Hip and Thigh Conditions Disability Benefits Questionnaire Instructions

Check this box if the functional impairment described in Question 10A applies to the Veteran’s right lower extremity. Fill only if 'Yes' is 'Yes'.

Check this box if the functional impairment described in Question 10A applies to the Veteran’s left lower extremity. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran has functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis.

Check this box if the Veteran does not have functional impairment of an extremity to the degree that an amputation with prosthesis would equally serve them.

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

Check this box if imaging studies were performed in conjunction with this examination.

Check this box if no imaging studies were performed in conjunction with this examination.

Check this box if degenerative or post-traumatic arthritis is documented (e.g., confirmed by imaging studies). Fill only if 'Yes' is 'Yes'.

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

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

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

Check this box if the documented degenerative or post-traumatic arthritis applies to both sides. Fill only if 'Yes' is 'Yes'.

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

Enter the other significant diagnostic test or procedure findings reviewed for the claimed condition(s), including the test type, the date performed, and a brief summary of the results. Fill only if 'Yes' is 'Yes'.

Check this box if there are other significant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es) that were reviewed with this examination.

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

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

Provide a brief summary of the Veteran’s hip or thigh condition history, including onset and course over time.

Check this box if the Veteran reports flare-ups of the hip or thigh.

Check this box if the Veteran does not report flare-ups of the hip or thigh.

Describe the Veteran’s hip/thigh flare-ups, including frequency, duration, characteristics, precipitating and alleviating factors, and the severity/extent of any functional impairment during flare-ups. Fill only if 'Yes' is 'Yes'.

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

Check this box if the Veteran does not report any functional loss or functional impairment of the joint or extremity being evaluated (including after repeated use over time).

Enter the Veteran's description, in their own words, of any functional loss or functional impairment of the affected hip/thigh joint or extremity, including after repeated use over time. Fill only if 'Yes' is 'Yes'.

Check this box if there is additional loss of function or range of motion after three repetitions (repetitive-use testing).

Check this box if there is no additional loss of function or range of motion after three repetitions (repetitive-use testing).

Enter the left hip flexion endpoint measured after completion of three repetitions. Fill only if 'Yes' is 'Yes'.

Enter the left hip extension endpoint measured after completion of three repetitions. Fill only if 'Yes' is 'Yes'.

Enter the left hip abduction endpoint measured after completion of three repetitions. Fill only if 'Yes' is 'Yes'.

Enter the left hip adduction endpoint measured after completion of three repetitions. Fill only if 'Yes' is 'Yes'.

Enter the left hip external rotation endpoint measured after completion of three repetitions. Fill only if 'Yes' is 'Yes'.

Enter the left hip internal rotation endpoint measured after completion of three repetitions. Fill only if 'Yes' is 'Yes'.

Check this box if limitation in adduction after observed repetitive use prevents the Veteran from crossing his/her legs.

Check this box if limitation in adduction after observed repetitive use does not prevent the Veteran from crossing his/her legs.

Check this box if pain is a factor that causes the functional loss related to crossing legs after observed repetitive use. Fill only if 'Prevents crossing legs: Yes' is 'Yes'.

Check this box if fatigability is a factor that causes the functional loss related to crossing legs after observed repetitive use. Fill only if 'Prevents crossing legs: Yes' is 'Yes'.

Check this box if weakness is a factor that causes the functional loss related to crossing legs after observed repetitive use. Fill only if 'Prevents crossing legs: Yes' is 'Yes'.

Check this box if lack of endurance is a factor that causes the functional loss related to crossing legs after observed repetitive use. Fill only if 'Prevents crossing legs: Yes' is 'Yes'.

Check this box if incoordination is a factor that causes the functional loss related to crossing legs after observed repetitive use. Fill only if 'Prevents crossing legs: Yes' is 'Yes'.

Check this box if another factor (not listed) causes the functional loss related to crossing legs after observed repetitive use. Fill only if 'Prevents crossing legs: Yes' is 'Yes'.

Describe any other factor not listed that contributes to the Veteran being unable to cross his/her legs due to limitation in adduction after observed repetitive use. Fill only if 'Prevents crossing legs: Yes', 'Other' is 'Yes' (all).

Check this box if no factors apply or if the contributing factors question is not applicable. Fill only if 'Prevents crossing legs: Yes' is 'Yes'.

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

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

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

Check this box if there is additional loss of function or range of motion after three repetitions for the right side.

Check this box if there is no additional loss of function or range of motion after three repetitions for the right side.

Enter the Veteran’s right hip flexion range-of-motion endpoint measured after completing three repetitive-use repetitions. Fill only if 'Additional loss after three repetitions - Yes (Right)' is 'Yes'.

Enter the Veteran’s right hip extension range-of-motion endpoint measured after completing three repetitive-use repetitions. Fill only if 'Additional loss after three repetitions - Yes (Right)' is 'Yes'.

Enter the Veteran’s right hip abduction range-of-motion endpoint measured after completing three repetitive-use repetitions. Fill only if 'Additional loss after three repetitions - Yes (Right)' is 'Yes'.

Enter the Veteran’s right hip adduction range-of-motion endpoint measured after completing three repetitive-use repetitions. Fill only if 'Additional loss after three repetitions - Yes (Right)' is 'Yes'.

Enter the Veteran’s right hip external rotation range-of-motion endpoint measured after completing three repetitive-use repetitions. Fill only if 'Additional loss after three repetitions - Yes (Right)' is 'Yes'.

Enter the Veteran’s right hip internal rotation range-of-motion endpoint measured after completing three repetitive-use repetitions. Fill only if 'Additional loss after three repetitions - Yes (Right)' is 'Yes'.

Check this box if limitation in adduction after observed repetitive use prevents the Veteran from crossing his/her legs (right side).

Check this box if limitation in adduction after observed repetitive use does not prevent the Veteran from crossing his/her legs (right side).

Check this box if pain contributes to the functional loss related to inability/limitation crossing the legs after observed repetitive use (right side). Fill only if 'Crossing legs prevented (Yes)' is 'Yes'.

Check this box if fatigability contributes to the functional loss related to inability/limitation crossing the legs after observed repetitive use (right side). Fill only if 'Crossing legs prevented (Yes)' is 'Yes'.

Check this box if weakness contributes to the functional loss related to inability/limitation crossing the legs after observed repetitive use (right side). Fill only if 'Crossing legs prevented (Yes)' is 'Yes'.

Check this box if lack of endurance contributes to the functional loss related to inability/limitation crossing the legs after observed repetitive use (right side). Fill only if 'Crossing legs prevented (Yes)' is 'Yes'.

Check this box if incoordination contributes to the functional loss related to inability/limitation crossing the legs after observed repetitive use (right side). Fill only if 'Crossing legs prevented (Yes)' is 'Yes'.

Check this box if another factor (not listed) contributes to the functional loss related to inability/limitation crossing the legs after observed repetitive use (right side). Fill only if 'Crossing legs prevented (Yes)' is 'Yes'.

Enter the other factor(s) contributing to functional loss that limits crossing the legs after observed repetitive use on the right side. Fill only if 'Crossing legs prevented (Yes)', 'Contributing factor: Other' is 'Yes' (all).

Check this box if no listed factors contribute to the functional loss related to inability/limitation crossing the legs after observed repetitive use (right side). Fill only if 'Crossing legs prevented (Yes)' is 'Yes'.

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

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

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

Enter the estimated left hip flexion range-of-motion endpoint (in degrees) immediately after repeated use over time.

Enter the estimated left hip extension range-of-motion endpoint (in degrees) immediately after repeated use over time.

Enter the estimated left hip abduction range-of-motion endpoint (in degrees) immediately after repeated use over time.

Enter the estimated left hip adduction range-of-motion endpoint (in degrees) immediately after repeated use over time.

Enter the estimated left hip external rotation range-of-motion endpoint (in degrees) immediately after repeated use over time.

Enter the estimated left hip internal rotation range-of-motion endpoint (in degrees) immediately after repeated use over time.

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

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

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

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

Check this box if pain is a factor contributing to functional loss with repeated use over time based on procured evidence. Fill only if 'Procured evidence suggests functional limits with repeated use over time — Yes' is 'Yes'.

Check this box if fatigability is a factor contributing to functional loss with repeated use over time based on procured evidence. Fill only if 'Procured evidence suggests functional limits with repeated use over time — Yes' is 'Yes'.

Check this box if weakness is a factor contributing to functional loss with repeated use over time based on procured evidence. Fill only if 'Procured evidence suggests functional limits with repeated use over time — Yes' is 'Yes'.

Check this box if lack of endurance is a factor contributing to functional loss with repeated use over time based on procured evidence. Fill only if 'Procured evidence suggests functional limits with repeated use over time — Yes' is 'Yes'.

Check this box if incoordination is a factor contributing to functional loss with repeated use over time based on procured evidence. Fill only if 'Procured evidence suggests functional limits with repeated use over time — Yes' is 'Yes'.

Check this box if another factor (not listed) contributes to functional loss with repeated use over time based on procured evidence. Fill only if 'Procured evidence suggests functional limits with repeated use over time — Yes' is 'Yes'.

Enter the other factor (not already listed) that contributes to the Veteran’s functional loss with repeated use over time. Fill only if 'Procured evidence suggests functional limits with repeated use over time — Yes', 'Other' is 'Yes' (all).

Check this box if no contributing factors apply for functional loss with repeated use over time. Fill only if 'Procured evidence suggests functional limits with repeated use over time — Yes' is 'Yes'.

Enter the estimated flexion range-of-motion endpoint for the right hip immediately after repeated use over time.

Enter the estimated extension range-of-motion endpoint for the right hip immediately after repeated use over time.

Enter the estimated abduction range-of-motion endpoint for the right hip immediately after repeated use over time.

Enter the estimated adduction range-of-motion endpoint for the right hip immediately after repeated use over time.

Enter the estimated external rotation range-of-motion endpoint for the right hip immediately after repeated use over time.

Enter the estimated internal rotation range-of-motion endpoint for the right hip immediately after repeated use over time.

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

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

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

Check this box if procured evidence does not indicate pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability with repeated use over time (Right).

Check this box if pain is a contributing factor to the functional loss with repeated use over time for the right side. Fill only if 'Procured evidence suggests functional limits with repeated use over time – Yes' is 'Yes'.

Check this box if fatigability is a contributing factor to the functional loss with repeated use over time for the right side. Fill only if 'Procured evidence suggests functional limits with repeated use over time – Yes' is 'Yes'.

Check this box if weakness is a contributing factor to the functional loss with repeated use over time for the right side. Fill only if 'Procured evidence suggests functional limits with repeated use over time – Yes' is 'Yes'.

Check this box if lack of endurance is a contributing factor to the functional loss with repeated use over time for the right side. Fill only if 'Procured evidence suggests functional limits with repeated use over time – Yes' is 'Yes'.

Check this box if incoordination is a contributing factor to the functional loss with repeated use over time for the right side. Fill only if 'Procured evidence suggests functional limits with repeated use over time – Yes' is 'Yes'.

Check this box if another factor not listed contributes to the functional loss with repeated use over time for the right side. Fill only if 'Procured evidence suggests functional limits with repeated use over time – Yes' is 'Yes'.

Describe any other factor from procured evidence that contributes to functional loss with repeated use over time for the right side, if 'Other' is selected. Fill only if 'Procured evidence suggests functional limits with repeated use over time – Yes', 'Other' is 'Yes' (all).

Check this box if no contributing factors apply for functional loss with repeated use over time for the right side. Fill only if 'Procured evidence suggests functional limits with repeated use over time – Yes' is 'Yes'.

Enter any additional hip or thigh diagnoses not already listed above, following the same format (diagnosis, side affected, ICD code, and date of diagnosis) if applicable. Fill only if 'Other (specify)' is 'Yes'.

Provide a narrative estimating the Veteran’s left-hip range of motion after repeated use over time and cite and discuss the specific evidence used to support the estimate (or explain why an estimate cannot be provided). Fill only if 'Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with repeated use over time?' is 'Yes'.

Check this box if limitation in adduction after repeated use over time prevents the Veteran from crossing his/her legs.

Check this box if limitation in adduction after repeated use over time does not prevent the Veteran from crossing his/her legs.

Provide a narrative estimating the Veteran’s right-hip range of motion after repeated use over time and cite/discuss the specific evidence used to support the estimate or explain why an estimate cannot be provided. Fill only if 'Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with repeated use over time?' is 'Yes'.

Check this box if limitation in adduction after repeated use over time prevents the Veteran from crossing his/her legs.

Check this box if limitation in adduction after repeated use over time does not prevent the Veteran from crossing his/her legs.

Describe each condition for which the Veteran uses an assistive device, including the affected side (left/right/bilateral) and the specific assistive device used for that condition. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran uses any assistive devices as a normal mode of locomotion.

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

Check this box if the Veteran uses a brace to assist with walking/ambulation as an assistive device. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran uses the ambulation brace occasionally. Fill only if 'Yes', 'Brace for ambulation' is 'Yes' (all) and is 'Yes'.

Check this box if the Veteran uses the ambulation brace regularly. Fill only if 'Yes', 'Brace for ambulation' is 'Yes' (all) and is 'Yes'.

Check this box if the Veteran uses the ambulation brace constantly. Fill only if 'Yes', 'Brace for ambulation' is 'Yes' (all) and is 'Yes'.

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

Check this box if the Veteran uses a cane only occasionally (intermittently, not most days). Fill only if 'Yes', 'Cane(s)' is 'Yes' (all) and is 'Yes'.

Check this box if the Veteran uses a cane regularly as part of their usual ambulation. Fill only if 'Yes', 'Cane(s)' is 'Yes' (all) and is 'Yes'.

Check this box if the Veteran requires a cane constantly for ambulation (essentially all the time). Fill only if 'Yes', 'Cane(s)' is 'Yes' (all) and is 'Yes'.

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

Check this box if the Veteran uses crutches occasionally. Fill only if 'Yes', 'Crutches' is 'Yes' (all) and is 'Yes'.

Check this box if the Veteran uses crutches regularly. Fill only if 'Yes', 'Crutches' is 'Yes' (all) and is 'Yes'.

Check this box if the Veteran uses crutches constantly. Fill only if 'Yes', 'Crutches' is 'Yes' (all) and is 'Yes'.

Check this box if the Veteran has a current diagnosis of another specified form of arthropathy (not gout) and you will specify it.

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

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

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

Check this box if the other specified arthropathy affects both sides/hips. Fill only if 'Other specified forms of arthropathy (excluding gout) (specify)' is 'Yes'.

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

Enter the date the specified other arthropathy diagnosis was made for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any).

Enter the date the specified other arthropathy diagnosis was made for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any).

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

Check this box if the avascular necrosis affects the right hip. Fill only if 'Avascular necrosis, hip' is 'Yes'.

Check this box if the avascular necrosis affects the left hip. Fill only if 'Avascular necrosis, hip' is 'Yes'.

Check this box if the avascular necrosis affects both hips. Fill only if 'Avascular necrosis, hip' is 'Yes'.

Enter the ICD diagnosis code for the veteran’s avascular necrosis of the hip. Fill only if 'Avascular necrosis, hip' is 'Yes'.

Provide the date the veteran was diagnosed with avascular necrosis of the right hip. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any).

Provide the date the veteran was diagnosed with avascular necrosis of the left hip. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any).

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

Check this box if the gonorrheal arthritis affects the right side/hip only. Fill only if 'Arthritis, gonorrheal' is 'Yes'.

Check this box if the gonorrheal arthritis affects the left side/hip only. Fill only if 'Arthritis, gonorrheal' is 'Yes'.

Check this box if the gonorrheal arthritis affects both sides/hips. Fill only if 'Arthritis, gonorrheal' is 'Yes'.

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

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

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

Check this box if you did not review any medical or service records as part of completing this questionnaire.

Check this box if you reviewed any records (e.g., service treatment records, VA treatment records, or private treatment records) when completing this questionnaire.

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

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

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

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

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

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

Enter the examiner’s mailing address.

Enter the examiner's signature to certify the accuracy and completeness of the information provided.

Enter the date on which the examiner signed this form.

Check this box if the veteran has a current diagnosis of rheumatoid arthritis affecting multiple joints.

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

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

Check this box if the rheumatoid arthritis (multi-joints) condition affects both sides. Fill only if 'Arthritis, rheumatoid (multi-joints)' is 'Yes'.

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

Enter the date the rheumatoid arthritis (multi-joints) diagnosis was made for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any).

Enter the date the rheumatoid arthritis (multi-joints) diagnosis was made for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any).

Check this box if the Veteran has a current diagnosis of femoral acetabular impingement syndrome (including labral tears).

Check this box if the femoral acetabular impingement syndrome affects the right hip only. Fill only if 'Femoral acetabular impingement syndrome (includes labral tears)' is 'Yes'.

Check this box if the femoral acetabular impingement syndrome affects the left hip only. Fill only if 'Femoral acetabular impingement syndrome (includes labral tears)' is 'Yes'.

Check this box if the femoral acetabular impingement syndrome affects both hips. Fill only if 'Femoral acetabular impingement syndrome (includes labral tears)' is 'Yes'.

Enter the ICD diagnosis code for femoral acetabular impingement syndrome (includes labral tears). Fill only if 'Femoral acetabular impingement syndrome (includes labral tears)' is 'Yes'.

Enter the date this condition was diagnosed for the right hip. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any).

Enter the date this condition was diagnosed for the left hip. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any).

Enter the measured active flexion range-of-motion endpoint in degrees. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Enter the measured active extension range-of-motion endpoint in degrees. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Enter the measured active abduction range-of-motion endpoint in degrees. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Enter the measured active adduction range-of-motion endpoint in degrees. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Enter the measured active external rotation range-of-motion endpoint in degrees. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Enter the measured active internal rotation range-of-motion endpoint in degrees. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Enter the flexion degree endpoint if the limitation endpoint differs from the ROM value listed above. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Enter the extension degree endpoint if the limitation endpoint differs from the ROM value listed above. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Enter the abduction degree endpoint if the limitation endpoint differs from the ROM value listed above. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Enter the adduction degree endpoint if the limitation endpoint differs from the ROM value listed above. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Enter the external rotation degree endpoint if the limitation endpoint differs from the ROM value listed above. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Enter the internal rotation degree endpoint if the limitation endpoint differs from the ROM value listed above. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Describe any active range-of-motion limitations attributable to pain, weakness, fatigability, incoordination, or other factors, including the degree(s) affected and any relevant notes. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Check this box if the patient exhibited pain during flexion active range of motion. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Check this box if the patient exhibited pain during extension active range of motion. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Check this box if the patient exhibited pain during abduction active range of motion. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Check this box if the patient exhibited pain during adduction active range of motion. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Check this box if the patient exhibited pain during external rotation active range of motion. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Check this box if the patient exhibited pain during internal rotation active range of motion. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Check this box if a limitation in adduction prevents the Veteran from crossing his/her legs. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Check this box if a limitation in adduction does not prevent the Veteran from crossing his/her legs. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Enter the measured passive shoulder abduction endpoint value in degrees. Fill only if 'Same as active ROM (Abduction endpoint)' is 'No'.

Check this box if the passive range of motion abduction endpoint is the same as the active range of motion abduction endpoint. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Enter the measured passive range-of-motion endpoint for hip adduction, in degrees. Fill only if 'Same as active ROM (Adduction endpoint)' is 'No'.

Check this box if the passive range of motion adduction endpoint (25 degrees) is the same as the active range of motion value. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Enter the measured passive range-of-motion extension endpoint in degrees for the first column. Fill only if 'Same as active ROM' is 'No'.

Check this box if the passive range of motion (ROM) extension endpoint is the same as the active ROM extension endpoint value. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Enter the measured passive range-of-motion endpoint for external rotation in degrees. Fill only if 'Same as active ROM (External rotation endpoint)' is 'No'.

Check this box if the passive external rotation endpoint measurement is the same as the active range of motion (ROM) value. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Enter the passive range of motion flexion endpoint value for the joint, in degrees. Fill only if 'Same as active ROM (Flexion endpoint)' is 'No'.

Check this box if the passive flexion endpoint is the same as the active range of motion (ROM) flexion endpoint value. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Enter the passive range of motion internal rotation endpoint measurement in degrees for the first column. Fill only if 'Same as active ROM (Internal rotation endpoint)' is 'No'.

Check this box if the passive internal rotation endpoint (40 degrees) is the same as the active range of motion value. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Check this box if passive hip flexion on exam produced pain. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Check this box if passive hip extension on exam produced pain. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Check this box if passive hip abduction on exam produced pain. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Check this box if passive hip adduction on exam produced pain. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Check this box if passive hip external rotation on exam produced pain. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

Check this box if passive hip internal rotation on exam produced pain. Fill only if 'Can testing be performed? (Right hip)' is 'Yes'.

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

Check this box if the diagnosed hip osteoarthritis affects the right hip. Fill only if 'Osteoarthritis, hip' is 'Yes'.

Check this box if the diagnosed hip osteoarthritis affects the left hip. Fill only if 'Osteoarthritis, hip' is 'Yes'.

Check this box if the diagnosed hip osteoarthritis affects both hips. Fill only if 'Osteoarthritis, hip' is 'Yes'.

Enter the ICD diagnostic code for the osteoarthritis of the hip. Fill only if 'Osteoarthritis, hip' is 'Yes'.

Enter the date the right hip osteoarthritis was diagnosed. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any).

Enter the date the left hip osteoarthritis was diagnosed. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any).

Enter the estimated hip flexion endpoint in degrees during flare-ups based on all procurable information. Fill only if 'Procured evidence suggests functional limitation with flare-ups – Yes' is 'Yes'.

Enter the estimated hip extension endpoint in degrees during flare-ups based on all procurable information. Fill only if 'Procured evidence suggests functional limitation with flare-ups – Yes' is 'Yes'.

Enter the estimated hip abduction endpoint in degrees during flare-ups based on all procurable information. Fill only if 'Procured evidence suggests functional limitation with flare-ups – Yes' is 'Yes'.

Enter the estimated hip adduction endpoint in degrees during flare-ups based on all procurable information. Fill only if 'Procured evidence suggests functional limitation with flare-ups – Yes' is 'Yes'.

Enter the estimated hip external rotation endpoint in degrees during flare-ups based on all procurable information. Fill only if 'Procured evidence suggests functional limitation with flare-ups – Yes' is 'Yes'.

Enter the estimated hip internal rotation endpoint in degrees during flare-ups based on all procurable information. Fill only if 'Procured evidence suggests functional limitation with flare-ups – Yes' is 'Yes'.

Provide a narrative explanation estimating the Veteran’s left hip range of motion during flare-ups, citing and discussing all case-specific procurable evidence used to support the estimate. Fill only if 'Does the Veteran report flare-ups of the hip or thigh?' is 'Yes'.

Check this box if the Veteran is being examined during a flare-up at the time of this examination. Fill only if 'Does the Veteran report flare-ups of the hip or thigh?' is 'Yes'.

Check this box if the Veteran is not being examined during a flare-up at the time of this examination. Fill only if 'Does the Veteran report flare-ups of the hip or thigh?' is 'Yes'.

Check this box if statements/evidence indicate flare-ups cause pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability. Fill only if 'Does the Veteran report flare-ups of the hip or thigh?' is 'Yes'.

Check this box if statements/evidence do not indicate flare-ups cause significant functional limitation. Fill only if 'Does the Veteran report flare-ups of the hip or thigh?' is 'Yes'.

Check this box if pain is a factor that causes functional loss during left hip flare-ups. Fill only if 'Procured evidence suggests functional limitation with flare-ups – Yes' is 'Yes'.

Check this box if fatigability is a factor that causes functional loss during left hip flare-ups. Fill only if 'Procured evidence suggests functional limitation with flare-ups – Yes' is 'Yes'.

Check this box if weakness is a factor that causes functional loss during left hip flare-ups. Fill only if 'Procured evidence suggests functional limitation with flare-ups – Yes' is 'Yes'.

Check this box if lack of endurance is a factor that causes functional loss during left hip flare-ups. Fill only if 'Procured evidence suggests functional limitation with flare-ups – Yes' is 'Yes'.

Check this box if incoordination is a factor that causes functional loss during left hip flare-ups. Fill only if 'Procured evidence suggests functional limitation with flare-ups – Yes' is 'Yes'.

Check this box if another factor not listed causes functional loss during left hip flare-ups. Fill only if 'Procured evidence suggests functional limitation with flare-ups – Yes' is 'Yes'.

Enter any other factor not listed that causes functional loss during left hip flare-ups. Fill only if 'Other' is 'Yes'.

Check this box if none of the listed factors cause functional loss during left hip flare-ups. Fill only if 'Procured evidence suggests functional limitation with flare-ups – Yes' is 'Yes'.

Enter the estimated flexion range-of-motion endpoint for the right hip during flare-ups, in degrees. Fill only if 'Functional loss with flare-ups (per evidence): Yes' is 'Yes'.

Enter the estimated extension range-of-motion endpoint for the right hip during flare-ups, in degrees. Fill only if 'Functional loss with flare-ups (per evidence): Yes' is 'Yes'.

Enter the estimated abduction range-of-motion endpoint for the right hip during flare-ups, in degrees. Fill only if 'Functional loss with flare-ups (per evidence): Yes' is 'Yes'.

Enter the estimated adduction range-of-motion endpoint for the right hip during flare-ups, in degrees. Fill only if 'Functional loss with flare-ups (per evidence): Yes' is 'Yes'.

Enter the estimated external rotation range-of-motion endpoint for the right hip during flare-ups, in degrees. Fill only if 'Functional loss with flare-ups (per evidence): Yes' is 'Yes'.

Enter the estimated internal rotation range-of-motion endpoint for the right hip during flare-ups, in degrees. Fill only if 'Functional loss with flare-ups (per evidence): Yes' is 'Yes'.

Provide a narrative citing and discussing the evidence used to estimate the Veteran’s right hip range of motion during flare-ups, including relevant medical records, lay statements, and examiner reasoning. Fill only if 'Does the Veteran report flare-ups of the hip or thigh?' is 'Yes'.

Check this box if the examination is being conducted during a flare-up. Fill only if 'Does the Veteran report flare-ups of the hip or thigh?' is 'Yes'.

Check this box if the examination is not being conducted during a flare-up. Fill only if 'Does the Veteran report flare-ups of the hip or thigh?' is 'Yes'.

Check this box if the evidence (including the Veteran’s statements) suggests flare-ups cause pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability. Fill only if 'Does the Veteran report flare-ups of the hip or thigh?' is 'Yes'.

Check this box if the evidence does not suggest flare-ups cause pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability. Fill only if 'Does the Veteran report flare-ups of the hip or thigh?' is 'Yes'.

Check this box if pain causes functional loss during right-hip flare-ups. Fill only if 'Functional loss with flare-ups (per evidence): Yes' is 'Yes'.

Check this box if fatigability causes functional loss during right-hip flare-ups. Fill only if 'Functional loss with flare-ups (per evidence): Yes' is 'Yes'.

Check this box if weakness causes functional loss during right-hip flare-ups. Fill only if 'Functional loss with flare-ups (per evidence): Yes' is 'Yes'.

Check this box if lack of endurance causes functional loss during right-hip flare-ups. Fill only if 'Functional loss with flare-ups (per evidence): Yes' is 'Yes'.

Check this box if incoordination causes functional loss during right-hip flare-ups. Fill only if 'Functional loss with flare-ups (per evidence): Yes' is 'Yes'.

Check this box if another factor (not listed) causes functional loss during right-hip flare-ups. Fill only if 'Functional loss with flare-ups (per evidence): Yes' is 'Yes'.

Describe any other factor during right-hip flare-ups that causes functional loss, if "Other" is selected. Fill only if 'Other' is 'Yes'.

Check this box if none of the listed factors cause functional loss during right-hip flare-ups. Fill only if 'Functional loss with flare-ups (per evidence): Yes' is 'Yes'.

Check this box if the veteran has a current diagnosis of syphilitic arthritis related to the claimed condition(s).

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

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

Check this box if the syphilitic arthritis affects both sides. Fill only if 'Arthritis, syphilitic' is 'Yes'.

Enter the ICD diagnostic code for the condition “Arthritis, syphilitic.” Fill only if 'Arthritis, syphilitic' is 'Yes'.

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

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

Check this box if the veteran has a current diagnosis of trochanteric pain syndrome (including trochanteric bursitis) associated with the claimed condition(s).

Check this box if the trochanteric pain syndrome affects the right hip. Fill only if 'Trochanteric pain syndrome (includes trochanteric bursitis)' is 'Yes'.

Check this box if the trochanteric pain syndrome affects the left hip. Fill only if 'Trochanteric pain syndrome (includes trochanteric bursitis)' is 'Yes'.

Check this box if the trochanteric pain syndrome affects both hips. Fill only if 'Trochanteric pain syndrome (includes trochanteric bursitis)' is 'Yes'.

Enter the ICD diagnostic code for trochanteric pain syndrome (includes trochanteric bursitis). Fill only if 'Trochanteric pain syndrome (includes trochanteric bursitis)' is 'Yes'.

Enter the date when trochanteric pain syndrome was diagnosed for the right hip. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any).

Enter the date when trochanteric pain syndrome was diagnosed for the left hip. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any).

Describe how the Veteran’s examination was conducted if it was not performed in person (e.g., telehealth/video, telephone, records review only). Fill only if 'No' is 'Yes'.

Check this box if the patient has an inflammatory condition not otherwise listed and you will specify the type.

Enter the specific inflammatory condition/type being diagnosed that is not otherwise listed. Fill only if 'Inflammatory other types (specify)' is 'Yes'.

Check this box if the inflammatory other type diagnosis affects the right side.

Check this box if the inflammatory other type diagnosis affects the left side.

Check this box if the inflammatory other type diagnosis affects both sides.

Provide any additional notes about which side(s) are affected for this inflammatory diagnosis.

Enter the diagnosis details specific to the right side.

Enter the diagnosis details specific to the left side.

Check this box if the Veteran has malunion or nonunion of the femur, a flail hip joint, or a leg length discrepancy (left hip).

Check this box if the Veteran does not have malunion or nonunion of the femur, a flail hip joint, or a leg length discrepancy (left hip).

Check this box if there is a fracture of the femur shaft or anatomical neck with nonunion and loose motion (spiral or oblique fracture). Fill only if 'Yes' is 'Yes'.

Check this box if there is a fracture of the femur shaft or anatomical neck resulting in nonunion without loose motion and weight-bearing is preserved with the aid of a brace. Fill only if 'Yes' is 'Yes'.

Check this box if there is a fracture of the femur surgical neck with a false joint. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran has malunion of the femur. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran has a flail hip joint. Fill only if 'Yes' is 'Yes'.

Check this box if there is a leg length discrepancy due to shortening of any bones of the lower extremity (and measurements will be provided). Fill only if 'Yes' is 'Yes'.

Provide a detailed narrative describing any additional factors that contribute to the left hip disability.

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

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

Check this box if the left hip condition causes an abnormal gait or otherwise disrupts walking/locomotion.

Check this box if the left hip has reduced range of motion or moves less than normal due to the condition.

Check this box if the left hip condition results in weakness or reduced strength with movement.

Check this box if the left hip condition causes unsteadiness or instability when standing or changing positions.

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

Check this box if the left hip condition involves swelling.

Check this box if there is a deformity of the left hip associated with the condition.

Check this box if the left hip shows excessive motion or abnormal looseness (e.g., hypermobility) due to the condition.

Check this box if there is muscle wasting/atrophy due to reduced use of the left hip or affected limb.

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

Check this box if there is ankylosis (immobilization) of the left hip and/or thigh.

Check this box if there is no ankylosis (immobilization) of the left hip and/or thigh.

Check this box if the Veteran’s left hip/thigh ankylosis is unfavorable/extremely unfavorable such that the foot does not reach the ground and crutches are needed. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran’s left hip/thigh ankylosis severity is intermediate—between favorable and unfavorable. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran’s left hip/thigh ankylosis is favorable, with flexion between 20 and 40 degrees and slight adduction or abduction. Fill only if 'Yes' is 'Yes'.

Check this box if limitation in abduction during flare-ups prevents the Veteran from crossing his/her legs.

Check this box if limitation in abduction during flare-ups does not prevent the Veteran from crossing his/her legs.

Provide an explanation for why left hip initial range-of-motion testing was unable to be performed or was not indicated. Fill only if 'Unable to test', 'Not indicated' is 'Yes' (any).

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

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

Check this box if you were unable to perform left hip initial ROM testing and provide an explanation in the space below.

Check this box if left hip initial ROM testing was not indicated and provide an explanation in the space below.

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

Check this box if the Veteran’s left hip muscle atrophy is not due to the claimed condition listed in the diagnosis section. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran has muscle atrophy in the left hip.

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

Provide the rationale explaining why left hip muscle atrophy is not due to the claimed condition in the diagnosis section. Fill only if 'No' is 'Yes'.

Check this box if the muscle atrophy measurements in Section IV, item 4C are for the Veteran’s left lower extremity (left hip), and then specify the measurement location (e.g., “10 cm above or below the hip”). Fill only if 'Yes' is 'Yes'.

Enter the specific location on the left lower extremity where the circumference was measured (e.g., how many centimeters above or below the hip). Fill only if 'Yes' is 'Yes'.

Enter the circumference measurement of the more normal side at the specified location for comparison. Fill only if 'Yes' is 'Yes'.

Enter the circumference measurement of the atrophied side at the same specified location. Fill only if 'Yes' is 'Yes'.

Check this box if there is objective evidence of crepitus in the left hip on examination.

Check this box if there is no objective evidence of crepitus in the left hip on examination.

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

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

Provide an explanation of any objective evidence of left hip crepitus and/or localized tenderness or pain on palpation, including the location, severity, and relationship to the condition(s). Fill only if 'Localized tenderness/pain on palpation — Yes' is 'Yes'.

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

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

Check this box if left hip pain is present during weight-bearing activities. Fill only if 'Evidence of pain - Yes' is 'Yes'.

Check this box if left hip pain is present during nonweight-bearing conditions. Fill only if 'Evidence of pain - Yes' is 'Yes'.

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

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

Check this box if left hip pain is present at rest or when not moving. Fill only if 'Evidence of pain - Yes' is 'Yes'.

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

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

Enter any comments describing the evidence and circumstances of the Veteran's left hip pain (including any factors checked above and related functional impact). Fill only if 'Pain causes functional loss' is 'Yes'.

Check this box if a limitation in passive adduction prevents the Veteran from crossing his/her legs.

Check this box if a limitation in passive adduction does not prevent the Veteran from crossing his/her legs.

Check this box if the left hip range of motion (ROM) abnormality itself contributes to functional loss.

Check this box if the left hip ROM abnormality does not itself contribute to functional loss.

Explain how the left hip range of motion abnormality contributes to functional loss, including the specific limitations it causes. Fill only if 'Yes' is 'Yes'.

Enter the degree at which left hip flexion is limited due to pain, weakness, fatigability, incoordination, or other factors (if different than previously noted). Fill only if 'Flexion endpoint (125 degrees)' is different than the value reported above.

Enter the degree at which left hip extension is limited due to pain, weakness, fatigability, incoordination, or other factors (if different than previously noted). Fill only if 'Extension endpoint (30 degrees)' is different than the value reported above.

Enter the degree at which left hip abduction is limited due to pain, weakness, fatigability, incoordination, or other factors (if different than previously noted). Fill only if 'Abduction endpoint (45 degrees)' is different than the value reported above.

Enter the degree at which left hip adduction is limited due to pain, weakness, fatigability, incoordination, or other factors (if different than previously noted). Fill only if 'Adduction endpoint (25 degrees)' is different than the value reported above.

Enter the degree at which left hip external rotation is limited due to pain, weakness, fatigability, incoordination, or other factors (if different than previously noted). Fill only if 'External rotation endpoint (60 degrees)' is different than the value reported above.

Enter the degree at which left hip internal rotation is limited due to pain, weakness, fatigability, incoordination, or other factors (if different than previously noted). Fill only if 'Internal rotation endpoint (40 degrees)' is different than the value reported above.

Describe any left hip limitation of motion attributable to pain, weakness, fatigability, incoordination, or other factors, including the specific degree endpoints for affected movements if different from those reported above.

Describe why the left hip range of motion is outside the normal range but is considered normal for the Veteran (e.g., due to age, body habitus, or other non–hip/thigh conditions). Fill only if 'Abnormal or outside of normal range' is 'Yes'.

Check this box if the left hip has ongoing residuals from arthroscopic or other hip surgery that should be described in the space provided. Fill only if 'Arthroscopic ligament repair' or 'Other surgery not described (specify below)' is 'Yes'.

Describe any residual symptoms, functional limitations, or complications resulting from the left hip arthroscopic or other hip surgery. Fill only if 'Arthroscopic ligament repair' or 'Other surgery not described (specify below)' is 'Yes'.

Check this box if the Veteran has not had any surgical procedures performed on the left hip.

Check this box if the Veteran has had left hip joint resurfacing surgery (and provide the date of surgery if requested).

Enter the date the Veteran had left hip joint resurfacing surgery. Fill only if 'Hip joint resurfacing' is 'Yes'.

Check this box if the Veteran has had a total left hip joint replacement (and provide the date of surgery if requested).

Enter the date the Veteran had a left total hip joint replacement. Fill only if 'Total hip joint replacement' is 'Yes'.

Check this box if the Veteran has had an arthroscopic ligament repair procedure on the left hip (and provide the date of surgery if requested).

Enter the date the Veteran had left hip arthroscopic ligament repair surgery. Fill only if 'Arthroscopic ligament repair' is 'Yes'.

Check this box if the Veteran had another type of left hip surgery not listed and specify the type and date of surgery as requested.

Enter the date the Veteran had the other left hip surgery not otherwise described on the form. Fill only if 'Other surgery not described (specify below)' is 'Yes'.

Describe the type of other left hip surgery performed. Fill only if 'Other surgery not described (specify below)' is 'Yes'.

Check this box if left hip testing can be performed.

Check this box if left hip testing cannot be performed, and provide an explanation in the space below.

Provide an explanation for why left hip testing cannot be performed if 'No' is selected. Fill only if 'Can testing be performed? (No)' is 'Yes'.

Check this box if the left hip is the unclaimed joint and it is damaged.

Check this box if the left hip is the unclaimed joint and it is undamaged.

Describe how the left leg length discrepancy relates to the conditions listed in the diagnosis section above. Fill only if 'Leg length discrepancy (shortening of any bones of the lower extremity)' is 'Yes'.

Enter the measured length of the left lower extremity for leg length discrepancy assessment. Fill only if 'Leg length discrepancy (shortening of any bones of the lower extremity)' is 'Yes'.

Check this box if the left leg length measurement is recorded in centimeters. Fill only if 'Leg length discrepancy (shortening of any bones of the lower extremity)' is 'Yes'.

Check this box if the left leg length measurement is recorded in inches. Fill only if 'Leg length discrepancy (shortening of any bones of the lower extremity)' is 'Yes'.

Check this box if the Veteran has no residual symptoms or functional impairment following the left total hip joint replacement. Fill only if 'Total hip joint replacement' is 'Yes'.

Check this box if the Veteran has moderately severe weakness, pain, and/or limitation of motion as residuals of the left total hip joint replacement. Fill only if 'Total hip joint replacement' is 'Yes'.

Check this box if the Veteran has markedly severe weakness, pain, and/or limitation of motion following implantation of the left hip prosthesis. Fill only if 'Total hip joint replacement' is 'Yes'.

Check this box if, after the left total hip joint replacement, the Veteran has painful motion or weakness severe enough to require the use of crutches. Fill only if 'Total hip joint replacement' is 'Yes'.

Check this box if the Veteran’s left total hip replacement residuals do not fit the listed options and you will describe the residuals in the space provided. Fill only if 'Total hip joint replacement' is 'Yes'.

Describe any other residuals or ongoing symptoms following the Veteran’s left total hip joint replacement that are not listed in the options above. Fill only if 'Other (describe)' is 'Yes'.

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

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

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

Check this box if the osteoporosis residuals affect both sides/hips. Fill only if 'Osteoporosis, residuals of' is 'Yes'.

Enter the ICD diagnostic code associated with the osteoporosis residuals diagnosis. Fill only if 'Osteoporosis, residuals of' is 'Yes'.

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

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

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

Check this box if the ankylosis of the hip joint affects the right hip. Fill only if 'Ankylosis of hip joint' is 'Yes'.

Check this box if the ankylosis of the hip joint affects the left hip. Fill only if 'Ankylosis of hip joint' is 'Yes'.

Check this box if the ankylosis of the hip joint affects both hips. Fill only if 'Ankylosis of hip joint' is 'Yes'.

Enter the ICD diagnostic code corresponding to ankylosis of the hip joint. Fill only if 'Ankylosis of hip joint' is 'Yes'.

Enter the date ankylosis of the right hip joint was diagnosed. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any).

Enter the date ankylosis of the left hip joint was diagnosed. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any).

Check this box if the Veteran does not currently have a diagnosis related to any of the claimed conditions listed above (and explain findings in the remarks section).

Check this box if the Veteran uses an assistive device for locomotion that is not listed (e.g., not wheelchair, brace, crutches, cane, or walker) and describe it in the space provided. Fill only if 'Yes' is 'Yes'.

Enter the type of other assistive device the Veteran uses that is not listed (e.g., scooter, prosthetic aid, or other equipment). Fill only if 'Yes', 'Other (describe) assistive device' is 'Yes' (all) and is 'Yes'.

Check this box if the Veteran uses the other assistive device only occasionally. Fill only if 'Yes', 'Other (describe) assistive device' is 'Yes' (all) and is 'Yes'.

Check this box if the Veteran uses the other assistive device on a regular basis. Fill only if 'Yes', 'Other (describe) assistive device' is 'Yes' (all) and is 'Yes'.

Check this box if the Veteran uses the other assistive device constantly. Fill only if 'Yes', 'Other (describe) assistive device' is 'Yes' (all) and is 'Yes'.

Enter the name or description of the first other diagnosis. Fill only if 'Other (specify)' is 'Yes'.

Check this box if Other diagnosis #1 affects the right side only.

Check this box if Other diagnosis #1 affects the left side only.

Check this box if Other diagnosis #1 affects both the right and left sides.

Enter the ICD code corresponding to Other Diagnosis #1. Fill only if 'Other (specify)' is 'Yes'.

Enter the date when Other Diagnosis #1 was diagnosed for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any fields selection).

Enter the date when Other Diagnosis #1 was diagnosed for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

Enter the name or description of the patient's second additional diagnosis. Fill only if 'Other (specify)' is 'Yes'.

Check this box if Other diagnosis #2 affects the right side only.

Check this box if Other diagnosis #2 affects the left side only.

Check this box if Other diagnosis #2 affects both the right and left sides.

Enter the ICD diagnosis code associated with Other Diagnosis #2. Fill only if 'Other (specify)' is 'Yes'.

Enter the right-side detail/value associated with Other Diagnosis #2. Fill only if 'Side affected (Other diagnosis #2): Right', 'Side affected (Other diagnosis #2): Both' is 'Yes' (any fields selection).

Enter the left-side detail/value associated with Other Diagnosis #2. Fill only if 'Side affected (Other diagnosis #2): Left', 'Side affected (Other diagnosis #2): Both' is 'Yes' (any fields selection).

Enter the name or description of the third additional diagnosis. Fill only if 'Other (specify)' is 'Yes'.

Check this box if Other diagnosis #3 affects the right side.

Check this box if Other diagnosis #3 affects the left side.

Check this box if Other diagnosis #3 affects both the right and left sides.

Enter the ICD diagnosis code for Other Diagnosis #3. Fill only if 'Other (specify)' is 'Yes'.

Enter the date when Other Diagnosis #3 was diagnosed for the right side. Fill only if 'Right', 'Both' is 'Yes' (any fields selection).

Enter the date when Other Diagnosis #3 was diagnosed for the left side. Fill only if 'Left', 'Both' is 'Yes' (any fields selection).

Check this box if the diagnosis is not listed elsewhere and you will provide the other diagnosis details in the space provided.

Check this box if the Veteran has other pertinent physical findings, complications, conditions, signs, or symptoms related to the diagnosed conditions.

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

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'.

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

Enter the full name of the patient/veteran.

Enter the patient/veteran's Social Security number.

Enter the date the examination was performed.

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

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

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

Check this box if the Veteran has malunion or nonunion of the femur, a flail hip joint, or a leg length discrepancy of the right hip/leg.

Check this box if the Veteran does not have malunion or nonunion of the femur, a flail hip joint, or a leg length discrepancy of the right hip/leg.

Check this box if there is a fracture of the shaft or neck with nonunion and loose motion (spiral or oblique fracture) on the right side. Fill only if 'Yes' is 'Yes'.

Check this box if there is a fracture of the shaft or neck resulting in nonunion without loose motion, with weight-bearing preserved using a brace, on the right side. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran has a fracture of the surgical neck with a false joint on the right side. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran has malunion of the femur on the right side. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran has a flail hip joint on the right side. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran has a leg length discrepancy (shortening of any bones of the lower extremity) on the right side. Fill only if 'Yes' is 'Yes'.

Provide a detailed description of any additional factors that contribute to the right hip disability (including any relevant details for items selected above or other factors).

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

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

Check this box if the right hip condition causes difficulty with walking or movement/ambulation.

Check this box if the right hip has reduced range of motion compared to normal.

Check this box if the right hip shows weakness that results in weakened movement.

Check this box if the right hip condition causes unsteadiness or instability while standing.

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

Check this box if swelling is an additional contributing factor of the right hip disability.

Check this box if there is deformity of the right hip contributing to the disability.

Check this box if the right hip has excessive movement (hypermobility) compared to normal.

Check this box if there is muscle atrophy due to disuse related to the right hip condition.

Check this box if another additional contributing factor applies and you will describe it in the space provided.

Check this box if the Veteran has ankylosis of the right hip and/or thigh.

Check this box if the Veteran does not have ankylosis of the right hip and/or thigh.

Check this box if the Veteran has right hip/thigh ankylosis that is extremely unfavorable, with the foot not reaching the ground and requiring crutches. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran’s right hip/thigh ankylosis severity is intermediate, between favorable and unfavorable. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran has right hip/thigh ankylosis that is favorable, with flexion between 20 and 40 degrees and slight abduction or adduction. Fill only if 'Yes' is 'Yes'.

Check this box if limitation in abduction during right hip flare-ups prevents the Veteran from crossing his/her legs.

Check this box if limitation in abduction during right hip flare-ups does not prevent the Veteran from crossing his/her legs.

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

Check this box if the right hip initial range of motion (ROM) measurements are all within normal limits.

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

Check this box if you were unable to perform initial ROM testing of the right hip.

Check this box if initial right hip ROM measurements were not indicated/required for this evaluation.

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

Check this box if the Veteran’s right hip muscle atrophy is not due to the claimed condition listed in the diagnosis section. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran has muscle atrophy of the right hip.

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

Provide the rationale explaining why the Veteran’s right hip muscle atrophy is not due to the claimed condition listed in the diagnosis section. Fill only if 'No' is 'Yes'.

Check this box if the muscle atrophy measurements being provided in item 4C are for the Veteran’s right lower extremity (right hip/leg), and specify the measurement location (e.g., “10 cm above or below the hip”). Fill only if 'Yes' is 'Yes'.

Describe the specific location on the right lower extremity where the circumference measurements were taken (e.g., how many centimeters above or below the hip). Fill only if 'Yes' is 'Yes'.

Enter the circumference measurement of the more normal (unaffected) side at the specified right hip measurement location. Fill only if 'Yes' is 'Yes'.

Enter the circumference measurement of the atrophied side at the specified right hip measurement location. Fill only if 'Yes' is 'Yes'.

Check this box if there is objective evidence of crepitus on examination of the right hip.

Check this box if there is no objective evidence of crepitus on examination of the right hip.

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

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

Describe the objective findings of localized tenderness or pain on palpation of the right hip or associated soft tissue, including location, severity, and relationship to the condition(s). Fill only if 'Localized tenderness/pain on palpation (joint or soft tissue) - Yes' is 'Yes'.

Check this box if there is evidence of right hip pain.

Check this box if there is no evidence of right hip pain.

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

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

Check this box if the right hip pain is present during active motion. Fill only if 'Evidence of pain: Yes' is 'Yes'.

Check this box if the right hip pain is present during passive motion. Fill only if 'Evidence of pain: Yes' is 'Yes'.

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

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

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

Enter any additional comments describing the evidence, type, severity, and functional impact of the Veteran’s right hip pain. Fill only if 'Pain causes functional loss' is 'Yes'.

Check this box if limitation in passive adduction prevents the Veteran from crossing his/her legs.

Check this box if limitation in passive adduction does not prevent the Veteran from crossing his/her legs.

Check this box if the right hip range of motion abnormality itself contributes to a functional loss.

Check this box if the right hip range of motion abnormality does not itself contribute to a functional loss.

Provide an explanation of whether and how the right hip range of motion contributes to functional loss, including details if you selected Yes or No. Fill only if 'Yes – ROM contributes to functional loss (Right hip)' is 'Yes'.

Enter the degree at which right hip flexion is limited due to pain, weakness, fatigability, incoordination, or other factors (if different from the value reported above). Fill only if 'Flexion endpoint (125 degrees)' is different than the value reported above.

Enter the degree at which right hip extension is limited due to pain, weakness, fatigability, incoordination, or other factors (if different from the value reported above). Fill only if 'Extension endpoint (30 degrees)' is different than the value reported above.

Enter the degree at which right hip abduction is limited due to pain, weakness, fatigability, incoordination, or other factors (if different from the value reported above). Fill only if 'Abduction endpoint (45 degrees)' is different than the value reported above.

Enter the degree at which right hip adduction is limited due to pain, weakness, fatigability, incoordination, or other factors (if different from the value reported above). Fill only if 'Adduction endpoint (25 degrees)' is different than the value reported above.

Enter the degree at which right hip external rotation is limited due to pain, weakness, fatigability, incoordination, or other factors (if different from the value reported above). Fill only if 'External rotation endpoint (60 degrees)' is different than the value reported above.

Enter the degree at which right hip internal rotation is limited due to pain, weakness, fatigability, incoordination, or other factors (if different from the value reported above). Fill only if 'Internal rotation endpoint (40 degrees)' is different than the value reported above.

Describe any right hip range-of-motion limitation attributable to pain, weakness, fatigability, incoordination, or other factors, including the degree endpoints for affected motions if different than previously recorded.

Describe why the right hip range of motion is outside the normal range but is considered normal for the individual (e.g., due to age, body habitus, or other non-hip/thigh conditions). Fill only if 'Abnormal or outside of normal range' is 'Yes'.

Check this box if the right hip condition includes residuals from a prior arthroscopic or other hip surgery. Fill only if 'Arthroscopic ligament repair' or 'Other surgery not described (specify below)' is 'Yes'.

Describe the Veteran's current residual symptoms or functional limitations resulting from arthroscopic or other right hip surgery. Fill only if 'Arthroscopic ligament repair' or 'Other surgery not described (specify below)' is 'Yes'.

Check this box if the Veteran has not had any right hip surgical procedures.

Check this box if the Veteran has had right hip joint resurfacing surgery, and provide the date of surgery.

Enter the date the Veteran had right hip joint resurfacing surgery. Fill only if 'Hip joint resurfacing' is 'Yes'.

Check this box if the Veteran has had a right total hip joint replacement, and provide the date of surgery.

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

Check this box if the Veteran has had right hip arthroscopic ligament repair, and provide the date of surgery.

Enter the date the Veteran had right hip arthroscopic ligament repair surgery. Fill only if 'Arthroscopic ligament repair' is 'Yes'.

Check this box if the Veteran had another type of right hip surgery not listed, and specify the type and date of surgery.

Enter the date the Veteran had the other right hip surgery not otherwise described on this form. Fill only if 'Other surgery not described (specify below)' is 'Yes'.

Describe the type or name of the other right hip surgery performed. Fill only if 'Other surgery not described (specify below)' is 'Yes'.

Check this box if right hip testing can be performed.

Check this box if right hip testing cannot be performed, and then provide an explanation in the space below.

Provide the reason testing of the right hip cannot be performed or is medically contraindicated. Fill only if 'Can testing be performed? (No)' is 'Yes'.

Check this box if the right hip is the unclaimed joint and it is damaged.

Check this box if the right hip is the unclaimed joint and it is undamaged.

Describe how the right leg length discrepancy relates to the diagnosed right hip/femur condition(s) noted above. Fill only if 'Leg length discrepancy (shortening)' is 'Yes'.

Enter the measured length of the right lower extremity for leg length discrepancy evaluation. Fill only if 'Leg length discrepancy (shortening)' is 'Yes'.

Check this box if the right leg length measurement is being recorded in centimeters. Fill only if 'Leg length discrepancy (shortening)' is 'Yes'.

Check this box if the right leg length measurement is being recorded in inches. Fill only if 'Leg length discrepancy (shortening)' is 'Yes'.

Check this box if the Veteran has no residuals from the right total hip joint replacement. Fill only if 'Total hip joint replacement' is 'Yes'.

Check this box if the right total hip joint replacement results in moderately severe weakness, pain, or limitation of motion. Fill only if 'Total hip joint replacement' is 'Yes'.

Check this box if, after implantation of the right hip prosthesis, the Veteran has markedly severe weakness, pain, or limitation of motion. Fill only if 'Total hip joint replacement' is 'Yes'.

Check this box if the right hip prosthesis causes painful motion or weakness that requires the Veteran to use crutches. Fill only if 'Total hip joint replacement' is 'Yes'.

Check this box if the right total hip joint replacement residuals are different from the options listed and you will describe them. Fill only if 'Total hip joint replacement' is 'Yes'.

Describe any other residuals or symptoms related to the Veteran's right total hip joint replacement that are not listed in the provided options. Fill only if 'Other (describe)' is 'Yes'.

Check this box if the Veteran has any scars or other skin disfigurement related to any listed condition or its treatment.

Check this box if the Veteran does not have any scars or other skin disfigurement related to any listed condition or its treatment.

Enter the measured active range-of-motion flexion endpoint value in degrees. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Enter the measured active range-of-motion extension endpoint value in degrees. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Enter the measured active range-of-motion abduction endpoint value in degrees. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Enter the measured active range-of-motion adduction endpoint value in degrees. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Enter the measured active range-of-motion external rotation endpoint value in degrees. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Enter the measured active range-of-motion internal rotation endpoint value in degrees. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Enter the flexion degree endpoint where motion is specifically limited due to pain, weakness, fatigability, incoordination, or other factors, if different from the value reported above. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Enter the extension degree endpoint where motion is specifically limited due to pain, weakness, fatigability, incoordination, or other factors, if different from the value reported above. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Enter the abduction degree endpoint where motion is specifically limited due to pain, weakness, fatigability, incoordination, or other factors, if different from the value reported above. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Enter the adduction degree endpoint where motion is specifically limited due to pain, weakness, fatigability, incoordination, or other factors, if different from the value reported above. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Enter the external rotation degree endpoint where motion is specifically limited due to pain, weakness, fatigability, incoordination, or other factors, if different from the value reported above. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Enter the internal rotation degree endpoint where motion is specifically limited due to pain, weakness, fatigability, incoordination, or other factors, if different from the value reported above. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Describe any factors limiting active range of motion (e.g., pain, weakness, fatigability, incoordination) and note the degree endpoint(s) affected if different from the values listed above. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Check this box if flexion range of motion exhibited pain on examination. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Check this box if extension range of motion exhibited pain on examination. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Check this box if abduction range of motion exhibited pain on examination. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Check this box if adduction range of motion exhibited pain on examination. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Check this box if external rotation range of motion exhibited pain on examination. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Check this box if internal rotation range of motion exhibited pain on examination. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Check this box if a limitation in adduction prevents the Veteran from crossing his/her legs. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Check this box if a limitation in adduction does not prevent the Veteran from crossing his/her legs. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Enter the measured passive range of motion abduction endpoint value for the joint being examined. Fill only if 'Same as active ROM' is 'No'.

Check this box if the passive abduction endpoint (degrees) is the same as the active ROM abduction endpoint. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Enter the passive range of motion endpoint measurement for hip adduction in degrees. Fill only if 'Same as active ROM (Adduction endpoint)' is 'No'.

Check this box if the passive range of motion adduction endpoint is the same as the active range of motion adduction endpoint. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Enter the passive range of motion extension endpoint value (in degrees) for the joint being evaluated. Fill only if 'Same as active ROM (Extension endpoint)' is 'No'.

Check this box if the passive extension endpoint measurement is the same as the active extension ROM measurement. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Enter the passive range of motion endpoint measurement for external rotation. Fill only if 'Same as active ROM' is 'No'.

Check this box if the Passive Range of Motion external rotation endpoint (60 degrees) is the same as the Active ROM measurement. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Enter the passive range-of-motion flexion endpoint value in degrees. Fill only if 'Same as active ROM' is 'No'.

Check this box if the passive range of motion flexion endpoint is the same as the active range of motion flexion endpoint. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Enter the passive range of motion endpoint value for internal rotation in degrees. Fill only if 'Same as active ROM (Internal rotation endpoint)' is 'No'.

Check this box if the passive internal rotation endpoint measurement is the same as the active range of motion value for internal rotation. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Check this box if passive range of motion (ROM) testing produced pain during flexion. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Check this box if passive range of motion (ROM) testing produced pain during extension. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Check this box if passive range of motion (ROM) testing produced pain during abduction. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Check this box if passive range of motion (ROM) testing produced pain during adduction. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Check this box if passive range of motion (ROM) testing produced pain during external rotation. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Check this box if passive range of motion (ROM) testing produced pain during internal rotation. Fill only if 'Can testing be performed? (Left hip)' is 'Yes'.

Check this box if the Veteran has a diagnosis of hip joint replacement associated with the claimed condition(s).

Check this box if the hip joint replacement affects the right hip. Fill only if 'Hip joint replacement' is 'Yes'.

Check this box if the hip joint replacement affects the left hip. Fill only if 'Hip joint replacement' is 'Yes'.

Check this box if the hip joint replacement affects both hips. Fill only if 'Hip joint replacement' is 'Yes'.

Enter the ICD diagnosis code corresponding to the hip joint replacement diagnosis. Fill only if 'Hip joint replacement' is 'Yes'.

Enter the date the right-side hip joint replacement diagnosis was made. Fill only if 'Hip joint replacement - Right', 'Hip joint replacement - Both' is 'Yes' (any).

Enter the date the left-side hip joint replacement diagnosis was made. Fill only if 'Hip joint replacement - Left', 'Hip joint replacement - Both' is 'Yes' (any).

Enter the hip and/or thigh condition(s) being claimed that this questionnaire addresses.

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

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

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'.

Enter any additional remarks or explanations, and identify the section of the form to which each remark pertains when appropriate. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed conditions listed above' is 'Yes'.

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

Check this box if the typhoid arthritis affects the right side. Fill only if 'Arthritis, typhoid' is 'Yes'.

Check this box if the typhoid arthritis affects the left side. Fill only if 'Arthritis, typhoid' is 'Yes'.

Check this box if the typhoid arthritis affects both sides. Fill only if 'Arthritis, typhoid' is 'Yes'.

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

Enter the date the typhoid arthritis was diagnosed for the right side. Fill only if 'Arthritis, typhoid - Side affected: Right', 'Arthritis, typhoid - Side affected: Both' is 'Yes' (any).

Enter the date the typhoid arthritis was diagnosed for the left side. Fill only if 'Arthritis, typhoid - Side affected: Left', 'Arthritis, typhoid - Side affected: Both' is 'Yes' (any).

Check this box if the Veteran has a diagnosis of a femoral neck stress fracture associated with the claimed condition(s).

Check this box if the femoral neck stress fracture affects the right hip. Fill only if 'Femoral neck stress fracture' is 'Yes'.

Check this box if the femoral neck stress fracture affects the left hip. Fill only if 'Femoral neck stress fracture' is 'Yes'.

Check this box if the femoral neck stress fracture affects both hips. Fill only if 'Femoral neck stress fracture' is 'Yes'.

Enter the ICD diagnostic code for the femoral neck stress fracture. Fill only if 'Femoral neck stress fracture' is 'Yes'.

Enter the date the right-side femoral neck stress fracture was diagnosed. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any).

Enter the date the left-side femoral neck stress fracture was diagnosed. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any).

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

Check this box if the Veteran’s post-traumatic arthritis affects the right side/hip only. Fill only if 'Post-traumatic arthritis' is 'Yes'.

Check this box if the Veteran’s post-traumatic arthritis affects the left side/hip only. Fill only if 'Post-traumatic arthritis' is 'Yes'.

Check this box if the Veteran’s post-traumatic arthritis affects both sides/hips. Fill only if 'Post-traumatic arthritis' is 'Yes'.

Enter the ICD diagnosis code for the post-traumatic arthritis condition. Fill only if 'Post-traumatic arthritis' is 'Yes'.

Enter the date the post-traumatic arthritis diagnosis was made for the right side. Fill only if 'Post-traumatic arthritis - Side affected: Right', 'Post-traumatic arthritis - Side affected: Both' is 'Yes' (any).

Enter the date the post-traumatic arthritis diagnosis was made for the left side. Fill only if 'Post-traumatic arthritis - Side affected: Left', 'Post-traumatic arthritis - Side affected: Both' is 'Yes' (any).

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

Check this box if the iliopsoas tendinitis affects the right side. Fill only if 'Iliopsoas tendinitis' is 'Yes'.

Check this box if the iliopsoas tendinitis affects the left side. Fill only if 'Iliopsoas tendinitis' is 'Yes'.

Check this box if the iliopsoas tendinitis affects both the right and left sides. Fill only if 'Iliopsoas tendinitis' is 'Yes'.

Enter the ICD diagnosis code for iliopsoas tendinitis. Fill only if 'Iliopsoas tendinitis' is 'Yes'.

Provide the date the right-sided iliopsoas tendinitis was diagnosed. Fill only if 'Iliopsoas tendinitis - Side affected: Right', 'Iliopsoas tendinitis - Side affected: Both' is 'Yes' (any).

Provide the date the left-sided iliopsoas tendinitis was diagnosed. Fill only if 'Iliopsoas tendinitis - Side affected: Left', 'Iliopsoas tendinitis - Side affected: Both' is 'Yes' (any).

Check this box if the veteran has a diagnosis of degenerative arthritis (not due to trauma) associated with the claimed condition(s).

Check this box if the degenerative arthritis (other than posttraumatic) affects the right side/hip. Fill only if 'Degenerative arthritis, other than posttraumatic' is 'Yes'.

Check this box if the degenerative arthritis (other than posttraumatic) affects the left side/hip. Fill only if 'Degenerative arthritis, other than posttraumatic' is 'Yes'.

Check this box if the degenerative arthritis (other than posttraumatic) affects both sides/hips. Fill only if 'Degenerative arthritis, other than posttraumatic' is 'Yes'.

Enter the ICD diagnostic code for degenerative arthritis (other than posttraumatic). Fill only if 'Degenerative arthritis, other than posttraumatic' is 'Yes'.

Enter the date degenerative arthritis (other than posttraumatic) was diagnosed for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any).

Enter the date degenerative arthritis (other than posttraumatic) was diagnosed for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any).

Check this box if hip joint resurfacing is a current diagnosis associated with the claimed condition(s).

Select this option if the diagnosed hip joint resurfacing affects the right hip. Fill only if 'Hip joint resurfacing' is 'Yes'.

Select this option if the diagnosed hip joint resurfacing affects the left hip. Fill only if 'Hip joint resurfacing' is 'Yes'.

Select this option if the diagnosed hip joint resurfacing affects both hips. Fill only if 'Hip joint resurfacing' is 'Yes'.

Enter the ICD diagnostic code corresponding to the hip joint resurfacing diagnosis. Fill only if 'Hip joint resurfacing' is 'Yes'.

Provide the date the right hip joint resurfacing diagnosis was made. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any).

Provide the date the left hip joint resurfacing diagnosis was made. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any).

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

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

Check this box if the streptococcic arthritis affects the right side only. Fill only if 'Arthritis, streptococcic' is 'Yes'.

Check this box if the streptococcic arthritis affects the left side only. Fill only if 'Arthritis, streptococcic' is 'Yes'.

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

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

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

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

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

Check this box if the diagnosed tenosynovitis affects the right side. Fill only if 'Tenosynovitis' is 'Yes'.

Check this box if the diagnosed tenosynovitis affects the left side. Fill only if 'Tenosynovitis' is 'Yes'.

Check this box if the diagnosed tenosynovitis affects both sides. Fill only if 'Tenosynovitis' is 'Yes'.

Enter the ICD diagnosis code for the tenosynovitis condition. Fill only if 'Tenosynovitis' is 'Yes'.

Enter the date the tenosynovitis diagnosis was made for the right side. Fill only if 'Tenosynovitis - Right', 'Tenosynovitis - Both' is 'Yes' (any).

Enter the date the tenosynovitis diagnosis was made for the left side. Fill only if 'Tenosynovitis - Left', 'Tenosynovitis - Both' is 'Yes' (any).

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

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

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

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

Enter the ICD diagnostic code corresponding to the diagnosis of pneumococcic arthritis. Fill only if 'Arthritis, pneumococcic' is 'Yes'.

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

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

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

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

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

Check this box if the osteomalacia residuals affect both sides/hips. Fill only if 'Osteomalacia, residuals of' is 'Yes'.

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

Enter the date the osteomalacia residuals were diagnosed for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any).

Enter the date the osteomalacia residuals were diagnosed for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any).

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

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

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

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

Enter the ICD diagnostic code corresponding to the tendinitis diagnosis. Fill only if 'Tendinitis' is 'Yes'.

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

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

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

Check this box if the myositis affects the right side (right hip/leg). Fill only if 'Myositis' is 'Yes'.

Check this box if the myositis affects the left side (left hip/leg). Fill only if 'Myositis' is 'Yes'.

Check this box if the myositis affects both sides. Fill only if 'Myositis' is 'Yes'.

Enter the ICD diagnostic code associated with the myositis diagnosis. Fill only if 'Myositis' is 'Yes'.

Enter the date myositis was diagnosed for the right side. Fill only if 'Myositis - Side affected: Right', 'Myositis - Side affected: Both' is 'Yes' (any).

Enter the date myositis was diagnosed for the left side. Fill only if 'Myositis - Side affected: Left', 'Myositis - Side affected: Both' is 'Yes' (any).

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

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

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

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

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

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).

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).

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

Check this box if the diagnosed bursitis affects the right side only. Fill only if 'Bursitis' is 'Yes'.

Check this box if the diagnosed bursitis affects the left side only. Fill only if 'Bursitis' is 'Yes'.

Check this box if the diagnosed bursitis affects both the right and left sides. Fill only if 'Bursitis' is 'Yes'.

Enter the ICD diagnosis code corresponding to the bursitis diagnosis. Fill only if 'Bursitis' is 'Yes'.

Enter the date the bursitis diagnosis was made for the right side. Fill only if 'Bursitis - Side affected: Right', 'Bursitis - Side affected: Both' is 'Yes' (any).

Enter the date the bursitis diagnosis was made for the left side. Fill only if 'Bursitis - Side affected: Left', 'Bursitis - Side affected: Both' is 'Yes' (any).

Check this box if the current diagnosis is tendinosis for the claimed condition.

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

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

Check this box if the diagnosed tendinosis affects both sides. Fill only if 'Tendinosis' is 'Yes'.

Enter the ICD diagnosis code for the tendinosis condition. Fill only if 'Tendinosis' is 'Yes'.

Enter the date the right-side tendinosis was diagnosed. Fill only if 'Tendinosis - Side affected: Right', 'Tendinosis - Side affected: Both' is 'Yes' (any).

Enter the date the left-side tendinosis was diagnosed. Fill only if 'Tendinosis - Side affected: Left', 'Tendinosis - Side affected: Both' is 'Yes' (any).

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

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

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

Check this box if osteitis deformans affects both sides. Fill only if 'Osteitis deformans' is 'Yes'.

Enter the ICD diagnosis code corresponding to osteitis deformans. Fill only if 'Osteitis deformans' is 'Yes'.

Enter the date when osteitis deformans was diagnosed for the right side. Fill only if 'Osteitis deformans - Side affected: Right', 'Osteitis deformans - Side affected: Both' is 'Yes' (any).

Enter the date when osteitis deformans was diagnosed for the left side. Fill only if 'Osteitis deformans - Side affected: Left', 'Osteitis deformans - Side affected: Both' is 'Yes' (any).

Check this box if tendinopathy is a current diagnosis associated with the claimed condition(s).

Check this box if the diagnosed tendinopathy affects the right side. Fill only if 'Tendinopathy' is 'Yes'.

Check this box if the diagnosed tendinopathy affects the left side. Fill only if 'Tendinopathy' is 'Yes'.

Check this box if the diagnosed tendinopathy affects both sides. Fill only if 'Tendinopathy' is 'Yes'.

Enter the ICD code for the tendinopathy diagnosis. Fill only if 'Tendinopathy' is 'Yes'.

Enter the date the tendinopathy diagnosis was made for the right side. Fill only if 'Tendinopathy - Right side affected', 'Tendinopathy - Both sides affected' is 'Yes' (any).

Enter the date the tendinopathy diagnosis was made for the left side. Fill only if 'Tendinopathy - Left side affected', 'Tendinopathy - Both sides affected' is 'Yes' (any).

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

Check this box if heterotopic ossification affects the right side. Fill only if 'Heterotopic ossification' is 'Yes'.

Check this box if heterotopic ossification affects the left side. Fill only if 'Heterotopic ossification' is 'Yes'.

Check this box if heterotopic ossification affects both the right and left sides. Fill only if 'Heterotopic ossification' is 'Yes'.

Enter the ICD diagnosis code for heterotopic ossification. Fill only if 'Heterotopic ossification' is 'Yes'.

Enter the date heterotopic ossification was diagnosed for the right side. Fill only if 'Heterotopic ossification - Right', 'Heterotopic ossification - Both' is 'Yes' (any).

Enter the date heterotopic ossification was diagnosed for the left side. Fill only if 'Heterotopic ossification - Left', 'Heterotopic ossification - Both' is 'Yes' (any).

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

Check this box if the gout diagnosis affects the right side only. Fill only if 'Gout' is 'Yes'.

Check this box if the gout diagnosis affects the left side only. Fill only if 'Gout' is 'Yes'.

Check this box if the gout diagnosis affects both the right and left sides. Fill only if 'Gout' is 'Yes'.

Enter the ICD diagnosis code for the gout condition. Fill only if 'Gout' is 'Yes'.

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).

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).

Check this box if you are a VA Healthcare provider.

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

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

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

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

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

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

Check this box if the Veteran uses a walker occasionally. Fill only if 'Yes', 'Walker' is 'Yes' (all) and is 'Yes'.

Check this box if the Veteran uses a walker regularly. Fill only if 'Yes', 'Walker' is 'Yes' (all) and is 'Yes'.

Check this box if the Veteran uses a walker constantly. Fill only if 'Yes', 'Walker' is 'Yes' (all) and is 'Yes'.

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

Check this box if the Veteran uses a wheelchair occasionally. Fill only if 'Yes', 'Wheelchair' is 'Yes' (all) and is 'Yes'.

Check this box if the Veteran uses a wheelchair on a regular basis. Fill only if 'Yes', 'Wheelchair' is 'Yes' (all) and is 'Yes'.

Check this box if the Veteran uses a wheelchair constantly. Fill only if 'Yes', 'Wheelchair' is 'Yes' (all) and is 'Yes'.