnosis)
Side (if yes): Right	Radiobutton	If surgical treatment was performed, check this box if it was done on the right foot only. Fill only if 'Surgical treatment for plantar fasciitis: Yes' is 'Yes'. Depends on: Surgical treatment for plantar fasciitis: Yes
Side (if yes): Left	Radiobutton	If surgical treatment was performed, check this box if it was done on the left foot only. Fill only if 'Surgical treatment for plantar fasciitis: Yes' is 'Yes'. Depends on: Surgical treatment for plantar fasciitis: Yes
Side (if yes): Both	Radiobutton	If surgical treatment was performed, check this box if it was done on both feet. Fill only if 'Surgical treatment for plantar fasciitis: Yes' is 'Yes'. Depends on: Surgical treatment for plantar fasciitis: Yes
4D Surgical Treatment Relieved Symptoms (Yes/No and Side Not Relieved)
Surgical treatment relieved symptoms — Yes	Radiobutton	Check this box if the Veteran’s surgical treatment for plantar fasciitis relieved the symptoms. Fill only if 'Surgical treatment for plantar fasciitis: Yes' is 'Yes'. Depends on: Surgical treatment for plantar fasciitis: Yes
Surgical treatment relieved symptoms — No	Radiobutton	Check this box if the Veteran’s surgical treatment for plantar fasciitis did not relieve the symptoms. Fill only if 'Surgical treatment for plantar fasciitis: Yes' is 'Yes'. Depends on: Surgical treatment for plantar fasciitis: Yes
Side not relieved — Right	Radiobutton	If surgical treatment did not relieve symptoms, check this box to indicate the right foot was not relieved. Fill only if 'Surgical treatment relieved symptoms — No' is 'Yes'. Depends on: Surgical treatment relieved symptoms — No
Side not relieved — Left	Radiobutton	If surgical treatment did not relieve symptoms, check this box to indicate the left foot was not relieved. Fill only if 'Surgical treatment relieved symptoms — No' is 'Yes'. Depends on: Surgical treatment relieved symptoms — No
Side not relieved — Both	Radiobutton	If surgical treatment did not relieve symptoms, check this box to indicate both feet were not relieved. Fill only if 'Surgical treatment relieved symptoms — No' is 'Yes'. Depends on: Surgical treatment relieved symptoms — No
4E Recommended for Surgery but Not a Candidate (Yes/No and Side)
Yes	Radiobutton	Check this box if the Veteran was recommended for surgical intervention but was not a surgical candidate (and has not undergone surgical treatment). Fill only if 'Surgical treatment for plantar fasciitis: No' is 'Yes'. Depends on: Surgical treatment for plantar fasciitis: No
No	Radiobutton	Check this box if the Veteran was not recommended for surgical intervention as described (or was a surgical candidate). Fill only if 'Surgical treatment for plantar fasciitis: No' is 'Yes'. Depends on: Surgical treatment for plantar fasciitis: No
Right	Radiobutton	Check this box to indicate the right foot is the affected side, if you answered Yes to being recommended for surgery but not a candidate. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left	Radiobutton	Check this box to indicate the left foot is the affected side, if you answered Yes to being recommended for surgery but not a candidate. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Both	Radiobutton	Check this box to indicate both feet are affected, if you answered Yes to being recommended for surgery but not a candidate. Fill only if 'Yes' is 'Yes'. Depends on: Yes
4F Functional Loss Due to Plantar Fasciitis (Yes/No, Side Affected, Description)
Yes	Radiobutton	Check this box if the Veteran has any functional loss of the foot/feet due to plantar fasciitis. Fill only if 'Plantar fasciitis' is 'Yes'. Depends on: Plantar fasciitis (diagnosis)
No	Radiobutton	Check this box if the Veteran does not have any functional loss of the foot/feet due to plantar fasciitis. Fill only if 'Plantar fasciitis' is 'Yes'. Depends on: Plantar fasciitis (diagnosis)
Right	Radiobutton	If functional loss is present, check this box if the right foot is affected. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left	Radiobutton	If functional loss is present, check this box if the left foot is affected. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Both	Radiobutton	If functional loss is present, check this box if both feet are affected. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Functional Loss Description	Text	Describe the Veteran’s functional loss of the foot/feet that is due to plantar fasciitis (e.g., limitations in standing, walking, weight-bearing, and impact on daily activities). Fill only if 'Yes' is 'Yes'. Depends on: Yes
4G Comments
Additional Comments	Text	Enter any additional comments or relevant notes regarding the Veteran's condition and findings for this section. Fill only if 'Plantar fasciitis' is 'Yes'. Depends on: Plantar fasciitis (diagnosis)
9A Toes effect - All toes hammer toes (side)
All toes hammer toes	Checkbox	Check this box if, due to pes cavus, all toes have a hammer-toe deformity. Fill only if 'Acquired pes cavus (claw foot)' is 'Yes'. Depends on: Acquired pes cavus (claw foot)
All toes hammer toes – Right	Radiobutton	Check this box if the all-toes hammer-toe effect applies to the right foot. Fill only if 'All toes hammer toes' is 'Yes'. Depends on: All toes hammer toes
All toes hammer toes – Left	Radiobutton	Check this box if the all-toes hammer-toe effect applies to the left foot. Fill only if 'All toes hammer toes' is 'Yes'. Depends on: All toes hammer toes
All toes hammer toes – Both	Radiobutton	Check this box if the all-toes hammer-toe effect applies to both feet. Fill only if 'All toes hammer toes' is 'Yes'. Depends on: All toes hammer toes
9A Toes effect - All toes tending to dorsiflexion (side)
All toes tending to dorsiflexion	Checkbox	Check this box if the patient’s pes cavus causes all toes to tend toward dorsiflexion. Fill only if 'Acquired pes cavus (claw foot)' is 'Yes'. Depends on: Acquired pes cavus (claw foot)
All toes tending to dorsiflexion — Right	Radiobutton	Check this box if all toes tending to dorsiflexion applies to the right foot only. Fill only if 'All toes tending to dorsiflexion' is 'Yes'. Depends on: All toes tending to dorsiflexion
All toes tending to dorsiflexion — Left	Radiobutton	Check this box if all toes tending to dorsiflexion applies to the left foot only. Fill only if 'All toes tending to dorsiflexion' is 'Yes'. Depends on: All toes tending to dorsiflexion
All toes tending to dorsiflexion — Both	Radiobutton	Check this box if all toes tending to dorsiflexion applies to both feet. Fill only if 'All toes tending to dorsiflexion' is 'Yes'. Depends on: All toes tending to dorsiflexion
9A Toes effect - Great toe dorsiflexed (side)
Great toe dorsiflexed	Checkbox	Check this box if the great toe is dorsiflexed as an effect of pes cavus. Fill only if 'Acquired pes cavus (claw foot)' is 'Yes'. Depends on: Acquired pes cavus (claw foot)
Great toe dorsiflexed - Right	Radiobutton	Check this box if the great toe dorsiflexion applies to the right foot. Fill only if 'Great toe dorsiflexed' is 'Yes'. Depends on: Great toe dorsiflexed
Great toe dorsiflexed - Left	Radiobutton	Check this box if the great toe dorsiflexion applies to the left foot. Fill only if 'Great toe dorsiflexed' is 'Yes'. Depends on: Great toe dorsiflexed
Great toe dorsiflexed - Both	Radiobutton	Check this box if the great toe dorsiflexion applies to both feet. Fill only if 'Great toe dorsiflexed' is 'Yes'. Depends on: Great toe dorsiflexed
9A Toes effect - None (side)
None	Checkbox	Check this box if pes cavus has no effect on the toes. Fill only if 'Acquired pes cavus (claw foot)' is 'Yes'. Depends on: Acquired pes cavus (claw foot)
Right	Radiobutton	Check this box if the selected toe effect (None) applies to the right foot only. Fill only if 'None' is 'Yes'. Depends on: None
Left	Radiobutton	Check this box if the selected toe effect (None) applies to the left foot only. Fill only if 'None' is 'Yes'. Depends on: None
Both	Radiobutton	Check this box if the selected toe effect (None) applies to both feet. Fill only if 'None' is 'Yes'. Depends on: None
9A Toes effect - Other description
Other (describe)	Checkbox	Check this box if there is another effect on the toes due to an etiology other than pes cavus and you will describe it in the space provided. Fill only if 'Acquired pes cavus (claw foot)' is 'Yes'. Depends on: Acquired pes cavus (claw foot)
Other toe effects description	Text	Describe any other effects on the toes and, if applicable, the etiology when the toe effects are due to a cause other than pes cavus. Fill only if 'Other (describe)' is 'Yes'. Depends on: Other (describe)
9B Pain/tenderness - Definite tenderness under metatarsal heads (side)
Definite tenderness under metatarsal heads	Checkbox	Check this box if there is definite pain/tenderness under the metatarsal heads due to pes cavus. Fill only if 'Acquired pes cavus (claw foot)' is 'Yes'. Depends on: Acquired pes cavus (claw foot)
Right	Radiobutton	Select this option if the definite tenderness under the metatarsal heads is on the right foot. Fill only if 'Definite tenderness under metatarsal heads' is 'Yes'. Depends on: Definite tenderness under metatarsal heads
Left	Radiobutton	Select this option if the definite tenderness under the metatarsal heads is on the left foot. Fill only if 'Definite tenderness under metatarsal heads' is 'Yes'. Depends on: Definite tenderness under metatarsal heads
Both	Radiobutton	Select this option if the definite tenderness under the metatarsal heads is present in both feet. Fill only if 'Definite tenderness under metatarsal heads' is 'Yes'. Depends on: Definite tenderness under metatarsal heads
9B Pain/tenderness - Marked tenderness under metatarsal heads (side)
Marked tenderness under metatarsal heads	Checkbox	Check this box if the patient has marked (severe) tenderness under the metatarsal heads due to pes cavus. Fill only if 'Acquired pes cavus (claw foot)' is 'Yes'. Depends on: Acquired pes cavus (claw foot)
Marked tenderness under metatarsal heads - Right	Radiobutton	Select this option if the marked tenderness under the metatarsal heads is present on the right foot. Fill only if 'Marked tenderness under metatarsal heads' is 'Yes'. Depends on: Marked tenderness under metatarsal heads
Marked tenderness under metatarsal heads - Left	Radiobutton	Select this option if the marked tenderness under the metatarsal heads is present on the left foot. Fill only if 'Marked tenderness under metatarsal heads' is 'Yes'. Depends on: Marked tenderness under metatarsal heads
Marked tenderness under metatarsal heads - Both	Radiobutton	Select this option if the marked tenderness under the metatarsal heads is present on both feet. Fill only if 'Marked tenderness under metatarsal heads' is 'Yes'. Depends on: Marked tenderness under metatarsal heads
9B Pain/tenderness - None (side)
None	Checkbox	Check this box if there is no pain or tenderness due to pes cavus. Fill only if 'Acquired pes cavus (claw foot)' is 'Yes'. Depends on: Acquired pes cavus (claw foot)
Right	Radiobutton	Check this box if the “None” finding applies to the right foot. Fill only if 'None' is 'Yes'. Depends on: None
Left	Radiobutton	Check this box if the “None” finding applies to the left foot. Fill only if 'None' is 'Yes'. Depends on: None
Both	Radiobutton	Check this box if the “None” finding applies to both feet. Fill only if 'None' is 'Yes'. Depends on: None
9B Pain/tenderness - Other description
Other (describe)	Checkbox	Check this box if the Veteran’s pain and tenderness are due to an etiology other than pes cavus, and provide the other etiology in the description area. Fill only if 'Acquired pes cavus (claw foot)' is 'Yes'. Depends on: Acquired pes cavus (claw foot)
Other Pain/Tenderness Description	Text	Describe the Veteran’s pain and tenderness when it is due to an etiology other than pes cavus, including the other etiology and relevant details. Fill only if 'Other (describe)' is 'Yes'. Depends on: Other (describe)
9B Pain/tenderness - Very painful callosities (side)
Very painful callosities	Checkbox	Check this box if the Veteran has very painful callosities due to pes cavus. Fill only if 'Acquired pes cavus (claw foot)' is 'Yes'. Depends on: Acquired pes cavus (claw foot)
Very painful callosities - Right	Radiobutton	Select this option if the very painful callosities are on the right foot. Fill only if 'Very painful callosities' is 'Yes'. Depends on: Very painful callosities
Very painful callosities - Left	Radiobutton	Select this option if the very painful callosities are on the left foot. Fill only if 'Very painful callosities' is 'Yes'. Depends on: Very painful callosities
Very painful callosities - Both	Radiobutton	Select this option if the very painful callosities are on both feet. Fill only if 'Very painful callosities' is 'Yes'. Depends on: Very painful callosities
9C Plantar fascia effect - Marked contraction with dropped forefoot (side)
Marked contraction of plantar fascia with dropped forefoot	Checkbox	Check this box if pes cavus causes a marked contraction of the plantar fascia with a dropped forefoot. Fill only if 'Acquired pes cavus (claw foot)' is 'Yes'. Depends on: Acquired pes cavus (claw foot)
Marked contraction with dropped forefoot — Right	Radiobutton	Check this box if the marked contraction of plantar fascia with dropped forefoot affects the right foot. Fill only if 'Marked contraction of plantar fascia with dropped forefoot' is 'Yes'. Depends on: Marked contraction of plantar fascia with dropped forefoot
Marked contraction with dropped forefoot — Left	Radiobutton	Check this box if the marked contraction of plantar fascia with dropped forefoot affects the left foot. Fill only if 'Marked contraction of plantar fascia with dropped forefoot' is 'Yes'. Depends on: Marked contraction of plantar fascia with dropped forefoot
Marked contraction with dropped forefoot — Both	Radiobutton	Check this box if the marked contraction of plantar fascia with dropped forefoot affects both feet. Fill only if 'Marked contraction of plantar fascia with dropped forefoot' is 'Yes'. Depends on: Marked contraction of plantar fascia with dropped forefoot
9C Plantar fascia effect - None (side)
None (no plantar fascia effect)	Checkbox	Check this box if there is no effect on the plantar fascia due to pes cavus. Fill only if 'Acquired pes cavus (claw foot)' is 'Yes'. Depends on: Acquired pes cavus (claw foot)
Side: Right	Radiobutton	Check this box if the selected plantar fascia finding (e.g., none) applies to the right foot. Fill only if 'None (no plantar fascia effect)' is 'Yes'. Depends on: None (no plantar fascia effect)
Side: Left	Radiobutton	Check this box if the selected plantar fascia finding (e.g., none) applies to the left foot. Fill only if 'None (no plantar fascia effect)' is 'Yes'. Depends on: None (no plantar fascia effect)
Side: Both	Radiobutton	Check this box if the selected plantar fascia finding (e.g., none) applies to both feet. Fill only if 'None (no plantar fascia effect)' is 'Yes'. Depends on: None (no plantar fascia effect)
9C Plantar fascia effect - Other description
Other (describe)	Checkbox	Check this box if there is another effect on the plantar fascia due to an etiology other than pes cavus, and provide the description in the space provided. Fill only if 'Acquired pes cavus (claw foot)' is 'Yes'. Depends on: Acquired pes cavus (claw foot)
Other Plantar Fascia Effect Description	Text	Describe any other effect on the plantar fascia due to an etiology other than pes cavus, including the alternative cause. Fill only if 'Other (describe)' is 'Yes'. Depends on: Other (describe)
9C Plantar fascia effect - Shortened plantar fascia (side)
Shortened plantar fascia	Checkbox	Check this box if the Veteran has a shortened plantar fascia as an effect of pes cavus. Fill only if 'Acquired pes cavus (claw foot)' is 'Yes'. Depends on: Acquired pes cavus (claw foot)
Shortened plantar fascia - Right	Radiobutton	Check this box if the shortened plantar fascia affects the right foot. Fill only if 'Shortened plantar fascia' is 'Yes'. Depends on: Shortened plantar fascia
Shortened plantar fascia - Left	Radiobutton	Check this box if the shortened plantar fascia affects the left foot. Fill only if 'Shortened plantar fascia' is 'Yes'. Depends on: Shortened plantar fascia
Shortened plantar fascia - Both	Radiobutton	Check this box if the shortened plantar fascia affects both feet. Fill only if 'Shortened plantar fascia' is 'Yes'. Depends on: Shortened plantar fascia
9D Dorsiflexion/varus deformity - Limitation to right angle (side)
Limitation of dorsiflexion at ankle to right angle	Checkbox	Check this box if the Veteran has dorsiflexion limited at the ankle to a right angle. Fill only if 'Acquired pes cavus (claw foot)' is 'Yes'. Depends on: Acquired pes cavus (claw foot)
Right	Radiobutton	Check this box if the limitation to a right angle applies to the right side. Fill only if 'Limitation of dorsiflexion at ankle to right angle' is 'Yes'. Depends on: Limitation of dorsiflexion at ankle to right angle
Left	Radiobutton	Check this box if the limitation to a right angle applies to the left side. Fill only if 'Limitation of dorsiflexion at ankle to right angle' is 'Yes'. Depends on: Limitation of dorsiflexion at ankle to right angle
Both	Radiobutton	Check this box if the limitation to a right angle applies to both sides. Fill only if 'Limitation of dorsiflexion at ankle to right angle' is 'Yes'. Depends on: Limitation of dorsiflexion at ankle to right angle
9D Dorsiflexion/varus deformity - Marked varus deformity (side)
Marked varus deformity	Checkbox	Check this box if the Veteran has a marked varus deformity associated with dorsiflexion/varus deformity findings. Fill only if 'Acquired pes cavus (claw foot)' is 'Yes'. Depends on: Acquired pes cavus (claw foot)
Right	Radiobutton	Check this box if the marked varus deformity applies to the right foot/ankle only. Fill only if 'Marked varus deformity' is 'Yes'. Depends on: Marked varus deformity
Left	Radiobutton	Check this box if the marked varus deformity applies to the left foot/ankle only. Fill only if 'Marked varus deformity' is 'Yes'. Depends on: Marked varus deformity
Both	Radiobutton	Check this box if the marked varus deformity applies to both the right and left feet/ankles. Fill only if 'Marked varus deformity' is 'Yes'. Depends on: Marked varus deformity
9D Dorsiflexion/varus deformity - None (side)
None	Checkbox	Check this box if there is no dorsiflexion and varus deformity due to pes cavus. Fill only if 'Acquired pes cavus (claw foot)' is 'Yes'. Depends on: Acquired pes cavus (claw foot)
Right	Radiobutton	Select this option if the “None” finding applies to the right foot. Fill only if 'None' is 'Yes'. Depends on: None
Left	Radiobutton	Select this option if the “None” finding applies to the left foot. Fill only if 'None' is 'Yes'. Depends on: None
Both	Radiobutton	Select this option if the “None” finding applies to both feet. Fill only if 'None' is 'Yes'. Depends on: None
9D Dorsiflexion/varus deformity - Other description
Other, describe	Checkbox	Check this box if the Veteran has dorsiflexion limitation and varus deformity due to an etiology other than pes cavus, and provide the other etiology in the space provided. Fill only if 'Acquired pes cavus (claw foot)' is 'Yes'. Depends on: Acquired pes cavus (claw foot)
Other Etiology Description	Text	Describe the other etiology causing the Veteran's dorsiflexion limitation and varus deformity (if not due to pes cavus). Fill only if 'Other, describe' is 'Yes'. Depends on: Other, describe
9D Dorsiflexion/varus deformity - Some limitation of dorsiflexion at ankle (side)
Some limitation of dorsiflexion at ankle	Checkbox	Check this box if the Veteran has some limitation of dorsiflexion at the ankle due to pes cavus. Fill only if 'Acquired pes cavus (claw foot)' is 'Yes'. Depends on: Acquired pes cavus (claw foot)
Right	Radiobutton	Check this box if the some limitation of dorsiflexion at the ankle applies to the right side. Fill only if 'Some limitation of dorsiflexion at ankle' is 'Yes'. Depends on: Some limitation of dorsiflexion at ankle
Left	Radiobutton	Check this box if the some limitation of dorsiflexion at the ankle applies to the left side. Fill only if 'Some limitation of dorsiflexion at ankle' is 'Yes'. Depends on: Some limitation of dorsiflexion at ankle
Both	Radiobutton	Check this box if the some limitation of dorsiflexion at the ankle applies to both sides. Fill only if 'Some limitation of dorsiflexion at ankle' is 'Yes'. Depends on: Some limitation of dorsiflexion at ankle
9E Comments
Additional comments	Text	Enter any additional comments or notes relevant to section 9E. Fill only if 'Acquired pes cavus (claw foot)' is 'Yes'. Depends on: Acquired pes cavus (claw foot)
Additional Foot Injuries/Conditions (11A)
Yes	Radiobutton	Check this box if the Veteran has any foot injuries or other foot conditions not already described elsewhere in the form. Fill only if 'Section 1B – Foot injury(ies), specify' is 'Yes'. Depends on: Foot injury(ies) (specify)
No	Radiobutton	Check this box if the Veteran does not have any additional foot injuries or other foot conditions not already described elsewhere in the form. Fill only if 'Section 1B – Foot injury(ies), specify' is 'Yes'. Depends on: Foot injury(ies) (specify)
Additional Foot Injury/Condition Description	Text	Describe any additional foot injuries or other foot conditions not already described, including frequency of symptoms and physical exam findings. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Additional Foot-Condition Diagnoses (Section 1C)
Additional Foot-Condition Diagnoses	Text	Enter any additional diagnoses related to the Veteran’s foot condition, listing each diagnosis and relevant details as indicated by the form’s above format.
Arthritic Conditions Diagnosis Options (Section 1B)
Arthritic conditions	Checkbox	Check this box if the Veteran has an arthritic condition diagnosis associated with the claimed condition(s), and then select the specific arthritis diagnosis option(s) listed under this section.
Assistive Device Details by Condition (16B)
Assistive Devices by Condition (16B)	Text	List each medical condition, the affected side (e.g., left/right/bilateral), and the assistive device used for that condition. Fill only if 'Yes', 'Wheelchair', 'Brace', 'Crutches', 'Cane (Assistive device used)', 'Walker', 'Other (assistive device)' is 'Yes' and any of fields 3, 7, 11, 15, 19, 23 is 'Yes'. Depends on: Yes, Wheelchair, Brace, Crutches, Cane (Assistive device used), Walker, Other (assistive device)
Assistive Devices Used (Yes/No)
Yes	Radiobutton	Check this box if the Veteran uses any assistive devices as a normal mode of locomotion.
No	Radiobutton	Check this box if the Veteran does not use any assistive devices as a normal mode of locomotion.
Atrophy of Disuse (14A)
Atrophy of disuse	Checkbox	Check this box if the veteran has atrophy due to disuse as a contributing factor of disability/functional loss for the claimed condition. Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
Atrophy of disuse — Right	Radiobutton	Check this box if the atrophy of disuse affects the right lower extremity. Fill only if 'Atrophy of disuse' is 'Yes'. Depends on: Atrophy of disuse
Atrophy of disuse — Left	Radiobutton	Check this box if the atrophy of disuse affects the left lower extremity. Fill only if 'Atrophy of disuse' is 'Yes'. Depends on: Atrophy of disuse
Atrophy of disuse — Both	Radiobutton	Check this box if the atrophy of disuse affects both lower extremities. Fill only if 'Atrophy of disuse' is 'Yes'. Depends on: Atrophy of disuse
Brace Use and Frequency
Brace	Checkbox	Check this box if the Veteran uses a brace as an assistive device for locomotion. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Brace frequency of use: Occasional	Radiobutton	Check this box if the Veteran uses the brace occasionally. Fill only if 'Brace' is 'Yes'. Depends on: Brace
Brace frequency of use: Regular	Radiobutton	Check this box if the Veteran uses the brace on a regular basis. Fill only if 'Brace' is 'Yes'. Depends on: Brace
Brace frequency of use: Constant	Radiobutton	Check this box if the Veteran uses the brace constantly. Fill only if 'Brace' is 'Yes'. Depends on: Brace
Cane Use and Frequency
Cane (Assistive device used)	Checkbox	Check this box if the Veteran uses a cane as an assistive device for locomotion. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Cane frequency: Occasional	Radiobutton	Check this box if the Veteran uses a cane occasionally. Fill only if 'Cane (Assistive device used)' is 'Yes'. Depends on: Cane (Assistive device used)
Cane frequency: Regular	Radiobutton	Check this box if the Veteran uses a cane on a regular basis. Fill only if 'Cane (Assistive device used)' is 'Yes'. Depends on: Cane (Assistive device used)
Cane frequency: Constant	Radiobutton	Check this box if the Veteran uses a cane constantly. Fill only if 'Cane (Assistive device used)' is 'Yes'. Depends on: Cane (Assistive device used)
Chronically Compromises Weight-Bearing (11C)
Yes	Radiobutton	Check this box if the foot condition chronically compromises weight-bearing. Fill only if 'Section 1B – Foot injury(ies), specify' is 'Yes'. Depends on: Foot injury(ies) (specify)
No	Radiobutton	Check this box if the foot condition does not chronically compromise weight-bearing. Fill only if 'Section 1B – Foot injury(ies), specify' is 'Yes'. Depends on: Foot injury(ies) (specify)
Claimed Condition(s) (Section 1A)
Claimed foot condition(s)	Text	List all claimed condition(s) that pertain to this foot conditions (including flatfoot/pes planus) questionnaire.
Comments (11E)
Comments (11E)	Text	Enter any additional comments or explanatory details related to the foot condition. Fill only if 'Section 1B – Foot injury(ies), specify' is 'Yes'. Depends on: Foot injury(ies) (specify)
Crutches Use and Frequency
Crutches	Checkbox	Check this box if the Veteran uses crutches as an assistive device for locomotion. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Crutches - Occasional	Radiobutton	Check this box if the Veteran uses crutches occasionally. Fill only if 'Crutches' is 'Yes'. Depends on: Crutches
Crutches - Regular	Radiobutton	Check this box if the Veteran uses crutches on a regular basis. Fill only if 'Crutches' is 'Yes'. Depends on: Crutches
Crutches - Constant	Radiobutton	Check this box if the Veteran uses crutches constantly. Fill only if 'Crutches' is 'Yes'. Depends on: Crutches
Deformity (14A)
Deformity	Checkbox	Check this box if deformity is a contributing factor to the Veteran’s functional loss/impairment for the claimed condition. Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
Deformity - Right	Radiobutton	Check this box if the deformity affects the right lower extremity. Fill only if 'Deformity' is 'Yes'. Depends on: Deformity
Deformity - Left	Radiobutton	Check this box if the deformity affects the left lower extremity. Fill only if 'Deformity' is 'Yes'. Depends on: Deformity
Deformity - Both	Radiobutton	Check this box if the deformity affects both lower extremities. Fill only if 'Deformity' is 'Yes'. Depends on: Deformity
Diagnosis: Acquired pes cavus (claw foot)
Acquired pes cavus (claw foot)	Checkbox	Check this box if the Veteran has a current diagnosis of acquired pes cavus (claw foot) associated with the claimed condition(s). Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Side affected: Right	Radiobutton	Check this box if the acquired pes cavus (claw foot) diagnosis affects the right foot only. Fill only if 'Acquired pes cavus (claw foot)' is 'Yes'. Depends on: Acquired pes cavus (claw foot)
Side affected: Left	Radiobutton	Check this box if the acquired pes cavus (claw foot) diagnosis affects the left foot only. Fill only if 'Acquired pes cavus (claw foot)' is 'Yes'. Depends on: Acquired pes cavus (claw foot)
Side affected: Both	Radiobutton	Check this box if the acquired pes cavus (claw foot) diagnosis affects both feet. Fill only if 'Acquired pes cavus (claw foot)' is 'Yes'. Depends on: Acquired pes cavus (claw foot)
ICD Code (Acquired pes cavus)	Text	Enter the ICD diagnosis code for acquired pes cavus (claw foot). Fill only if 'Acquired pes cavus (claw foot)' is 'Yes'. Depends on: Acquired pes cavus (claw foot)
Date of Diagnosis – Right (Acquired pes cavus)	Date	Enter the date the right foot was diagnosed with acquired pes cavus (claw foot). Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Right, Side affected: Both
Date of Diagnosis – Left (Acquired pes cavus)	Date	Enter the date the left foot was diagnosed with acquired pes cavus (claw foot). Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Left, Side affected: Both
Diagnosis: Arthritis, degenerative (other than post-traumatic)
Arthritis, degenerative (other than post-traumatic)	Checkbox	Check this box if the veteran has a current diagnosis of degenerative arthritis that is not due to a post-traumatic cause. Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Side affected: Right	Radiobutton	Check this box if the degenerative (non–post-traumatic) arthritis affects the right side only. Fill only if 'Arthritis, degenerative (other than post-traumatic)' is 'Yes'. Depends on: Arthritis, degenerative (other than post-traumatic)
Side affected: Left	Radiobutton	Check this box if the degenerative (non–post-traumatic) arthritis affects the left side only. Fill only if 'Arthritis, degenerative (other than post-traumatic)' is 'Yes'. Depends on: Arthritis, degenerative (other than post-traumatic)
Side affected: Both	Radiobutton	Check this box if the degenerative (non–post-traumatic) arthritis affects both the right and left sides. Fill only if 'Arthritis, degenerative (other than post-traumatic)' is 'Yes'. Depends on: Arthritis, degenerative (other than post-traumatic)
ICD Code (Degenerative Arthritis, Non-Post-Traumatic)	Text	Enter the ICD diagnostic code for arthritis, degenerative (other than post-traumatic). Fill only if 'Arthritis, degenerative (other than post-traumatic)' is 'Yes'. Depends on: Arthritis, degenerative (other than post-traumatic)
Date of Diagnosis - Right (Degenerative Arthritis, Non-Post-Traumatic)	Date	Enter the date this condition was diagnosed for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Right, Side affected: Both
Date of Diagnosis - Left (Degenerative Arthritis, Non-Post-Traumatic)	Date	Enter the date this condition was diagnosed for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Left, Side affected: Both
Diagnosis: Arthritis, gonorrheal
Arthritis, gonorrheal	Checkbox	Check this box if the Veteran has a current diagnosis of gonorrheal arthritis associated with the claimed condition(s). Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Side affected: Right	Radiobutton	Select this option if the gonorrheal arthritis affects the right side only. Fill only if 'Arthritis, gonorrheal' is 'Yes'. Depends on: Arthritis, gonorrheal
Side affected: Left	Radiobutton	Select this option if the gonorrheal arthritis affects the left side only. Fill only if 'Arthritis, gonorrheal' is 'Yes'. Depends on: Arthritis, gonorrheal
Side affected: Both	Radiobutton	Select this option if the gonorrheal arthritis affects both the right and left sides. Fill only if 'Arthritis, gonorrheal' is 'Yes'. Depends on: Arthritis, gonorrheal
ICD Code (Arthritis, gonorrheal)	Text	Enter the ICD diagnosis code for gonorrheal arthritis. Fill only if 'Arthritis, gonorrheal' is 'Yes'. Depends on: Arthritis, gonorrheal
Date of Diagnosis – Right (Arthritis, gonorrheal)	Date	Enter the date gonorrheal arthritis was diagnosed for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Right, Side affected: Both
Date of Diagnosis – Left (Arthritis, gonorrheal)	Date	Enter the date gonorrheal arthritis was diagnosed for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Left, Side affected: Both
Diagnosis: Arthritis, multi-joint (active process; excluding post-traumatic and gout)
Arthritis, multi-joint (active process; excluding post-traumatic and gout)	Checkbox	Check this box if the veteran has an active multi-joint arthritis diagnosis that is not post-traumatic and not gout. Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Side affected: Right	Radiobutton	Select this option if the arthritis affects the right side only. Fill only if 'Arthritis, multi-joint (active process; excluding post-traumatic and gout)' is 'Yes'. Depends on: Arthritis, multi-joint (active process; excluding post-traumatic and gout)
Side affected: Left	Radiobutton	Select this option if the arthritis affects the left side only. Fill only if 'Arthritis, multi-joint (active process; excluding post-traumatic and gout)' is 'Yes'. Depends on: Arthritis, multi-joint (active process; excluding post-traumatic and gout)
Side affected: Both	Radiobutton	Select this option if the arthritis affects both the right and left sides. Fill only if 'Arthritis, multi-joint (active process; excluding post-traumatic and gout)' is 'Yes'. Depends on: Arthritis, multi-joint (active process; excluding post-traumatic and gout)
ICD Code (Arthritis, multi-joint active process)	Text	Enter the ICD diagnostic code for arthritis affecting multiple joints as an active process (excluding post-traumatic and gout). Fill only if 'Arthritis, multi-joint (active process; excluding post-traumatic and gout)' is 'Yes'. Depends on: Arthritis, multi-joint (active process; excluding post-traumatic and gout)
Date of Diagnosis (Right)	Date	Provide the date this multi-joint arthritis active process diagnosis was made for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Right, Side affected: Both
Date of Diagnosis (Left)	Date	Provide the date this multi-joint arthritis active process diagnosis was made for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Left, Side affected: Both
Diagnosis: Arthritis, other specified forms of arthropathy (excluding gout) (with specification)
Arthritis, other specified forms of arthropathy (excluding gout)	Checkbox	Check this box if the Veteran has a current diagnosis of an arthritis/arthropathy condition that is specified as “other” and is not gout. Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Arthropathy specification	Text	Specify the other form of arthropathy/arthritis diagnosed (excluding gout). Fill only if 'Arthritis, other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Arthritis, other specified forms of arthropathy (excluding gout)
Side affected: Right	Radiobutton	Select this option if the arthropathy affects the right side only. Fill only if 'Arthritis, other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Arthritis, other specified forms of arthropathy (excluding gout)
Side affected: Left	Radiobutton	Select this option if the arthropathy affects the left side only. Fill only if 'Arthritis, other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Arthritis, other specified forms of arthropathy (excluding gout)
Side affected: Both	Radiobutton	Select this option if the arthropathy affects both the right and left sides. Fill only if 'Arthritis, other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Arthritis, other specified forms of arthropathy (excluding gout)
ICD code	Text	Enter the ICD code for the specified arthritis/arthropathy diagnosis. Fill only if 'Arthritis, other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Arthritis, other specified forms of arthropathy (excluding gout)
Date of diagnosis (right)	Date	Enter the date this arthritis/arthropathy diagnosis was made for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Right, Side affected: Both
Date of diagnosis (left)	Date	Enter the date this arthritis/arthropathy diagnosis was made for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Left, Side affected: Both
Diagnosis: Arthritis, pneumococcic
Arthritis, pneumococcic	Checkbox	Check this box if the veteran has a diagnosis of pneumococcic arthritis associated with the claimed condition(s). Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Side affected (pneumococcic arthritis): Right	Radiobutton	Select this option if the pneumococcic arthritis affects the right side only. Fill only if 'Arthritis, pneumococcic' is 'Yes'. Depends on: Arthritis, pneumococcic
Side affected (pneumococcic arthritis): Left	Radiobutton	Select this option if the pneumococcic arthritis affects the left side only. Fill only if 'Arthritis, pneumococcic' is 'Yes'. Depends on: Arthritis, pneumococcic
Side affected (pneumococcic arthritis): Both	Radiobutton	Select this option if the pneumococcic arthritis affects both sides. Fill only if 'Arthritis, pneumococcic' is 'Yes'. Depends on: Arthritis, pneumococcic
Arthritis, pneumococcic ICD code	Text	Enter the ICD diagnostic code for the diagnosis of pneumococcic arthritis. Fill only if 'Arthritis, pneumococcic' is 'Yes'. Depends on: Arthritis, pneumococcic
Arthritis, pneumococcic date of diagnosis (right)	Date	Enter the date the pneumococcic arthritis was diagnosed for the right side. Fill only if 'Side affected (pneumococcic arthritis): Right', 'Side affected (pneumococcic arthritis): Both' is 'Yes' (any fields selection). Depends on: Side affected (pneumococcic arthritis): Right, Side affected (pneumococcic arthritis): Both
Arthritis, pneumococcic date of diagnosis (left)	Date	Enter the date the pneumococcic arthritis was diagnosed for the left side. Fill only if 'Side affected (pneumococcic arthritis): Left', 'Side affected (pneumococcic arthritis): Both' is 'Yes' (any fields selection). Depends on: Side affected (pneumococcic arthritis): Left, Side affected (pneumococcic arthritis): Both
Diagnosis: Arthritis, post-traumatic
Arthritis, post-traumatic	Checkbox	Check this box if the Veteran has a diagnosis of post-traumatic arthritis associated with the claimed condition(s). Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Side affected: Right	Radiobutton	Check this box if the post-traumatic arthritis affects the right side. Fill only if 'Arthritis, post-traumatic' is 'Yes'. Depends on: Arthritis, post-traumatic
Side affected: Left	Radiobutton	Check this box if the post-traumatic arthritis affects the left side. Fill only if 'Arthritis, post-traumatic' is 'Yes'. Depends on: Arthritis, post-traumatic
Side affected: Both	Radiobutton	Check this box if the post-traumatic arthritis affects both the right and left sides. Fill only if 'Arthritis, post-traumatic' is 'Yes'. Depends on: Arthritis, post-traumatic
ICD Code (Arthritis, post-traumatic)	Text	Enter the ICD diagnosis code for post-traumatic arthritis. Fill only if 'Arthritis, post-traumatic' is 'Yes'. Depends on: Arthritis, post-traumatic
Date of Diagnosis – Right (Arthritis, post-traumatic)	Date	Provide the date post-traumatic arthritis was diagnosed for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Right, Side affected: Both
Date of Diagnosis – Left (Arthritis, post-traumatic)	Date	Provide the date post-traumatic arthritis was diagnosed for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Left, Side affected: Both
Diagnosis: Arthritis, streptococcic
Arthritis, streptococcic	Checkbox	Check this box if the current diagnosis includes streptococcic arthritis. Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Side affected: Right	Radiobutton	Check this box if the streptococcic arthritis affects the right side/foot only. Fill only if 'Arthritis, streptococcic' is 'Yes'. Depends on: Arthritis, streptococcic
Side affected: Left	Radiobutton	Check this box if the streptococcic arthritis affects the left side/foot only. Fill only if 'Arthritis, streptococcic' is 'Yes'. Depends on: Arthritis, streptococcic
Side affected: Both	Radiobutton	Check this box if the streptococcic arthritis affects both the right and left sides/feet. Fill only if 'Arthritis, streptococcic' is 'Yes'. Depends on: Arthritis, streptococcic
ICD Code (Arthritis, streptococcic)	Text	Enter the ICD diagnostic code for streptococcic arthritis. Fill only if 'Arthritis, streptococcic' is 'Yes'. Depends on: Arthritis, streptococcic
Date of Diagnosis – Right (Arthritis, streptococcic)	Date	Enter the date streptococcic arthritis was diagnosed for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Right, Side affected: Both
Date of Diagnosis – Left (Arthritis, streptococcic)	Date	Enter the date streptococcic arthritis was diagnosed for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Left, Side affected: Both
Diagnosis: Arthritis, syphilitic
Arthritis, syphilitic	Checkbox	Check this box if the veteran has a diagnosis of syphilitic arthritis associated with the claimed condition(s). Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Side affected: Right	Radiobutton	Check this box if the syphilitic arthritis affects the right side/foot only. Fill only if 'Arthritis, syphilitic' is 'Yes'. Depends on: Arthritis, syphilitic
Side affected: Left	Radiobutton	Check this box if the syphilitic arthritis affects the left side/foot only. Fill only if 'Arthritis, syphilitic' is 'Yes'. Depends on: Arthritis, syphilitic
Side affected: Both	Radiobutton	Check this box if the syphilitic arthritis affects both sides/feet. Fill only if 'Arthritis, syphilitic' is 'Yes'. Depends on: Arthritis, syphilitic
ICD Code (Arthritis, syphilitic)	Text	Enter the ICD diagnosis code for syphilitic arthritis. Fill only if 'Arthritis, syphilitic' is 'Yes'. Depends on: Arthritis, syphilitic
Date of Diagnosis – Right (Arthritis, syphilitic)	Date	Enter the date syphilitic arthritis was diagnosed for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Right, Side affected: Both
Date of Diagnosis – Left (Arthritis, syphilitic)	Date	Enter the date syphilitic arthritis was diagnosed for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Left, Side affected: Both
Diagnosis: Arthritis, typhoid
Arthritis, typhoid	Checkbox	Check this box if the veteran has a current diagnosis of typhoid arthritis associated with the claimed condition(s). Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Side affected: Right	Radiobutton	Select this option if the typhoid arthritis affects the right side only. Fill only if 'Arthritis, typhoid' is 'Yes'. Depends on: Arthritis, typhoid
Side affected: Left	Radiobutton	Select this option if the typhoid arthritis affects the left side only. Fill only if 'Arthritis, typhoid' is 'Yes'. Depends on: Arthritis, typhoid
Side affected: Both	Radiobutton	Select this option if the typhoid arthritis affects both the right and left sides. Fill only if 'Arthritis, typhoid' is 'Yes'. Depends on: Arthritis, typhoid
Arthritis, typhoid ICD code	Text	Enter the ICD diagnostic code for the arthritis, typhoid diagnosis. Fill only if 'Arthritis, typhoid' is 'Yes'. Depends on: Arthritis, typhoid
Arthritis, typhoid date of diagnosis (right)	Date	Enter the date the arthritis, typhoid condition was diagnosed for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Right, Side affected: Both
Arthritis, typhoid date of diagnosis (left)	Date	Enter the date the arthritis, typhoid condition was diagnosed for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Left, Side affected: Both
Diagnosis: Bones, neoplasm (benign)
Bones, neoplasm, benign	Checkbox	Check this box if the Veteran has a diagnosis of a benign bone neoplasm related to the claimed condition(s). Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Side affected: Right	Radiobutton	Check this box if the benign bone neoplasm affects the right side only. Fill only if 'Bones, neoplasm, benign' is 'Yes'. Depends on: Bones, neoplasm, benign
Side affected: Left	Radiobutton	Check this box if the benign bone neoplasm affects the left side only. Fill only if 'Bones, neoplasm, benign' is 'Yes'. Depends on: Bones, neoplasm, benign
Side affected: Both	Radiobutton	Check this box if the benign bone neoplasm affects both the right and left sides. Fill only if 'Bones, neoplasm, benign' is 'Yes'. Depends on: Bones, neoplasm, benign
ICD Code (Benign bone neoplasm)	Text	Enter the ICD diagnosis code for the benign bone neoplasm diagnosis. Fill only if 'Bones, neoplasm, benign' is 'Yes'. Depends on: Bones, neoplasm, benign
Date of diagnosis (Right side)	Date	Enter the date the benign bone neoplasm was diagnosed on the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Right, Side affected: Both
Date of diagnosis (Left side)	Date	Enter the date the benign bone neoplasm was diagnosed on the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Left, Side affected: Both
Diagnosis: Bones, neoplasm (malignant; primary or secondary)
Bones, neoplasm, malignant (primary or secondary)	Checkbox	Check this box if the Veteran has a malignant bone neoplasm (primary bone cancer or metastasis to bone) associated with the claimed condition(s). Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Side affected: Right	Radiobutton	Check this box if the malignant bone neoplasm affects the right side only. Fill only if 'Bones, neoplasm, malignant (primary or secondary)' is 'Yes'. Depends on: Bones, neoplasm, malignant (primary or secondary)
Side affected: Left	Radiobutton	Check this box if the malignant bone neoplasm affects the left side only. Fill only if 'Bones, neoplasm, malignant (primary or secondary)' is 'Yes'. Depends on: Bones, neoplasm, malignant (primary or secondary)
Side affected: Both	Radiobutton	Check this box if the malignant bone neoplasm affects both the right and left sides. Fill only if 'Bones, neoplasm, malignant (primary or secondary)' is 'Yes'. Depends on: Bones, neoplasm, malignant (primary or secondary)
ICD Code (Bones Neoplasm Malignant)	Text	Enter the ICD diagnostic code for the malignant bone neoplasm (primary or secondary). Fill only if 'Bones, neoplasm, malignant (primary or secondary)' is 'Yes'. Depends on: Bones, neoplasm, malignant (primary or secondary)
Date of Diagnosis (Right Side)	Date	Enter the date the malignant bone neoplasm was diagnosed on the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Right, Side affected: Both
Date of Diagnosis (Left Side)	Date	Enter the date the malignant bone neoplasm was diagnosed on the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Left, Side affected: Both
Diagnosis: Bursitis
Bursitis	Checkbox	Check this box if the patient is diagnosed with bursitis. Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Bursitis - Right	Radiobutton	Check this box if the bursitis affects the right side. Fill only if 'Bursitis' is 'Yes'. Depends on: Bursitis
Bursitis - Left	Radiobutton	Check this box if the bursitis affects the left side. Fill only if 'Bursitis' is 'Yes'. Depends on: Bursitis
Bursitis - Both	Radiobutton	Check this box if the bursitis affects both sides. Fill only if 'Bursitis' is 'Yes'. Depends on: Bursitis
Bursitis Notes	Text	Enter any additional details needed to describe the bursitis diagnosis (such as the specific bursa or joint involved). Fill only if 'Bursitis' is 'Yes'. Depends on: Bursitis
Right Side Details	Text	Enter the specific right-side body area or joint affected by bursitis. Fill only if 'Bursitis - Right', 'Bursitis - Both' is 'Yes' (any fields selection). Depends on: Bursitis - Right, Bursitis - Both
Left Side Details	Text	Enter the specific left-side body area or joint affected by bursitis. Fill only if 'Bursitis - Left', 'Bursitis - Both' is 'Yes' (any fields selection). Depends on: Bursitis - Left, Bursitis - Both
Diagnosis: Flat foot (pes planus)
Flat foot (pes planus)	Checkbox	Check this box if the Veteran has a current diagnosis of flat foot (pes planus). Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Side affected: Right	Radiobutton	Check this box if the flat foot (pes planus) diagnosis affects the right foot only. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
Side affected: Left	Radiobutton	Check this box if the flat foot (pes planus) diagnosis affects the left foot only. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
Side affected: Both	Radiobutton	Check this box if the flat foot (pes planus) diagnosis affects both feet. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
ICD Code (Flat foot/pes planus)	Text	Enter the ICD diagnostic code corresponding to the flat foot (pes planus) diagnosis. Fill only if 'Flat foot (pes planus)' is 'Yes'. Depends on: Flat foot (pes planus)
Date of Diagnosis (Right Foot)	Date	Provide the date when flat foot (pes planus) was diagnosed for the right foot. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Right, Side affected: Both
Date of Diagnosis (Left Foot)	Date	Provide the date when flat foot (pes planus) was diagnosed for the left foot. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Left, Side affected: Both
Diagnosis: Foot injury(ies) (with specification)
Foot injury(ies) (specify)	Checkbox	Check this box if the Veteran has a diagnosis of one or more foot injuries and you will specify the injury in the space provided. Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Side affected: Right	Radiobutton	Check this box if the diagnosed foot injury(ies) affects the right foot only. Fill only if 'Foot injury(ies) (specify)' is 'Yes'. Depends on: Foot injury(ies) (specify)
Side affected: Left	Radiobutton	Check this box if the diagnosed foot injury(ies) affects the left foot only. Fill only if 'Foot injury(ies) (specify)' is 'Yes'. Depends on: Foot injury(ies) (specify)
Side affected: Both	Radiobutton	Check this box if the diagnosed foot injury(ies) affects both feet. Fill only if 'Foot injury(ies) (specify)' is 'Yes'. Depends on: Foot injury(ies) (specify)
Foot Injury ICD Code	Text	Enter the ICD code for the specified foot injury diagnosis. Fill only if 'Foot injury(ies) (specify)' is 'Yes'. Depends on: Foot injury(ies) (specify)
Foot Injury Date of Diagnosis (Right)	Date	Provide the date the foot injury was diagnosed for the right foot. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Right, Side affected: Both
Foot Injury Date of Diagnosis (Left)	Date	Provide the date the foot injury was diagnosed for the left foot. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Left, Side affected: Both
Foot Injury Diagnosis (Specify)	Text	Describe the specific foot injury diagnosis being claimed (e.g., type and location of injury). Fill only if 'Foot injury(ies) (specify)' is 'Yes'. Depends on: Foot injury(ies) (specify)
Diagnosis: Gout
Gout	Checkbox	Check this box if the Veteran has a current diagnosis of gout associated with the claimed condition(s). Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Gout – Side affected: Right	Radiobutton	Select this option if the gout affects the right side only. Fill only if 'Gout' is 'Yes'. Depends on: Gout
Gout – Side affected: Left	Radiobutton	Select this option if the gout affects the left side only. Fill only if 'Gout' is 'Yes'. Depends on: Gout
Gout – Side affected: Both	Radiobutton	Select this option if the gout affects both the right and left sides. Fill only if 'Gout' is 'Yes'. Depends on: Gout
Gout ICD Code	Text	Enter the ICD diagnostic code for the gout diagnosis. Fill only if 'Gout' is 'Yes'. Depends on: Gout
Gout Date of Diagnosis (Right)	Date	Enter the date the gout diagnosis was made for the right side. Fill only if 'Gout – Side affected: Right', 'Gout – Side affected: Both' is 'Yes' (any fields selection). Depends on: Gout – Side affected: Right, Gout – Side affected: Both
Gout Date of Diagnosis (Left)	Date	Enter the date the gout diagnosis was made for the left side. Fill only if 'Gout – Side affected: Left', 'Gout – Side affected: Both' is 'Yes' (any fields selection). Depends on: Gout – Side affected: Left, Gout – Side affected: Both
Diagnosis: Hallux rigidus
Hallux rigidus	Checkbox	Check this box if the veteran has a current diagnosis of hallux rigidus associated with the claimed condition(s). Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Side affected: Right	Radiobutton	Check this box if the hallux rigidus diagnosis affects the right foot only. Fill only if 'Hallux rigidus' is 'Yes'. Depends on: Hallux rigidus
Side affected: Left	Radiobutton	Check this box if the hallux rigidus diagnosis affects the left foot only. Fill only if 'Hallux rigidus' is 'Yes'. Depends on: Hallux rigidus
Side affected: Both	Radiobutton	Check this box if the hallux rigidus diagnosis affects both feet. Fill only if 'Hallux rigidus' is 'Yes'. Depends on: Hallux rigidus
Hallux rigidus ICD code	Text	Enter the ICD diagnostic code for hallux rigidus. Fill only if 'Hallux rigidus' is 'Yes'. Depends on: Hallux rigidus
Hallux rigidus date of diagnosis (right)	Date	Enter the date hallux rigidus was diagnosed for the right foot. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Right, Side affected: Both
Hallux rigidus date of diagnosis (left)	Date	Enter the date hallux rigidus was diagnosed for the left foot. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Left, Side affected: Both
Diagnosis: Hallux valgus
Hallux valgus	Checkbox	Check this box if the Veteran has a diagnosis of hallux valgus associated with the claimed condition(s). Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Side affected — Right	Radiobutton	Check this box if the hallux valgus affects the right foot only. Fill only if 'Hallux valgus' is 'Yes'. Depends on: Hallux valgus
Side affected — Left	Radiobutton	Check this box if the hallux valgus affects the left foot only. Fill only if 'Hallux valgus' is 'Yes'. Depends on: Hallux valgus
Side affected — Both	Radiobutton	Check this box if the hallux valgus affects both feet. Fill only if 'Hallux valgus' is 'Yes'. Depends on: Hallux valgus
Hallux valgus ICD code	Text	Enter the ICD diagnostic code for the hallux valgus diagnosis. Fill only if 'Hallux valgus' is 'Yes'. Depends on: Hallux valgus
Hallux valgus date of diagnosis (Right)	Date	Enter the date the hallux valgus diagnosis was made for the right foot. Fill only if 'Side affected — Right', 'Side affected — Both' is 'Yes' (any fields selection). Depends on: Side affected — Right, Side affected — Both
Hallux valgus date of diagnosis (Left)	Date	Enter the date the hallux valgus diagnosis was made for the left foot. Fill only if 'Side affected — Left', 'Side affected — Both' is 'Yes' (any fields selection). Depends on: Side affected — Left, Side affected — Both
Diagnosis: Hammer toes
Hammer toes	Checkbox	Check this box if the veteran has a current diagnosis of hammer toes associated with the claimed condition(s). Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Hammer toes — Right	Radiobutton	Check this box if the hammer toes diagnosis affects the right foot only. Fill only if 'Hammer toes' is 'Yes'. Depends on: Hammer toes
Hammer toes — Left	Radiobutton	Check this box if the hammer toes diagnosis affects the left foot only. Fill only if 'Hammer toes' is 'Yes'. Depends on: Hammer toes
Hammer toes — Both	Radiobutton	Check this box if the hammer toes diagnosis affects both feet. Fill only if 'Hammer toes' is 'Yes'. Depends on: Hammer toes
Hammer Toes ICD Code	Text	Enter the ICD diagnostic code corresponding to the hammer toes diagnosis. Fill only if 'Hammer toes' is 'Yes'. Depends on: Hammer toes
Hammer Toes Date of Diagnosis (Right)	Date	Enter the date the hammer toes diagnosis was made for the right foot. Fill only if 'Hammer toes — Right', 'Hammer toes — Both' is 'Yes' (any fields selection). Depends on: Hammer toes — Right, Hammer toes — Both
Hammer Toes Date of Diagnosis (Left)	Date	Enter the date the hammer toes diagnosis was made for the left foot. Fill only if 'Hammer toes — Left', 'Hammer toes — Both' is 'Yes' (any fields selection). Depends on: Hammer toes — Left, Hammer toes — Both
Diagnosis: Malunion/nonunion of tarsal/metatarsal bones
Malunion/nonunion of tarsal/metatarsal bones	Checkbox	Check this box if the Veteran has a current diagnosis of malunion or nonunion involving the tarsal and/or metatarsal bones. Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Side affected: Right	Radiobutton	Check this box if the malunion/nonunion of tarsal/metatarsal bones affects the right foot. Fill only if 'Malunion/nonunion of tarsal/metatarsal bones' is 'Yes'. Depends on: Malunion/nonunion of tarsal/metatarsal bones
Side affected: Left	Radiobutton	Check this box if the malunion/nonunion of tarsal/metatarsal bones affects the left foot. Fill only if 'Malunion/nonunion of tarsal/metatarsal bones' is 'Yes'. Depends on: Malunion/nonunion of tarsal/metatarsal bones
Side affected: Both	Radiobutton	Check this box if the malunion/nonunion of tarsal/metatarsal bones affects both feet. Fill only if 'Malunion/nonunion of tarsal/metatarsal bones' is 'Yes'. Depends on: Malunion/nonunion of tarsal/metatarsal bones
ICD Code (Malunion/Nonunion of Tarsal/Metatarsal Bones)	Text	Enter the ICD diagnostic code for malunion/nonunion of the tarsal/metatarsal bones. Fill only if 'Malunion/nonunion of tarsal/metatarsal bones' is 'Yes'. Depends on: Malunion/nonunion of tarsal/metatarsal bones
Date of Diagnosis - Right	Date	Enter the date the malunion/nonunion of the tarsal/metatarsal bones was diagnosed for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Right, Side affected: Both
Date of Diagnosis - Left	Date	Enter the date the malunion/nonunion of the tarsal/metatarsal bones was diagnosed for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Left, Side affected: Both
Diagnosis: Metatarsalgia
Metatarsalgia	Checkbox	Check this box if the Veteran has a current diagnosis of metatarsalgia associated with the claimed condition(s). Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Metatarsalgia – Side affected: Right	Radiobutton	Check this box if the metatarsalgia affects the right foot. Fill only if 'Metatarsalgia' is 'Yes'. Depends on: Metatarsalgia
Metatarsalgia – Side affected: Left	Radiobutton	Check this box if the metatarsalgia affects the left foot. Fill only if 'Metatarsalgia' is 'Yes'. Depends on: Metatarsalgia
Metatarsalgia – Side affected: Both	Radiobutton	Check this box if the metatarsalgia affects both feet. Fill only if 'Metatarsalgia' is 'Yes'. Depends on: Metatarsalgia
Metatarsalgia ICD Code	Text	Enter the ICD diagnostic code for the metatarsalgia diagnosis. Fill only if 'Metatarsalgia' is 'Yes'. Depends on: Metatarsalgia
Metatarsalgia Date of Diagnosis (Right)	Date	Enter the date the metatarsalgia diagnosis was made for the right side. Fill only if 'Metatarsalgia – Side affected: Right', 'Metatarsalgia – Side affected: Both' is 'Yes' (any fields selection). Depends on: Metatarsalgia – Side affected: Right, Metatarsalgia – Side affected: Both
Metatarsalgia Date of Diagnosis (Left)	Date	Enter the date the metatarsalgia diagnosis was made for the left side. Fill only if 'Metatarsalgia – Side affected: Left', 'Metatarsalgia – Side affected: Both' is 'Yes' (any fields selection). Depends on: Metatarsalgia – Side affected: Left, Metatarsalgia – Side affected: Both
Diagnosis: Morton's neuroma
Morton's neuroma	Checkbox	Check this box if the Veteran has a current diagnosis of Morton's neuroma associated with the claimed condition(s). Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Morton's neuroma – Right	Radiobutton	Check this box if the Morton's neuroma affects the right side/foot. Fill only if 'Morton's neuroma' is 'Yes'. Depends on: Morton's neuroma
Morton's neuroma – Left	Radiobutton	Check this box if the Morton's neuroma affects the left side/foot. Fill only if 'Morton's neuroma' is 'Yes'. Depends on: Morton's neuroma
Morton's neuroma – Both	Radiobutton	Check this box if the Morton's neuroma affects both sides/feet. Fill only if 'Morton's neuroma' is 'Yes'. Depends on: Morton's neuroma
Morton's neuroma ICD code	Text	Enter the ICD diagnostic code corresponding to Morton's neuroma. Fill only if 'Morton's neuroma' is 'Yes'. Depends on: Morton's neuroma
Morton's neuroma diagnosis date (Right)	Date	Enter the date Morton's neuroma was diagnosed for the right side. Fill only if 'Morton's neuroma – Right', 'Morton's neuroma – Both' is 'Yes' (any fields selection). Depends on: Morton's neuroma – Right, Morton's neuroma – Both
Morton's neuroma diagnosis date (Left)	Date	Enter the date Morton's neuroma was diagnosed for the left side. Fill only if 'Morton's neuroma – Left', 'Morton's neuroma – Both' is 'Yes' (any fields selection). Depends on: Morton's neuroma – Left, Morton's neuroma – Both
Diagnosis: Myositis
Myositis	Checkbox	Check this box if the patient has a diagnosis of myositis. Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Myositis - Right	Radiobutton	Check this box if the myositis affects the right side. Fill only if 'Myositis' is 'Yes'. Depends on: Myositis
Myositis - Left	Radiobutton	Check this box if the myositis affects the left side. Fill only if 'Myositis' is 'Yes'. Depends on: Myositis
Myositis - Both	Radiobutton	Check this box if the myositis affects both sides. Fill only if 'Myositis' is 'Yes'. Depends on: Myositis
Myositis details	Text	Enter details describing the myositis diagnosis, such as the affected muscle/area or any relevant notes. Fill only if 'Myositis' is 'Yes'. Depends on: Myositis
Myositis (right) details	Text	Enter details specific to myositis affecting the right side, such as the affected muscle/area or notes. Fill only if 'Myositis - Right', 'Myositis - Both' is 'Yes' (any fields selection). Depends on: Myositis - Right, Myositis - Both
Myositis (left) details	Text	Enter details specific to myositis affecting the left side, such as the affected muscle/area or notes. Fill only if 'Myositis - Left', 'Myositis - Both' is 'Yes' (any fields selection). Depends on: Myositis - Left, Myositis - Both
Diagnosis: Myositis ossificans
Myositis ossificans	Checkbox	Check this box if the diagnosis is myositis ossificans. Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Right	Radiobutton	Check this box if the myositis ossificans is on the right side. Fill only if 'Myositis ossificans' is 'Yes'. Depends on: Myositis ossificans
Left	Radiobutton	Check this box if the myositis ossificans is on the left side. Fill only if 'Myositis ossificans' is 'Yes'. Depends on: Myositis ossificans
Both	Radiobutton	Check this box if the myositis ossificans affects both sides. Fill only if 'Myositis ossificans' is 'Yes'. Depends on: Myositis ossificans
Myositis ossificans location	Text	Enter the anatomical location or area affected by myositis ossificans. Fill only if 'Myositis ossificans' is 'Yes'. Depends on: Myositis ossificans
Right side details	Text	Provide details for the right side involvement of myositis ossificans (e.g., specific site or area). Fill only if 'Right', 'Both' is 'Yes' (any fields selection). Depends on: Right, Both
Left side details	Text	Provide details for the left side involvement of myositis ossificans (e.g., specific site or area). Fill only if 'Left', 'Both' is 'Yes' (any fields selection). Depends on: Left, Both
Diagnosis: Osteitis deformans
Osteitis deformans	Checkbox	Check this box if the veteran has a current diagnosis of osteitis deformans associated with the claimed condition(s). Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Osteitis deformans - Side affected: Right	Radiobutton	Select this option if osteitis deformans affects the right side only. Fill only if 'Osteitis deformans' is 'Yes'. Depends on: Osteitis deformans
Osteitis deformans - Side affected: Left	Radiobutton	Select this option if osteitis deformans affects the left side only. Fill only if 'Osteitis deformans' is 'Yes'. Depends on: Osteitis deformans
Osteitis deformans - Side affected: Both	Radiobutton	Select this option if osteitis deformans affects both the right and left sides. Fill only if 'Osteitis deformans' is 'Yes'. Depends on: Osteitis deformans
Osteitis deformans ICD code	Text	Enter the ICD diagnosis code for osteitis deformans. Fill only if 'Osteitis deformans' is 'Yes'. Depends on: Osteitis deformans
Osteitis deformans date of diagnosis (Right)	Date	Enter the date osteitis deformans was diagnosed for the right side. Fill only if 'Osteitis deformans - Side affected: Right', 'Osteitis deformans - Side affected: Both' is 'Yes' (any fields selection). Depends on: Osteitis deformans - Side affected: Right, Osteitis deformans - Side affected: Both
Osteitis deformans date of diagnosis (Left)	Date	Enter the date osteitis deformans was diagnosed for the left side. Fill only if 'Osteitis deformans - Side affected: Left', 'Osteitis deformans - Side affected: Both' is 'Yes' (any fields selection). Depends on: Osteitis deformans - Side affected: Left, Osteitis deformans - Side affected: Both
Diagnosis: Osteomalacia, residuals of
Osteomalacia, residuals of	Checkbox	Check this box if the Veteran has a current diagnosis of residuals of osteomalacia associated with the claimed condition(s). Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Side affected: Right	Radiobutton	Select this option if the osteomalacia residuals affect the right side only. Fill only if 'Osteomalacia, residuals of' is 'Yes'. Depends on: Osteomalacia, residuals of
Side affected: Left	Radiobutton	Select this option if the osteomalacia residuals affect the left side only. Fill only if 'Osteomalacia, residuals of' is 'Yes'. Depends on: Osteomalacia, residuals of
Side affected: Both	Radiobutton	Select this option if the osteomalacia residuals affect both the right and left sides. Fill only if 'Osteomalacia, residuals of' is 'Yes'. Depends on: Osteomalacia, residuals of
Osteomalacia ICD Code	Text	Enter the ICD diagnosis code for osteomalacia, residuals of. Fill only if 'Osteomalacia, residuals of' is 'Yes'. Depends on: Osteomalacia, residuals of
Osteomalacia Diagnosis Date (Right)	Date	Enter the date of diagnosis for osteomalacia, residuals of, affecting the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Right, Side affected: Both
Osteomalacia Diagnosis Date (Left)	Date	Enter the date of diagnosis for osteomalacia, residuals of, affecting the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Left, Side affected: Both
Diagnosis: Osteoporosis, residuals of
Osteoporosis, residuals of	Checkbox	Check this box if the Veteran has a current diagnosis of osteoporosis with residuals associated with the claimed condition(s). Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Side affected: Right	Radiobutton	Select this option if the osteoporosis residuals affect the right side only. Fill only if 'Osteoporosis, residuals of' is 'Yes'. Depends on: Osteoporosis, residuals of
Side affected: Left	Radiobutton	Select this option if the osteoporosis residuals affect the left side only. Fill only if 'Osteoporosis, residuals of' is 'Yes'. Depends on: Osteoporosis, residuals of
Side affected: Both	Radiobutton	Select this option if the osteoporosis residuals affect both the right and left sides. Fill only if 'Osteoporosis, residuals of' is 'Yes'. Depends on: Osteoporosis, residuals of
Osteoporosis Residuals ICD Code	Text	Enter the ICD diagnosis code for osteoporosis residuals of. Fill only if 'Osteoporosis, residuals of' is 'Yes'. Depends on: Osteoporosis, residuals of
Osteoporosis Residuals Date of Diagnosis (Right)	Date	Enter the date of diagnosis for osteoporosis residuals of affecting the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Right, Side affected: Both
Osteoporosis Residuals Date of Diagnosis (Left)	Date	Enter the date of diagnosis for osteoporosis residuals of affecting the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Left, Side affected: Both
Diagnosis: Other specified forms (with specification)
Other specified forms	Checkbox	Check this box if the diagnosis is an “other specified form” (not listed elsewhere) and you will specify the condition on the provided line. Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Other specified form (description)	Text	Enter the name/description of the other specified diagnosis form that applies. Fill only if 'Other specified forms' is 'Yes'. Depends on: Other specified forms
Right	Radiobutton	Check this box if the specified “other specified form” diagnosis involves the right side only. Fill only if 'Other specified forms' is 'Yes'. Depends on: Other specified forms
Left	Radiobutton	Check this box if the specified “other specified form” diagnosis involves the left side only. Fill only if 'Other specified forms' is 'Yes'. Depends on: Other specified forms
Both	Radiobutton	Check this box if the specified “other specified form” diagnosis involves both sides. Fill only if 'Other specified forms' is 'Yes'. Depends on: Other specified forms
Other specified form (site/structure)	Text	Provide the specific anatomical site or structure involved for the other specified form. Fill only if 'Other specified forms' is 'Yes'. Depends on: Other specified forms
Other specified form – Right (details)	Text	Enter the right-side details (site/structure or other specification) for the other specified form, if applicable. Fill only if 'Right', 'Both' is 'Yes' (any fields selection). Depends on: Right, Both
Other specified form – Left (details)	Text	Enter the left-side details (site/structure or other specification) for the other specified form, if applicable. Fill only if 'Left', 'Both' is 'Yes' (any fields selection). Depends on: Left, Both
Diagnosis: Plantar fasciitis
Plantar fasciitis (diagnosis)	Checkbox	Check this box if the veteran has a current diagnosis of plantar fasciitis associated with the claimed condition(s). Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Side affected: Right	Radiobutton	Check this box if the plantar fasciitis affects the right foot only. Fill only if 'Plantar fasciitis (diagnosis)' is 'Yes'. Depends on: Plantar fasciitis (diagnosis)
Side affected: Left	Radiobutton	Check this box if the plantar fasciitis affects the left foot only. Fill only if 'Plantar fasciitis (diagnosis)' is 'Yes'. Depends on: Plantar fasciitis (diagnosis)
Side affected: Both	Radiobutton	Check this box if the plantar fasciitis affects both feet. Fill only if 'Plantar fasciitis (diagnosis)' is 'Yes'. Depends on: Plantar fasciitis (diagnosis)
Plantar fasciitis ICD code	Text	Enter the ICD diagnostic code for the Veteran’s plantar fasciitis. Fill only if 'Plantar fasciitis (diagnosis)' is 'Yes'. Depends on: Plantar fasciitis (diagnosis)
Plantar fasciitis diagnosis date (Right)	Date	Enter the date the Veteran was diagnosed with plantar fasciitis affecting the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Right, Side affected: Both
Plantar fasciitis diagnosis date (Left)	Date	Enter the date the Veteran was diagnosed with plantar fasciitis affecting the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection). Depends on: Side affected: Left, Side affected: Both
Disturbance of Locomotion (14A)
Disturbance of locomotion	Checkbox	Check this box if the claimed condition causes disturbance of locomotion (difficulty or abnormality in walking/ambulation). Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
Disturbance of locomotion - Right	Radiobutton	Check this box if the disturbance of locomotion affects the right lower extremity. Fill only if 'Disturbance of locomotion' is 'Yes'. Depends on: Disturbance of locomotion
Disturbance of locomotion - Left	Radiobutton	Check this box if the disturbance of locomotion affects the left lower extremity. Fill only if 'Disturbance of locomotion' is 'Yes'. Depends on: Disturbance of locomotion
Disturbance of locomotion - Both	Radiobutton	Check this box if the disturbance of locomotion affects both lower extremities. Fill only if 'Disturbance of locomotion' is 'Yes'. Depends on: Disturbance of locomotion
EVIDENCE REVIEW
No records were reviewed	Radiobutton	Check this box if no medical or other evidence records were reviewed for this examination.
Records reviewed	Radiobutton	Check this box if you reviewed any evidence records (e.g., service treatment records, VA treatment records, or private treatment records) for this examination.
Evidence Reviewed and Date Range	Text	List the evidence/records reviewed (e.g., service treatment records, VA treatment records, private treatment records) and include the applicable date range. Fill only if 'Records reviewed' is 'Yes'. Depends on: Records reviewed
Examiner Certification Signature
Examiner Signature	Text	Enter the examiner’s signature to certify the accuracy and completeness of the information provided.
Examiner Printed Name and Title	Text	Enter the examiner’s printed full name and professional title/credentials.
Examiner Area of Practice/Specialty	Text	Enter the examiner’s medical area of practice or specialty.
Date Signed	Date	Enter the date the examiner signed this certification.
Examiner Contact and Credentials
Examiner Phone/Fax Numbers	Text	Enter the examiner’s phone number and/or fax number(s) where they can be contacted.
NPI Number	Text	Enter the examiner’s National Provider Identifier (NPI) number.
Medical License Number and State	Text	Enter the examiner’s medical license number and the state that issued the license.
Examiner Address	Text	Enter the examiner’s mailing address.
Fatigue (14A)
Fatigue	Checkbox	Check this box if fatigue is a contributing factor to the Veteran’s functional loss/impairment for the claimed lower extremity condition. Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
Fatigue – Right	Radiobutton	Check this box if the fatigue-related functional loss affects the right lower extremity. Fill only if 'Fatigue' is 'Yes'. Depends on: Fatigue
Fatigue – Left	Radiobutton	Check this box if the fatigue-related functional loss affects the left lower extremity. Fill only if 'Fatigue' is 'Yes'. Depends on: Fatigue
Fatigue – Both	Radiobutton	Check this box if the fatigue-related functional loss affects both lower extremities. Fill only if 'Fatigue' is 'Yes'. Depends on: Fatigue
Flare-ups Impact on Foot Function (Yes/No and Details)
Yes	Radiobutton	Check this box if the Veteran reports that flare-ups impact the function of the foot. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed conditions listed above.' is 'No'. Depends on: No current diagnosis for any claimed condition
No	Radiobutton	Check this box if the Veteran reports that flare-ups do not impact the function of the foot. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed conditions listed above.' is 'No'. Depends on: No current diagnosis for any claimed condition
Flare-ups Impact Description	Text	Describe the Veteran’s flare-ups that affect foot function, including frequency, duration, characteristics, precipitating and alleviating factors, and the severity and extent of functional impairment during flare-ups. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Foot Condition History Summary
Foot Condition History Summary	Text	Provide a brief summary describing the history of the Veteran’s foot condition, including onset and how it has progressed over time. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed conditions listed above.' is 'No'. Depends on: No current diagnosis for any claimed condition
Foot Pain Report (Yes/No and Description)
Yes	Radiobutton	Check this box if the Veteran reports pain in the foot being evaluated on this questionnaire. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed conditions listed above.' is 'No'. Depends on: No current diagnosis for any claimed condition
No	Radiobutton	Check this box if the Veteran does not report pain in the foot being evaluated on this questionnaire. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed conditions listed above.' is 'No'. Depends on: No current diagnosis for any claimed condition
Foot Pain Description	Text	Enter the Veteran's description of the pain in the foot being evaluated, in the Veteran's own words. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Foot Surgery History (12A Yes/No)
Yes	Radiobutton	Check this box if the Veteran has had foot surgery (arthroscopic or open).
No	Radiobutton	Check this box if the Veteran has not had foot surgery (arthroscopic or open).
Functional Limitation Over Time Yes/No and Side Affected (14B)
14B: Yes	Radiobutton	Check this box if the evidence suggests pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability during flare-ups and/or after repeated use over time. Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
14B: No	Radiobutton	Check this box if the evidence does not suggest pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability during flare-ups and/or after repeated use over time. Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
Side affected: Right	Radiobutton	If you answered Yes to 14B, check this box to indicate the right side is affected. Fill only if '14B: Yes' is 'Yes'. Depends on: 14B: Yes
Side affected: Left	Radiobutton	If you answered Yes to 14B, check this box to indicate the left side is affected. Fill only if '14B: Yes' is 'Yes'. Depends on: 14B: Yes
Side affected: Both	Radiobutton	If you answered Yes to 14B, check this box to indicate both sides are affected. Fill only if '14B: Yes' is 'Yes'. Depends on: 14B: Yes
Functional Loss Description Over Time (14B)
Functional Loss Description During Flare-Ups/Repeated Use Over Time	Text	Describe the functional loss caused by pain, fatigability, weakness, lack of endurance, or incoordination during flare-ups and/or after repeated use over time, and cite and discuss the supporting evidence. Fill only if '14B: Yes' is 'Yes'. Depends on: 14B: Yes
Functional Loss/Impairment Report (Yes/No and Description)
Yes	Radiobutton	Check this box if the Veteran reports any functional loss or functional impairment of the joint or extremity being evaluated (including due to repeated use over time). Fill only if 'The Veteran does not have a current diagnosis associated with any claimed conditions listed above.' is 'No'. Depends on: No current diagnosis for any claimed condition
No	Radiobutton	Check this box if the Veteran does not report any functional loss or functional impairment of the joint or extremity being evaluated (including due to repeated use over time). Fill only if 'The Veteran does not have a current diagnosis associated with any claimed conditions listed above.' is 'No'. Depends on: No current diagnosis for any claimed condition
Functional Loss/Impairment Description	Text	Enter the Veteran’s own words describing any functional loss or functional impairment of the joint or extremity being evaluated, including effects from repeated use over time. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Hallux Rigidus Comments
Hallux Rigidus Comments	Text	Enter any additional comments or explanatory notes regarding the Veteran’s hallux rigidus symptoms, severity, and related functional impact. Fill only if 'Hallux rigidus' is 'Yes'. Depends on: Hallux rigidus
Hallux Rigidus Severity - Mild/Moderate (Side Affected)
Mild or moderate symptoms	Checkbox	Check this box if the Veteran has mild or moderate symptoms due to hallux rigidus. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected: Right	Radiobutton	Check this box if the Veteran’s hallux rigidus with mild or moderate symptoms affects the right foot. Fill only if 'Mild or moderate symptoms' is 'Yes'. Depends on: Mild or moderate symptoms
Side affected: Left	Radiobutton	Check this box if the Veteran’s hallux rigidus with mild or moderate symptoms affects the left foot. Fill only if 'Mild or moderate symptoms' is 'Yes'. Depends on: Mild or moderate symptoms
Side affected: Both	Radiobutton	Check this box if the Veteran’s hallux rigidus with mild or moderate symptoms affects both feet. Fill only if 'Mild or moderate symptoms' is 'Yes'. Depends on: Mild or moderate symptoms
Hallux Rigidus Severity - Severe (Side Affected)
Severe symptoms (function equivalent to amputation of great toe)	Checkbox	Check this box if the Veteran’s hallux rigidus symptoms are severe and the functional impairment is equivalent to amputation of the great toe. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected: Right	Radiobutton	Check this box if the severe hallux rigidus symptoms affect the right side (right great toe/foot). Fill only if 'Severe symptoms (function equivalent to amputation of great toe)' is 'Yes'. Depends on: Severe symptoms (function equivalent to amputation of great toe)
Side affected: Left	Radiobutton	Check this box if the severe hallux rigidus symptoms affect the left side (left great toe/foot). Fill only if 'Severe symptoms (function equivalent to amputation of great toe)' is 'Yes'. Depends on: Severe symptoms (function equivalent to amputation of great toe)
Side affected: Both	Radiobutton	Check this box if the severe hallux rigidus symptoms affect both sides (both great toes/feet). Fill only if 'Severe symptoms (function equivalent to amputation of great toe)' is 'Yes'. Depends on: Severe symptoms (function equivalent to amputation of great toe)
Hallux Rigidus Symptoms Present (Yes/No)
Yes	Radiobutton	Check this box if the Veteran has symptoms due to hallux rigidus. Fill only if 'Hallux rigidus' is 'Yes'. Depends on: Hallux rigidus
No	Radiobutton	Check this box if the Veteran does not have symptoms due to hallux rigidus. Fill only if 'Hallux rigidus' is 'Yes'. Depends on: Hallux rigidus
Hallux Valgus Comments (7C)
Hallux Valgus Comments	Text	Enter any additional comments or details regarding the Veteran’s hallux valgus condition, including symptoms, severity, treatments, or other relevant information. Fill only if 'Hallux valgus' is 'Yes'. Depends on: Hallux valgus
Hallux Valgus Severity - Mild/Moderate (7A)
Mild or moderate symptoms	Checkbox	Check this box if the Veteran’s hallux valgus symptoms are mild or moderate. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected: Right	Radiobutton	Check this box if the mild/moderate hallux valgus symptoms affect the right foot. Fill only if 'Mild or moderate symptoms' is selected. Depends on: Mild or moderate symptoms
Side affected: Left	Radiobutton	Check this box if the mild/moderate hallux valgus symptoms affect the left foot. Fill only if 'Mild or moderate symptoms' is selected. Depends on: Mild or moderate symptoms
Side affected: Both	Radiobutton	Check this box if the mild/moderate hallux valgus symptoms affect both feet. Fill only if 'Mild or moderate symptoms' is selected. Depends on: Mild or moderate symptoms
Hallux Valgus Severity - Severe (7A)
Severe symptoms (function equivalent to amputation of great toe)	Checkbox	Check this box if the Veteran’s hallux valgus symptoms are severe and the functional impairment is equivalent to amputation of the great toe. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Side affected: Right (severe symptoms)	Radiobutton	Check this box if the severe hallux valgus symptoms apply to the right foot. Fill only if 'Severe symptoms (function equivalent to amputation of great toe)' is selected. Depends on: Severe symptoms (function equivalent to amputation of great toe)
Side affected: Left (severe symptoms)	Radiobutton	Check this box if the severe hallux valgus symptoms apply to the left foot. Fill only if 'Severe symptoms (function equivalent to amputation of great toe)' is selected. Depends on: Severe symptoms (function equivalent to amputation of great toe)
Side affected: Both (severe symptoms)	Radiobutton	Check this box if the severe hallux valgus symptoms apply to both feet. Fill only if 'Severe symptoms (function equivalent to amputation of great toe)' is selected. Depends on: Severe symptoms (function equivalent to amputation of great toe)
Hallux Valgus Surgery - Metatarsal Head Resection
Resection of metatarsal head	Checkbox	Check this box if the Veteran has had hallux valgus surgery involving resection of the metatarsal head. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Metatarsal Head Resection Surgery Date	Date	Enter the date the Veteran had surgery for hallux valgus involving resection of the metatarsal head. Fill only if 'Resection of metatarsal head' is selected. Depends on: Resection of metatarsal head
Side affected: Right	Radiobutton	Check this box if the metatarsal head resection surgery was performed on the right foot. Fill only if 'Resection of metatarsal head' is selected. Depends on: Resection of metatarsal head
Side affected: Left	Radiobutton	Check this box if the metatarsal head resection surgery was performed on the left foot. Fill only if 'Resection of metatarsal head' is selected. Depends on: Resection of metatarsal head
Side affected: Both	Radiobutton	Check this box if the metatarsal head resection surgery was performed on both feet. Fill only if 'Resection of metatarsal head' is selected. Depends on: Resection of metatarsal head
Hallux Valgus Surgery - Other (Describe/Date/Side)
Other surgery for hallux valgus	Checkbox	Check this box if the Veteran had a hallux valgus surgery other than the listed types, and you will provide the description, date of surgery, and side affected. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other Hallux Valgus Surgery Description	Text	Enter a brief description of the other type of hallux valgus surgery performed. Fill only if 'Other surgery for hallux valgus' is selected. Depends on: Other surgery for hallux valgus
Other Hallux Valgus Surgery Date	Date	Enter the date when the other hallux valgus surgery was performed. Fill only if 'Other surgery for hallux valgus' is selected. Depends on: Other surgery for hallux valgus
Side affected (Other surgery): Right	Radiobutton	Check this box if the Veteran’s other hallux valgus surgery was performed on the right foot. Fill only if 'Other surgery for hallux valgus' is selected. Depends on: Other surgery for hallux valgus
Side affected (Other surgery): Left	Radiobutton	Check this box if the Veteran’s other hallux valgus surgery was performed on the left foot. Fill only if 'Other surgery for hallux valgus' is selected. Depends on: Other surgery for hallux valgus
Side affected (Other surgery): Both	Radiobutton	Check this box if the Veteran’s other hallux valgus surgery was performed on both feet. Fill only if 'Other surgery for hallux valgus' is selected. Depends on: Other surgery for hallux valgus
Hallux Valgus Surgery - Tarsal/Metatarsal Head Osteotomy
Tarsal osteotomy/metatarsal head osteotomy (equivalent to metatarsal head resection)	Checkbox	Check this box if the Veteran has had hallux valgus surgery consisting of a tarsal osteotomy and/or metatarsal head osteotomy. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Tarsal/Metatarsal Head Osteotomy Surgery Date	Date	Enter the date the Veteran underwent a tarsal osteotomy/metatarsal head osteotomy for hallux valgus. Fill only if 'Tarsal osteotomy/metatarsal head osteotomy (equivalent to metatarsal head resection)' is selected. Depends on: Tarsal osteotomy/metatarsal head osteotomy (equivalent to metatarsal head resection)
Side affected: Right	Radiobutton	Select this option if the tarsal/metatarsal head osteotomy surgery was performed on the right foot. Fill only if 'Tarsal osteotomy/metatarsal head osteotomy (equivalent to metatarsal head resection)' is selected. Depends on: Tarsal osteotomy/metatarsal head osteotomy (equivalent to metatarsal head resection)
Side affected: Left	Radiobutton	Select this option if the tarsal/metatarsal head osteotomy surgery was performed on the left foot. Fill only if 'Tarsal osteotomy/metatarsal head osteotomy (equivalent to metatarsal head resection)' is selected. Depends on: Tarsal osteotomy/metatarsal head osteotomy (equivalent to metatarsal head resection)
Side affected: Both	Radiobutton	Select this option if the tarsal/metatarsal head osteotomy surgery was performed on both feet. Fill only if 'Tarsal osteotomy/metatarsal head osteotomy (equivalent to metatarsal head resection)' is selected. Depends on: Tarsal osteotomy/metatarsal head osteotomy (equivalent to metatarsal head resection)
Hallux Valgus Surgery History (7B)
Yes	Radiobutton	Check this box if the Veteran has had surgery for hallux valgus. Fill only if 'Hallux valgus' is 'Yes'. Depends on: Hallux valgus
No	Radiobutton	Check this box if the Veteran has not had surgery for hallux valgus. Fill only if 'Hallux valgus' is 'Yes'. Depends on: Hallux valgus
Hallux Valgus Symptoms Presence (7A)
Yes	Radiobutton	Check this box if the Veteran has symptoms due to a hallux valgus condition. Fill only if 'Hallux valgus' is 'Yes'. Depends on: Hallux valgus
No	Radiobutton	Check this box if the Veteran does not have symptoms due to a hallux valgus condition. Fill only if 'Hallux valgus' is 'Yes'. Depends on: Hallux valgus
Hammer Toe Affected Toes (Left Foot)
Left foot: None	Checkbox	Check this box if the Veteran has hammer toe(s) but no toes on the left foot are affected. Fill only if 'Hammer toes' is 'Yes'. Depends on: Hammer toes
Left foot: Great toe	Checkbox	Check this box if the great toe on the left foot is affected by hammer toe. Fill only if 'Hammer toes' is 'Yes'. Depends on: Hammer toes
Left foot: Second toe	Checkbox	Check this box if the second toe on the left foot is affected by hammer toe. Fill only if 'Hammer toes' is 'Yes'. Depends on: Hammer toes
Left foot: Third toe	Checkbox	Check this box if the third toe on the left foot is affected by hammer toe. Fill only if 'Hammer toes' is 'Yes'. Depends on: Hammer toes
Left foot: Fourth toe	Checkbox	Check this box if the fourth toe on the left foot is affected by hammer toe. Fill only if 'Hammer toes' is 'Yes'. Depends on: Hammer toes
Left foot: Little toe	Checkbox	Check this box if the little toe on the left foot is affected by hammer toe. Fill only if 'Hammer toes' is 'Yes'. Depends on: Hammer toes
Hammer Toe Affected Toes (Right Foot)
None (Right)	Checkbox	Check this box if the Veteran has hammer toes but no toes on the right foot are affected. Fill only if 'Hammer toes' is 'Yes'. Depends on: Hammer toes
Great toe (Right)	Checkbox	Check this box if the great toe on the right foot is affected by hammer toe. Fill only if 'Hammer toes' is 'Yes'. Depends on: Hammer toes
Second toe (Right)	Checkbox	Check this box if the second toe on the right foot is affected by hammer toe. Fill only if 'Hammer toes' is 'Yes'. Depends on: Hammer toes
Third toe (Right)	Checkbox	Check this box if the third toe on the right foot is affected by hammer toe. Fill only if 'Hammer toes' is 'Yes'. Depends on: Hammer toes
Fourth toe (Right)	Checkbox	Check this box if the fourth toe on the right foot is affected by hammer toe. Fill only if 'Hammer toes' is 'Yes'. Depends on: Hammer toes
Little toe (Right)	Checkbox	Check this box if the little toe on the right foot is affected by hammer toe. Fill only if 'Hammer toes' is 'Yes'. Depends on: Hammer toes
Hammer Toe Comments
Hammer Toe Comments	Text	Enter any additional comments or clinical details regarding the Veteran’s hammer toe condition, including symptoms, severity, functional impact, and relevant findings. Fill only if 'Hammer toes' is 'Yes'. Depends on: Hammer toes
In-Person Examination and If Not, How Conducted
Examined in person: Yes	Radiobutton	Check this box if the Veteran was examined in person (face-to-face) for this evaluation.
Examined in person: No	Radiobutton	Check this box if the Veteran was not examined in person, and then describe how the examination was conducted in the space provided.
How Examination Was Conducted (If Not In Person)	Text	Describe how the Veteran’s examination was conducted if it was not performed in person (e.g., telephone, video visit, records review, or other method). Fill only if 'Examined in person: No' is 'Yes'. Depends on: Examined in person: No
Incoordination (14A)
Incoordination	Checkbox	Check this box if incoordination is a contributing factor to the Veteran’s functional loss or disability. Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
Incoordination - Right	Radiobutton	Select this option if the incoordination affects the right lower extremity. Fill only if 'Incoordination' is 'Yes'. Depends on: Incoordination
Incoordination - Left	Radiobutton	Select this option if the incoordination affects the left lower extremity. Fill only if 'Incoordination' is 'Yes'. Depends on: Incoordination
Incoordination - Both	Radiobutton	Select this option if the incoordination affects both lower extremities. Fill only if 'Incoordination' is 'Yes'. Depends on: Incoordination
Inflammatory Conditions Diagnosis Options (Section 1B)
Inflammatory conditions	Checkbox	Check this box if the Veteran has an inflammatory condition diagnosis associated with the claimed condition(s) being evaluated.
Instability of Station (14A)
Instability of station	Checkbox	Check this box if instability of station is a contributing factor to the Veteran’s functional loss/disability for the lower extremity being evaluated. Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
Instability of station – Right	Radiobutton	Check this box if instability of station affects the right lower extremity. Fill only if 'Instability of station' is 'Yes'. Depends on: Instability of station
Instability of station – Left	Radiobutton	Check this box if instability of station affects the left lower extremity. Fill only if 'Instability of station' is 'Yes'. Depends on: Instability of station
Instability of station – Both	Radiobutton	Check this box if instability of station affects both lower extremities. Fill only if 'Instability of station' is 'Yes'. Depends on: Instability of station
Interference With Sitting (14A)
Interference with sitting	Checkbox	Check this box if the claimed condition causes functional loss due to interference with sitting. Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
Interference with sitting – Right	Radiobutton	Check this box if interference with sitting affects the right lower extremity. Fill only if 'Interference with sitting' is 'Yes'. Depends on: Interference with sitting
Interference with sitting – Left	Radiobutton	Check this box if interference with sitting affects the left lower extremity. Fill only if 'Interference with sitting' is 'Yes'. Depends on: Interference with sitting
Interference with sitting – Both	Radiobutton	Check this box if interference with sitting affects both lower extremities. Fill only if 'Interference with sitting' is 'Yes'. Depends on: Interference with sitting
Interference With Standing (14A)
Interference with standing	Checkbox	Check this box if the claimed condition causes functional loss due to interference with standing. Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
Interference with standing — Right	Radiobutton	Check this box if the interference with standing affects the right lower extremity. Fill only if 'Interference with standing' is 'Yes'. Depends on: Interference with standing
Interference with standing — Left	Radiobutton	Check this box if the interference with standing affects the left lower extremity. Fill only if 'Interference with standing' is 'Yes'. Depends on: Interference with standing
Interference with standing — Both	Radiobutton	Check this box if the interference with standing affects both lower extremities. Fill only if 'Interference with standing' is 'Yes'. Depends on: Interference with standing
Lack of Endurance (14A)
Lack of endurance	Checkbox	Check this box if lack of endurance is a contributing factor to the functional loss for the evaluated joint or extremity. Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
Lack of endurance - Right	Radiobutton	Check this box if the lack of endurance affects the right side. Fill only if 'Lack of endurance' is 'Yes'. Depends on: Lack of endurance
Lack of endurance - Left	Radiobutton	Check this box if the lack of endurance affects the left side. Fill only if 'Lack of endurance' is 'Yes'. Depends on: Lack of endurance
Lack of endurance - Both	Radiobutton	Check this box if the lack of endurance affects both sides. Fill only if 'Lack of endurance' is 'Yes'. Depends on: Lack of endurance
Left Foot Pain Assessment
Left foot pain on physical exam — Yes	Radiobutton	Check this box if pain is present in the left foot on physical examination.
Left foot pain on physical exam — No	Radiobutton	Check this box if pain is not present in the left foot on physical examination.
Left Foot Pain Rationale (If No on Exam)	Text	Provide the rationale if there is no left foot pain on physical exam but the Veteran reported left foot pain in their medical history. Fill only if 'Left foot pain on physical exam — No' is 'Yes'. Depends on: Left foot pain on physical exam — No
Left foot pain contributes to functional loss — Yes	Radiobutton	Check this box if the left foot pain found on physical exam contributes to functional loss or additional limitations. Fill only if 'Left foot pain on physical exam — Yes' is 'Yes'. Depends on: Left foot pain on physical exam — Yes
Left foot pain contributes to functional loss — No	Radiobutton	Check this box if the left foot pain found on physical exam does not contribute to functional loss or additional limitations. Fill only if 'Left foot pain on physical exam — Yes' is 'Yes'. Depends on: Left foot pain on physical exam — Yes
Left Foot Pain—Why No Functional Loss	Text	Explain why the left foot pain does not contribute to functional loss or additional limitations. Fill only if 'Left foot pain contributes to functional loss — No' is 'Yes'. Depends on: Left foot pain contributes to functional loss — No
Left Foot Surgery Details
Left foot procedure	Checkbox	Check this box if the Veteran has had foot surgery on the left foot and you will provide the procedure type and date of surgery. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left Foot Procedure Type	Text	Enter the type of surgical procedure performed on the left foot. Fill only if 'Yes', 'Left foot procedure' is 'Yes' (all). Depends on: Yes, Left foot procedure
Left Foot Surgery Date	Date	Enter the date the left foot surgery was performed. Fill only if 'Yes', 'Left foot procedure' is 'Yes' (all). Depends on: Yes, Left foot procedure
Less Movement Than Normal (14A)
Less movement than normal	Checkbox	Check this box if the Veteran has reduced range of motion or movement compared to normal for the evaluated joint/extremity due to the claimed condition. Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
Less movement than normal — Right	Radiobutton	Select this option if the “Less movement than normal” finding applies to the right side. Fill only if 'Less movement than normal' is 'Yes'. Depends on: Less movement than normal
Less movement than normal — Left	Radiobutton	Select this option if the “Less movement than normal” finding applies to the left side. Fill only if 'Less movement than normal' is 'Yes'. Depends on: Less movement than normal
Less movement than normal — Both	Radiobutton	Select this option if the “Less movement than normal” finding applies to both sides. Fill only if 'Less movement than normal' is 'Yes'. Depends on: Less movement than normal
Malunion/Nonunion Comments
Malunion/Nonunion Comments	Text	Enter any additional comments or details about the malunion or nonunion of the Veteran’s tarsal or metatarsal bones. Fill only if 'Malunion/nonunion of tarsal/ metatarsal bones' is 'Yes'. Depends on: Malunion/nonunion of tarsal/metatarsal bones
Metatarsalgia (5B) - Presence and Side Affected
Yes	Radiobutton	Check this box if the Veteran has metatarsalgia. Fill only if 'Metatarsalgia' is 'Yes'. Depends on: Metatarsalgia
No	Radiobutton	Check this box if the Veteran does not have metatarsalgia. Fill only if 'Metatarsalgia' is 'Yes'. Depends on: Metatarsalgia
Right	Radiobutton	Check this box if metatarsalgia affects the right foot. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left	Radiobutton	Check this box if metatarsalgia affects the left foot. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Both	Radiobutton	Check this box if metatarsalgia affects both feet. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Moderate Malunion/Nonunion Severity and Side
Moderate	Checkbox	Check this box if the Veteran’s malunion or nonunion of the tarsal or metatarsal bones is assessed as moderate. Fill only if 'Malunion/nonunion of tarsal/ metatarsal bones' is 'Yes'. Depends on: Malunion/nonunion of tarsal/metatarsal bones
Moderate - Right	Radiobutton	Check this box if the moderate malunion/nonunion affects the right foot. Fill only if 'Moderate' is selected. Depends on: Moderate
Moderate - Left	Radiobutton	Check this box if the moderate malunion/nonunion affects the left foot. Fill only if 'Moderate' is selected. Depends on: Moderate
Moderate - Both	Radiobutton	Check this box if the moderate malunion/nonunion affects both feet. Fill only if 'Moderate' is selected. Depends on: Moderate
Moderately Severe Malunion/Nonunion Severity and Side
Moderately severe	Checkbox	Check this box if the Veteran’s malunion or nonunion of the tarsal or metatarsal bones is assessed as moderately severe. Fill only if 'Malunion/nonunion of tarsal/ metatarsal bones' is 'Yes'. Depends on: Malunion/nonunion of tarsal/metatarsal bones
Moderately severe - Right	Radiobutton	Check this box if the malunion/nonunion is moderately severe and affects the right foot only. Fill only if 'Moderately severe' is selected. Depends on: Moderately severe
Moderately severe - Left	Radiobutton	Check this box if the malunion/nonunion is moderately severe and affects the left foot only. Fill only if 'Moderately severe' is selected. Depends on: Moderately severe
Moderately severe - Both	Radiobutton	Check this box if the malunion/nonunion is moderately severe and affects both feet. Fill only if 'Moderately severe' is selected. Depends on: Moderately severe
More Movement Than Normal (14A)
More movement than normal	Checkbox	Check this box if the claimed condition causes the joint or lower extremity to have more movement than normal (hypermobility/instability). Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
More movement than normal - Right	Radiobutton	Check this box if more movement than normal applies to the right lower extremity. Fill only if 'More movement than normal' is 'Yes'. Depends on: More movement than normal
More movement than normal - Left	Radiobutton	Check this box if more movement than normal applies to the left lower extremity. Fill only if 'More movement than normal' is 'Yes'. Depends on: More movement than normal
More movement than normal - Both	Radiobutton	Check this box if more movement than normal applies to both lower extremities. Fill only if 'More movement than normal' is 'Yes'. Depends on: More movement than normal
Morton's Neuroma (5A) - Presence and Side Affected
Yes	Radiobutton	Check this box if the Veteran has Morton's neuroma. Fill only if 'Morton's neuroma' is 'Yes'. Depends on: Morton's neuroma
No	Radiobutton	Check this box if the Veteran does not have Morton's neuroma. Fill only if 'Morton's neuroma' is 'Yes'. Depends on: Morton's neuroma
Right	Radiobutton	Check this box if Morton's neuroma affects the right foot. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left	Radiobutton	Check this box if Morton's neuroma affects the left foot. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Both	Radiobutton	Check this box if Morton's neuroma affects both feet. Fill only if 'Yes' is 'Yes'. Depends on: Yes
No Current Diagnosis Statement (Section 1B)
No current diagnosis for any claimed condition	Checkbox	Check this box if the Veteran does not currently have a diagnosis associated with any of the claimed conditions listed above.
No Functional Loss Statements (14A)
No functional loss (left lower extremity)	Checkbox	Check this box if there is no functional loss for the left lower extremity attributable to the claimed condition. Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Left foot pain contributes to functional loss — Yes
No functional loss (right lower extremity)	Checkbox	Check this box if there is no functional loss for the right lower extremity attributable to the claimed condition. Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes
Other Assistive Device and Frequency
Other (assistive device)	Checkbox	Check this box if the Veteran uses an assistive device other than the listed options, and then specify the device on the line provided. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other Assistive Device	Text	Enter the name of any other assistive device the veteran uses that is not listed (e.g., wheelchair, brace, crutches, cane, walker). Fill only if 'Other (assistive device)' is 'Yes'. Depends on: Other (assistive device)
Other device frequency: Occasional	Radiobutton	Check this box if the Veteran uses the other assistive device occasionally. Fill only if 'Other (assistive device)' is 'Yes'. Depends on: Other (assistive device)
Other device frequency: Regular	Radiobutton	Check this box if the Veteran uses the other assistive device regularly. Fill only if 'Other (assistive device)' is 'Yes'. Depends on: Other (assistive device)
Other device frequency: Constant	Radiobutton	Check this box if the Veteran uses the other assistive device constantly. Fill only if 'Other (assistive device)' is 'Yes'. Depends on: Other (assistive device)
Other Diagnosis #1
Diagnosis #1 (Other diagnosis)	Checkbox	Check this box if you are selecting/entering an “Other, specify” diagnosis as Diagnosis #1. Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Other Diagnosis #1 Name	Text	Enter the name of the other diagnosis being specified as Diagnosis #1. Fill only if 'Diagnosis #1 (Other diagnosis)' is 'Yes'. Depends on: Diagnosis #1 (Other diagnosis)
Diagnosis #1 – Right	Radiobutton	Check this box if Diagnosis #1 applies to the right side. Fill only if 'Diagnosis #1 (Other diagnosis)' is 'Yes'. Depends on: Diagnosis #1 (Other diagnosis)
Diagnosis #1 – Left	Radiobutton	Check this box if Diagnosis #1 applies to the left side. Fill only if 'Diagnosis #1 (Other diagnosis)' is 'Yes'. Depends on: Diagnosis #1 (Other diagnosis)
Diagnosis #1 – Both	Radiobutton	Check this box if Diagnosis #1 applies to both the right and left sides. Fill only if 'Diagnosis #1 (Other diagnosis)' is 'Yes'. Depends on: Diagnosis #1 (Other diagnosis)
Other Diagnosis #1 Details	Text	Provide any additional details for Diagnosis #1 (such as the affected area or specific condition information). Fill only if 'Diagnosis #1 (Other diagnosis)' is 'Yes'. Depends on: Diagnosis #1 (Other diagnosis)
Other Diagnosis #1 Right Details	Text	Enter the right-side specifics for Diagnosis #1, if applicable. Fill only if 'Diagnosis #1 – Right', 'Diagnosis #1 – Both' is 'Yes' (any fields selection). Depends on: Diagnosis #1 – Right, Diagnosis #1 – Both
Other Diagnosis #1 Left Details	Text	Enter the left-side specifics for Diagnosis #1, if applicable. Fill only if 'Diagnosis #1 – Left', 'Diagnosis #1 – Both' is 'Yes' (any fields selection). Depends on: Diagnosis #1 – Left, Diagnosis #1 – Both
Other Diagnosis #2
Diagnosis #2	Checkbox	Check this box if you are selecting and providing details for the second additional diagnosis. Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Other Diagnosis #2 Description	Text	Enter the name or description of the second additional diagnosis. Fill only if 'Diagnosis #2' is 'Yes'. Depends on: Diagnosis #2
Diagnosis #2 - Right	Radiobutton	Check this box if Diagnosis #2 applies to the right side. Fill only if 'Diagnosis #2' is 'Yes'. Depends on: Diagnosis #2
Diagnosis #2 - Left	Radiobutton	Check this box if Diagnosis #2 applies to the left side. Fill only if 'Diagnosis #2' is 'Yes'. Depends on: Diagnosis #2
Diagnosis #2 - Both	Radiobutton	Check this box if Diagnosis #2 applies to both the right and left sides. Fill only if 'Diagnosis #2' is 'Yes'. Depends on: Diagnosis #2
Other Diagnosis #2 Code (Both)	Text	Enter the diagnosis code that applies when this condition affects both sides. Fill only if 'Diagnosis #2' is 'Yes'. Depends on: Diagnosis #2
Other Diagnosis #2 Code (Right)	Text	Enter the diagnosis code that applies to the right side for this condition. Fill only if 'Diagnosis #2 - Right', 'Diagnosis #2 - Both' is 'Yes' (any fields selection). Depends on: Diagnosis #2 - Right, Diagnosis #2 - Both
Other Diagnosis #2 Code (Left)	Text	Enter the diagnosis code that applies to the left side for this condition. Fill only if 'Diagnosis #2 - Left', 'Diagnosis #2 - Both' is 'Yes' (any fields selection). Depends on: Diagnosis #2 - Left, Diagnosis #2 - Both
Other Diagnosis #3
Diagnosis #3	Checkbox	Check this box if you are providing a third additional diagnosis in the “Other, specify” section. Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Diagnosis #3 Name	Text	Enter the name or description of the third additional diagnosis. Fill only if 'Diagnosis #3' is 'Yes'. Depends on: Diagnosis #3
Diagnosis #3 – Right	Radiobutton	Check this box if Diagnosis #3 applies to the right side/foot. Fill only if 'Diagnosis #3' is 'Yes'. Depends on: Diagnosis #3
Diagnosis #3 – Left	Radiobutton	Check this box if Diagnosis #3 applies to the left side/foot. Fill only if 'Diagnosis #3' is 'Yes'. Depends on: Diagnosis #3
Diagnosis #3 – Both	Radiobutton	Check this box if Diagnosis #3 applies to both sides/feet. Fill only if 'Diagnosis #3' is 'Yes'. Depends on: Diagnosis #3
Diagnosis #3 Code	Text	Enter the diagnosis code or other short identifier associated with diagnosis #3. Fill only if 'Diagnosis #3' is 'Yes'. Depends on: Diagnosis #3
Diagnosis #3 Right Details	Text	Provide any required details for diagnosis #3 specific to the right side. Fill only if 'Diagnosis #3 – Right', 'Diagnosis #3 – Both' is 'Yes' (any fields selection). Depends on: Diagnosis #3 – Right, Diagnosis #3 – Both
Diagnosis #3 Left Details	Text	Provide any required details for diagnosis #3 specific to the left side. Fill only if 'Diagnosis #3 – Left', 'Diagnosis #3 – Both' is 'Yes' (any fields selection). Depends on: Diagnosis #3 – Left, Diagnosis #3 – Both
Other Functional Loss Description (14C)
Other Functional Loss Description	Text	Describe any other functional loss during flare-ups and/or after repeated use over time, including what activities are limited and how. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other Functional Loss Factor and Description (14A)
Other (describe)	Checkbox	Check this box if there is another contributing factor to functional loss not listed above and you will describe it in the provided space. Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
Other – Side affected: Right	Radiobutton	Select this option if the “Other (describe)” functional loss factor applies to the right lower extremity. Fill only if 'Other (describe)' is 'Yes'. Depends on: Other (describe)
Other – Side affected: Left	Radiobutton	Select this option if the “Other (describe)” functional loss factor applies to the left lower extremity. Fill only if 'Other (describe)' is 'Yes'. Depends on: Other (describe)
Other – Side affected: Both	Radiobutton	Select this option if the “Other (describe)” functional loss factor applies to both lower extremities. Fill only if 'Other (describe)' is 'Yes'. Depends on: Other (describe)
Other Functional Loss Factor Description	Text	Describe any other contributing factor(s) of functional loss not listed above for the affected extremity. Fill only if 'Other (describe)' is 'Yes'. Depends on: Other (describe)
Other Functional Loss Over Time Yes/No and Side Affected (14C)
Yes	Radiobutton	Check this box if there is other functional loss during flare-ups and/or after repeated use over time. Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
No	Radiobutton	Check this box if there is no other functional loss during flare-ups and/or after repeated use over time. Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
Right	Radiobutton	If you answered Yes, check this box to indicate the right side is affected. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left	Radiobutton	If you answered Yes, check this box to indicate the left side is affected. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Both	Radiobutton	If you answered Yes, check this box to indicate both sides are affected. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other specified forms (with specification)
Other, specify	Checkbox	Check this box if the applicable condition is not listed in the provided options and you will specify the other condition in the space provided.
Pain (14A)
Pain	Checkbox	Check this box if pain is a contributing factor to functional loss for the claimed lower extremity condition. Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
Pain - Right	Radiobutton	Check this box if the pain contributing to functional loss affects the right lower extremity. Fill only if 'Pain' is 'Yes'. Depends on: Pain
Pain - Left	Radiobutton	Check this box if the pain contributing to functional loss affects the left lower extremity. Fill only if 'Pain' is 'Yes'. Depends on: Pain
Pain - Both	Radiobutton	Check this box if the pain contributing to functional loss affects both lower extremities. Fill only if 'Pain' is 'Yes'. Depends on: Pain
Pain Evidence Description (14D)
Pain Evidence Description	Text	Describe the evidence of pain observed for the selected conditions (e.g., on passive motion, active motion, weight-bearing, nonweight-bearing, or at rest/non-movement) and include any relevant details such as symptoms and side affected. Fill only if 'Passive motion', 'Active motion', 'Weight-bearing', 'Nonweight-bearing', 'On rest/non-movement' is 'Yes' (any). Depends on: Passive motion, Active motion, Weight-bearing, Nonweight-bearing, On rest/non-movement
Pain Evidence on Active Motion and Side (14D)
Active motion	Checkbox	Check this box if there is evidence of pain during active motion of the joint. Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
Active motion pain side: Right	Radiobutton	Check this box if pain on active motion is present on the right side. Fill only if 'Active motion' is 'Yes'. Depends on: Active motion
Active motion pain side: Left	Radiobutton	Check this box if pain on active motion is present on the left side. Fill only if 'Active motion' is 'Yes'. Depends on: Active motion
Active motion pain side: Both	Radiobutton	Check this box if pain on active motion is present on both the right and left sides. Fill only if 'Active motion' is 'Yes'. Depends on: Active motion
Pain Evidence on Nonweight-Bearing and Side (14D)
Nonweight-bearing	Checkbox	Check this box if there is evidence of pain when the joint/foot is tested in a nonweight-bearing position. Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
Nonweight-bearing pain side: Right	Radiobutton	Select this option if the nonweight-bearing pain is present on the right side. Fill only if 'Nonweight-bearing' is 'Yes'. Depends on: Nonweight-bearing
Nonweight-bearing pain side: Left	Radiobutton	Select this option if the nonweight-bearing pain is present on the left side. Fill only if 'Nonweight-bearing' is 'Yes'. Depends on: Nonweight-bearing
Nonweight-bearing pain side: Both	Radiobutton	Select this option if the nonweight-bearing pain is present on both the right and left sides. Fill only if 'Nonweight-bearing' is 'Yes'. Depends on: Nonweight-bearing
Pain Evidence on Passive Motion and Side (14D)
Passive motion	Checkbox	Check this box if there is evidence of pain during passive motion (movement performed by the examiner). Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
Passive motion - Right	Radiobutton	Check this box if pain on passive motion is present on the right side. Fill only if 'Passive motion' is 'Yes'. Depends on: Passive motion
Passive motion - Left	Radiobutton	Check this box if pain on passive motion is present on the left side. Fill only if 'Passive motion' is 'Yes'. Depends on: Passive motion
Passive motion - Both	Radiobutton	Check this box if pain on passive motion is present on both the right and left sides. Fill only if 'Passive motion' is 'Yes'. Depends on: Passive motion
Pain Evidence on Rest/Non-Movement and Side (14D)
On rest/non-movement	Checkbox	Check this box if there is evidence of pain when the joint/foot is at rest or not moving. Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
Right (rest/non-movement)	Radiobutton	Check this box if the pain on rest/non-movement is present on the right side. Fill only if 'On rest/non-movement' is 'Yes'. Depends on: On rest/non-movement
Left (rest/non-movement)	Radiobutton	Check this box if the pain on rest/non-movement is present on the left side. Fill only if 'On rest/non-movement' is 'Yes'. Depends on: On rest/non-movement
Both (rest/non-movement)	Radiobutton	Check this box if the pain on rest/non-movement is present on both the right and left sides. Fill only if 'On rest/non-movement' is 'Yes'. Depends on: On rest/non-movement
Pain Evidence on Weight-Bearing and Side (14D)
Weight-bearing	Checkbox	Check this box if there is evidence of pain with weight-bearing. Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
Weight-bearing pain - Right	Radiobutton	Check this box if the weight-bearing pain applies to the right side. Fill only if 'Weight-bearing' is 'Yes'. Depends on: Weight-bearing
Weight-bearing pain - Left	Radiobutton	Check this box if the weight-bearing pain applies to the left side. Fill only if 'Weight-bearing' is 'Yes'. Depends on: Weight-bearing
Weight-bearing pain - Both	Radiobutton	Check this box if the weight-bearing pain applies to both sides. Fill only if 'Weight-bearing' is 'Yes'. Depends on: Weight-bearing
Patient/Veteran Identification
Patient/Veteran Name	Text	Enter the full name of the patient/veteran.
Patient/Veteran Social Security Number	Text	Enter the patient/veteran's Social Security number.
Date of Examination	Date	Enter the date the examination was performed.
Rationale If Unable to Assess (14D)
Rationale for Unable to Assess (14D)	Text	Provide the reason the examiner is unable to assess pain evidence for item 14D (e.g., the foot is in a cast or the contralateral unclaimed foot is damaged). Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
Requesting Party (Veteran/Claimant, Third Party, or Other)
Veteran/Claimant	Checkbox	Check this box if you are completing this Disability Benefits Questionnaire at the request of the Veteran/Claimant.
Third party	Checkbox	Check this box if you are completing this questionnaire at the request of a third party (and list the organization(s) or individual(s) in the space provided).
Third Party Requesting (Name/Organization)	Text	Enter the name(s) of the third-party individual(s) or organization(s) requesting completion of this questionnaire. Fill only if 'Third party' is 'Yes'. Depends on: Third party
Other	Checkbox	Check this box if you are completing this questionnaire at the request of someone or for a reason not covered above, and describe the requester in the space provided.
Other Requesting Party Description	Text	Describe the requesting party if the request does not fall under Veteran/Claimant or Third Party. Fill only if 'Other' is 'Yes'. Depends on: Other
Requires Arch Supports/Orthotics/Shoe Modifications (11D)
Yes	Radiobutton	Check this box if the foot condition requires arch supports, custom orthotic inserts, or shoe modifications. Fill only if 'Section 1B – Foot injury(ies), specify' is 'Yes'. Depends on: Foot injury(ies) (specify)
No	Radiobutton	Check this box if the foot condition does not require arch supports, custom orthotic inserts, or shoe modifications. Fill only if 'Section 1B – Foot injury(ies), specify' is 'Yes'. Depends on: Foot injury(ies) (specify)
Residual Signs/Symptoms After Foot Surgery (12B)
Yes	Radiobutton	Check this box if the Veteran has any residual signs or symptoms due to arthroscopic or other foot surgery.
No	Radiobutton	Check this box if the Veteran does not have any residual signs or symptoms due to arthroscopic or other foot surgery.
Residual Signs/Symptoms Description	Text	Describe any residual signs or symptoms the Veteran has due to arthroscopic or other foot surgery. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right Foot Pain Assessment
Right Foot: Pain on physical exam — Yes	Radiobutton	Check this box if the Veteran has pain in the right foot on physical examination.
Right Foot: Pain on physical exam — No	Radiobutton	Check this box if the Veteran does not have pain in the right foot on physical examination.
Right Foot Pain Rationale (If Not on Exam)	Text	Provide the medical history or other rationale explaining the Veteran's reported right foot pain when pain is not observed on physical examination. Fill only if 'Right Foot: Pain on physical exam — No' is 'Yes'. Depends on: Right Foot: Pain on physical exam — No
Right Foot: Pain contributes to functional loss — Yes	Radiobutton	Check this box if the right foot pain contributes to functional loss (additional limitations), as indicated by pain on physical exam. Fill only if 'Right Foot: Pain on physical exam — Yes' is 'Yes'. Depends on: Right Foot: Pain on physical exam — Yes
Right Foot: Pain contributes to functional loss — No	Radiobutton	Check this box if the right foot pain does not contribute to functional loss or additional limitations. Fill only if 'Right Foot: Pain on physical exam — Yes' is 'Yes'. Depends on: Right Foot: Pain on physical exam — Yes
Right Foot Pain Explanation (If No Functional Loss)	Text	Explain why the Veteran's right foot pain does not contribute to functional loss or additional limitations. Fill only if 'Right Foot: Pain contributes to functional loss — No' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — No
Right Foot Surgery Details
Right foot procedure	Checkbox	Check this box if the Veteran has had foot surgery on the right foot and you will provide the procedure type and date of surgery. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right Foot Procedure Type	Text	Enter the type and brief description of the surgical procedure performed on the right foot. Fill only if 'Yes', 'Right foot procedure' is 'Yes' (all). Depends on: Yes, Right foot procedure
Right Foot Surgery Date	Date	Enter the date the right foot surgery was performed. Fill only if 'Yes', 'Right foot procedure' is 'Yes' (all). Depends on: Yes, Right foot procedure
Section V Comments (5C)
Section V Comments	Text	Enter any additional comments or explanatory notes related to Section V (Morton's neuroma/Morton's disease and metatarsalgia).
SECTION XIX - FUNCTIONAL IMPACT
Yes	Radiobutton	Check this box if the condition(s) listed in the diagnosis section impact the Veteran’s ability to perform any type of occupational task (e.g., standing, walking, lifting, sitting).
No	Radiobutton	Check this box if the condition(s) listed in the diagnosis section do not impact the Veteran’s ability to perform any type of occupational task.
Functional Impact Description	Text	Describe how the diagnosed condition(s) affect the Veteran’s ability to perform occupational tasks (e.g., standing, walking, lifting, sitting), providing one or more examples. Fill only if 'Yes' is 'Yes'. Depends on: Yes
SECTION XX - REMARKS
Remarks	Text	Enter any additional remarks or clarifications, identifying the related section of the form when appropriate.
Severe Malunion/Nonunion Severity and Side
Severe	Checkbox	Check this box if the malunion or nonunion of the tarsal or metatarsal bones is severe. Fill only if 'Malunion/nonunion of tarsal/ metatarsal bones' is 'Yes'. Depends on: Malunion/nonunion of tarsal/metatarsal bones
Right	Radiobutton	Check this box if the severe malunion/nonunion affects the right foot. Fill only if 'Severe' is selected. Depends on: Severe
Left	Radiobutton	Check this box if the severe malunion/nonunion affects the left foot. Fill only if 'Severe' is selected. Depends on: Severe
Both	Radiobutton	Check this box if the severe malunion/nonunion affects both feet. Fill only if 'Severe' is selected. Depends on: Severe
Severity and Side Affected (11B)
Not affected	Checkbox	Check this box if the condition does not affect the foot. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Not affected - Right	Radiobutton	Check this box if the condition is not affected and the side selected is the right foot. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Not affected - Left	Radiobutton	Check this box if the condition is not affected and the side selected is the left foot. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Not affected - Both	Radiobutton	Check this box if the condition is not affected and the side selected is both feet. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Mild	Checkbox	Check this box if the condition severity is mild. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Mild - Right	Radiobutton	Check this box if the condition is mild and affects the right foot. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Mild - Left	Radiobutton	Check this box if the condition is mild and affects the left foot. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Mild - Both	Radiobutton	Check this box if the condition is mild and affects both feet. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Moderate	Checkbox	Check this box if the condition severity is moderate. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Moderate - Right	Radiobutton	Check this box if the condition is moderate and affects the right foot. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Moderate - Left	Radiobutton	Check this box if the condition is moderate and affects the left foot. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Moderate - Both	Radiobutton	Check this box if the condition is moderate and affects both feet. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Moderately severe	Checkbox	Check this box if the condition severity is moderately severe. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Moderately severe - Right	Radiobutton	Check this box if the condition is moderately severe and affects the right foot. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Moderately severe - Left	Radiobutton	Check this box if the condition is moderately severe and affects the left foot. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Moderately severe - Both	Radiobutton	Check this box if the condition is moderately severe and affects both feet. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Severe	Checkbox	Check this box if the condition severity is severe. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Severe - Right	Radiobutton	Check this box if the condition is severe and affects the right foot. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Severe - Left	Radiobutton	Check this box if the condition is severe and affects the left foot. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Severe - Both	Radiobutton	Check this box if the condition is severe and affects both feet. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Swelling (14A)
Swelling	Checkbox	Check this box if swelling is a contributing factor to functional loss for the claimed lower-extremity condition. Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
Swelling - Right	Radiobutton	Check this box if the swelling affects the right lower extremity. Fill only if 'Swelling' is 'Yes'. Depends on: Swelling
Swelling - Left	Radiobutton	Check this box if the swelling affects the left lower extremity. Fill only if 'Swelling' is 'Yes'. Depends on: Swelling
Swelling - Both	Radiobutton	Check this box if the swelling affects both lower extremities. Fill only if 'Swelling' is 'Yes'. Depends on: Swelling
Tendinopathy Type and Details (select one if known)
Tendinopathy (select one if known)	Checkbox	Check this box if the condition is tendinopathy and you are selecting this category (and its side) as the diagnosis.
Tendinopathy - Right	Radiobutton	Check this box if the tendinopathy affects the right side.
Tendinopathy - Left	Radiobutton	Check this box if the tendinopathy affects the left side.
Tendinopathy - Both	Radiobutton	Check this box if the tendinopathy affects both the right and left sides.
Tendinopathy Details (General)	Text	Enter the tendon or anatomical area affected and any general details for the tendinopathy (if known).
Tendinopathy Details (Right)	Text	Enter the tendon/anatomical area and any details specific to the right-side tendinopathy (if applicable).
Tendinopathy Details (Left)	Text	Enter the tendon/anatomical area and any details specific to the left-side tendinopathy (if applicable).
Tendinitis	Checkbox	Check this box if the specific tendinopathy type is tendinitis. Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Tendinitis - Right	Radiobutton	Check this box if the tendinitis affects the right side. Fill only if 'Tendinitis' is 'Yes'. Depends on: Tendinitis
Tendinitis - Left	Radiobutton	Check this box if the tendinitis affects the left side. Fill only if 'Tendinitis' is 'Yes'. Depends on: Tendinitis
Tendinitis - Both	Radiobutton	Check this box if the tendinitis affects both the right and left sides. Fill only if 'Tendinitis' is 'Yes'. Depends on: Tendinitis
Tendinitis Details (General)	Text	Enter the tendon or anatomical area affected and any general details for the tendinitis (if known). Fill only if 'Tendinitis' is 'Yes'. Depends on: Tendinitis
Tendinitis Details (Right)	Text	Enter the tendon/anatomical area and any details specific to the right-side tendinitis (if applicable). Fill only if 'Tendinitis - Right', 'Tendinitis - Both' is 'Yes' (any fields selection). Depends on: Tendinitis - Right, Tendinitis - Both
Tendinitis Details (Left)	Text	Enter the tendon/anatomical area and any details specific to the left-side tendinitis (if applicable). Fill only if 'Tendinitis - Left', 'Tendinitis - Both' is 'Yes' (any fields selection). Depends on: Tendinitis - Left, Tendinitis - Both
Tendinosis	Checkbox	Check this box if the specific tendinopathy type is tendinosis. Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Tendinosis - Right	Radiobutton	Check this box if the tendinosis affects the right side. Fill only if 'Tendinosis' is 'Yes'. Depends on: Tendinosis
Tendinosis - Left	Radiobutton	Check this box if the tendinosis affects the left side. Fill only if 'Tendinosis' is 'Yes'. Depends on: Tendinosis
Tendinosis - Both	Radiobutton	Check this box if the tendinosis affects both the right and left sides. Fill only if 'Tendinosis' is 'Yes'. Depends on: Tendinosis
Tendinosis Details (General)	Text	Enter the tendon or anatomical area affected and any general details for the tendinosis (if known). Fill only if 'Tendinosis' is 'Yes'. Depends on: Tendinosis
Tendinosis Details (Right)	Text	Enter the tendon/anatomical area and any details specific to the right-side tendinosis (if applicable). Fill only if 'Tendinosis - Right', 'Tendinosis - Both' is 'Yes' (any fields selection). Depends on: Tendinosis - Right, Tendinosis - Both
Tendinosis Details (Left)	Text	Enter the tendon/anatomical area and any details specific to the left-side tendinosis (if applicable). Fill only if 'Tendinosis - Left', 'Tendinosis - Both' is 'Yes' (any fields selection). Depends on: Tendinosis - Left, Tendinosis - Both
Tenosynovitis	Checkbox	Check this box if the specific tendinopathy type is tenosynovitis. Fill only if 'No current diagnosis for any claimed condition' is 'No'. Depends on: No current diagnosis for any claimed condition
Tenosynovitis - Right	Radiobutton	Check this box if the tenosynovitis affects the right side. Fill only if 'Tenosynovitis' is 'Yes'. Depends on: Tenosynovitis
Tenosynovitis - Left	Radiobutton	Check this box if the tenosynovitis affects the left side. Fill only if 'Tenosynovitis' is 'Yes'. Depends on: Tenosynovitis
Tenosynovitis - Both	Radiobutton	Check this box if the tenosynovitis affects both the right and left sides. Fill only if 'Tenosynovitis' is 'Yes'. Depends on: Tenosynovitis
Tenosynovitis Details (General)	Text	Enter the tendon or anatomical area affected and any general details for the tenosynovitis (if known). Fill only if 'Tenosynovitis' is 'Yes'. Depends on: Tenosynovitis
Tenosynovitis Details (Right)	Text	Enter the tendon/anatomical area and any details specific to the right-side tenosynovitis (if applicable). Fill only if 'Tenosynovitis - Right', 'Tenosynovitis - Both' is 'Yes' (any fields selection). Depends on: Tenosynovitis - Right, Tenosynovitis - Both
Tenosynovitis Details (Left)	Text	Enter the tendon/anatomical area and any details specific to the left-side tenosynovitis (if applicable). Fill only if 'Tenosynovitis - Left', 'Tenosynovitis - Both' is 'Yes' (any fields selection). Depends on: Tenosynovitis - Left, Tenosynovitis - Both
VA Healthcare Provider and Clinic Relationship
VA Healthcare provider - Yes	Radiobutton	Check this box if you are a VA Healthcare provider.
VA Healthcare provider - No	Radiobutton	Check this box if you are not a VA Healthcare provider.
Veteran regularly seen in your clinic - Yes	Radiobutton	Check this box if the Veteran is regularly seen as a patient in your clinic.
Veteran regularly seen in your clinic - No	Radiobutton	Check this box if the Veteran is not regularly seen as a patient in your clinic.
Walker Use and Frequency
Walker	Checkbox	Check this box if the Veteran uses a walker as an assistive device for locomotion. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Walker - Occasional	Radiobutton	Check this box if the Veteran uses a walker occasionally. Fill only if 'Walker' is 'Yes'. Depends on: Walker
Walker - Regular	Radiobutton	Check this box if the Veteran uses a walker on a regular basis. Fill only if 'Walker' is 'Yes'. Depends on: Walker
Walker - Constant	Radiobutton	Check this box if the Veteran uses a walker constantly. Fill only if 'Walker' is 'Yes'. Depends on: Walker
Weakened Movement (14A)
Weakened movement	Checkbox	Check this box if the veteran has weakened movement as a contributing factor to functional loss for the claimed lower extremity condition. Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
Weakened movement - Right	Radiobutton	Check this box if weakened movement affects the right lower extremity. Fill only if 'Weakened movement' is 'Yes'. Depends on: Weakened movement
Weakened movement - Left	Radiobutton	Check this box if weakened movement affects the left lower extremity. Fill only if 'Weakened movement' is 'Yes'. Depends on: Weakened movement
Weakened movement - Both	Radiobutton	Check this box if weakened movement affects both lower extremities. Fill only if 'Weakened movement' is 'Yes'. Depends on: Weakened movement
Weakness (14A)
Weakness	Checkbox	Check this box if weakness is a contributing factor to the Veteran’s functional loss for the claimed condition. Fill only if 'Does the pain contribute to functional loss?' is 'Yes'. Depends on: Right Foot: Pain contributes to functional loss — Yes, Left foot pain contributes to functional loss — Yes
Weakness - Right	Radiobutton	Check this box if the weakness applies to the right side/lower extremity. Fill only if 'Weakness' is 'Yes'. Depends on: Weakness
Weakness - Left	Radiobutton	Check this box if the weakness applies to the left side/lower extremity. Fill only if 'Weakness' is 'Yes'. Depends on: Weakness
Weakness - Both	Radiobutton	Check this box if the weakness applies to both sides/lower extremities. Fill only if 'Weakness' is 'Yes'. Depends on: Weakness
Wheelchair Use and Frequency
Wheelchair	Checkbox	Check this box if the Veteran uses a wheelchair as an assistive device for locomotion. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Wheelchair frequency: Occasional	Radiobutton	Check this box if the Veteran uses a wheelchair occasionally. Fill only if 'Wheelchair' is 'Yes'. Depends on: Wheelchair
Wheelchair frequency: Regular	Radiobutton	Check this box if the Veteran uses a wheelchair regularly. Fill only if 'Wheelchair' is 'Yes'. Depends on: Wheelchair
Wheelchair frequency: Constant	Radiobutton	Check this box if the Veteran uses a wheelchair constantly. Fill only if 'Wheelchair' is 'Yes'. Depends on: Wheelchair

Foot Conditions, Including Flatfoot (Pes Planus) Disability Benefits Questionnaire Instructions