This form contains 785 fields organized into 166 sections. Below is a complete list of every field, its type, and what information is expected.

Field Name	Type	Description
11A Assistive Devices Used (Yes/No)
Yes	Radiobutton	Check this box if the Veteran uses any assistive devices as a normal mode of locomotion.
No	Radiobutton	Check this box if the Veteran does not use any assistive devices as a normal mode of locomotion.
11B Conditions/Sides and Assistive Devices Details
Assistive Device Conditions and Details	Text	Describe each condition requiring an assistive device, the affected side (left, right, or both), and the specific assistive device used for each condition. Fill only if 'Yes' is 'Yes'. Depends on: Yes
12A Functional impairment equivalent to amputation (lower extremity) and affected side
Yes – Functional impairment equivalent to amputation with prosthesis	Radiobutton	Check this box if the Veteran’s lower extremity function is so diminished that an amputation with prosthesis would equally serve the Veteran.
No – Not equivalent to amputation with prosthesis	Radiobutton	Check this box if the Veteran’s lower extremity function is not so diminished that an amputation with prosthesis would equally serve the Veteran.
Right lower extremity	Checkbox	Check this box if the functional impairment equivalent to amputation applies to the right lower extremity. Fill only if 'Yes – Functional impairment equivalent to amputation with prosthesis' is 'Yes'. Depends on: Yes – Functional impairment equivalent to amputation with prosthesis
Left lower extremity	Checkbox	Check this box if the functional impairment equivalent to amputation applies to the left lower extremity. Fill only if 'Yes – Functional impairment equivalent to amputation with prosthesis' is 'Yes'. Depends on: Yes – Functional impairment equivalent to amputation with prosthesis
12B Loss of effective function summary and examples
Loss of Effective Function Summary and Examples	Text	For each checked extremity, enter the condition causing loss of function, describe the loss of effective function, and provide specific brief examples. Fill only if 'Right lower extremity', 'Left lower extremity' is 'Yes' for any fields selection. Depends on: Right lower extremity, Left lower extremity
13A Diagnostic Imaging/Procedures Performed or Reviewed (Yes/No)
Yes	Radiobutton	Check this box if clinically relevant diagnostic imaging studies or other diagnostic procedures have been performed or reviewed in conjunction with this examination.
No	Radiobutton	Check this box if no clinically relevant diagnostic imaging studies or other diagnostic procedures have been performed or reviewed in conjunction with this examination.
13B Arthritis Documented and Side (Yes/No + Right/Left/Both)
Arthritis documented - Yes	Radiobutton	Check this box if degenerative or post-traumatic arthritis is documented (e.g., confirmed by imaging). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Arthritis documented - No	Radiobutton	Check this box if degenerative or post-traumatic arthritis is not documented. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Affected side - Right	Radiobutton	Check this box if the documented arthritis affects the right side. Fill only if 'Arthritis documented - Yes' is 'Yes'. Depends on: Arthritis documented - Yes
Affected side - Left	Radiobutton	Check this box if the documented arthritis affects the left side. Fill only if 'Arthritis documented - Yes' is 'Yes'. Depends on: Arthritis documented - Yes
Affected side - Both	Radiobutton	Check this box if the documented arthritis affects both sides (right and left). Fill only if 'Arthritis documented - Yes' is 'Yes'. Depends on: Arthritis documented - Yes
13C Diagnostic Test/Procedure Details (Type/Date/Results Summary)
Diagnostic Test/Procedure Type, Date, and Results Summary	Text	Enter the type of diagnostic test or procedure performed or reviewed, the date it occurred, and a brief summary of the results. Fill only if 'Arthritis documented - Yes' is 'Yes'. Depends on: Arthritis documented - Yes
13D Other Clinically Relevant Diagnostic Findings (Yes/No + Summary)
Yes	Radiobutton	Check this box if there are other clinically relevant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es) that were reviewed with this examination.
No	Radiobutton	Check this box if there are no other clinically relevant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es) that were reviewed with this examination.
Other Diagnostic Findings Summary	Text	Provide the type of other clinically relevant diagnostic test/procedure, the date performed or reviewed, and a brief summary of the results related to the claimed condition(s) or diagnosis(es). Fill only if 'Yes' is 'Yes'. Depends on: Yes
13E Relationship of Abnormal Findings to Diagnosed Conditions
Relationship of Abnormal Findings to Diagnosed Conditions	Text	Describe how any abnormal diagnostic test findings relate to the diagnosed condition(s), including which diagnosis each abnormal result supports or explains.
2A History Brief Summary
History Brief Summary	Text	Provide a brief summary describing the history of the Veteran’s knee and/or lower leg condition(s), including onset and course over time.
2B Knee/Lower Leg Flare-Ups (Yes/No and Description)
Yes	Radiobutton	Check this box if the Veteran reports flare-ups of the knee and/or lower leg.
No	Radiobutton	Check this box if the Veteran does not report flare-ups of the knee and/or lower leg.
Flare-Ups Description	Text	Describe the Veteran’s reported knee and/or lower leg flare-ups, including frequency, duration, characteristics, precipitating factors, alleviating factors, and the severity or functional impairment during flare-ups. Fill only if 'Yes' is 'Yes'. Depends on: Yes
2C Functional Loss/Impairment (Yes/No and Description)
Yes	Radiobutton	Check this box if the Veteran reports any functional loss or functional impairment of the joint or extremity being evaluated, including after repeated use over time.
No	Radiobutton	Check this box if the Veteran does not report any functional loss or functional impairment of the joint or extremity being evaluated, including after repeated use over time.
Functional loss/impairment description	Text	Enter the Veteran's description, in their own words, of any functional loss or functional impairment of the joint or extremity being evaluated (including after repeated use over time). Fill only if 'Yes' is 'Yes'. Depends on: Yes
2D Instability or Recurrent Subluxation (Yes/No and Description)
Yes	Radiobutton	Check this box if the Veteran reports or has a history of knee instability or recurrent subluxation.
No	Radiobutton	Check this box if the Veteran does not report and has no history of knee instability or recurrent subluxation.
Instability/Recurrent Subluxation Description	Text	Enter the Veteran’s description of knee instability or recurrent subluxation in their own words. Fill only if 'Yes' is 'Yes'. Depends on: Yes
2E Frequent Knee Effusion (Yes/No and Description)
Yes	Radiobutton	Check this box if the Veteran reports or has a history of frequent effusion (recurrent swelling/fluid) of the knee.
No	Radiobutton	Check this box if the Veteran does not report and has no history of frequent effusion (recurrent swelling/fluid) of the knee.
Frequent Knee Effusion Description	Text	Provide details describing the Veteran’s frequent knee effusion (swelling/fluid in the knee), including whether it is related to a diagnosis listed in Section 1. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Additional Disability Factors (Left Column - Description)
Additional Disability Factors Description	Text	Describe any additional factors contributing to the disability, including details for any items selected above and any other relevant contributing factors.
Additional Disability Factors (Left Column - Selections)
None	Checkbox	Check this box if there are no additional factors contributing to the disability beyond those already addressed.
Interference with sitting	Checkbox	Check this box if the condition interferes with the person’s ability to sit normally or for an expected duration.
Interference with standing	Checkbox	Check this box if the condition interferes with the person’s ability to stand normally or for an expected duration.
Swelling	Checkbox	Check this box if swelling is present and contributes to the disability.
Disturbance of locomotion	Checkbox	Check this box if the condition causes difficulty walking or otherwise disrupts normal movement/ambulation.
Deformity	Checkbox	Check this box if there is a deformity related to the condition that contributes to functional impairment.
Less movement than normal	Checkbox	Check this box if the affected body part has reduced range of motion compared with normal.
More movement than normal	Checkbox	Check this box if the affected body part has excessive motion or laxity compared with normal (e.g., due to instability).
Nonunion of fracture	Checkbox	Check this box if there is nonunion of a fracture (the fracture has not healed/fused as expected). Fill only if 'More movement than normal' is 'Yes'. Depends on: More movement than normal
Weakened movement	Checkbox	Check this box if the condition causes weakness that reduces the ability to move the affected body part normally.
Atrophy of disuse	Checkbox	Check this box if there is muscle wasting/atrophy due to reduced use of the affected body part.
Instability of station	Checkbox	Check this box if the person has unsteadiness or instability while standing or maintaining posture due to the condition.
Other (describe)	Checkbox	Check this box if there is another additional contributing factor not listed, and provide details in the description area.
Additional Disability Factors (Right Column - Description)
Additional Contributing Factors Description	Text	Describe any additional factors contributing to the disability (e.g., swelling, deformity, instability, interference with sitting/standing) and provide relevant details.
Additional Disability Factors (Right Column - Selections)
None	Checkbox	Check this box if there are no additional factors contributing to the disability beyond those already addressed.
Interference with sitting	Checkbox	Check this box if the condition interferes with the ability to sit.
Interference with standing	Checkbox	Check this box if the condition interferes with the ability to stand.
Swelling	Checkbox	Check this box if swelling is an additional factor contributing to the disability.
Disturbance of locomotion	Checkbox	Check this box if the condition causes difficulty walking or otherwise affects locomotion.
Deformity	Checkbox	Check this box if deformity is present and contributes to the disability.
Less movement than normal	Checkbox	Check this box if the affected area has reduced range of motion compared with normal.
More movement than normal	Checkbox	Check this box if the affected area has excessive motion compared with normal (e.g., instability or hypermobility).
Nonunion of fracture	Checkbox	Check this box if there is a nonunion of a fracture associated with the condition. Fill only if 'More movement than normal' is 'Yes'. Depends on: More movement than normal
Weakened movement	Checkbox	Check this box if the condition causes weakness or weakened movement of the affected area.
Atrophy of disuse	Checkbox	Check this box if there is muscle atrophy due to disuse related to the condition.
Instability of station	Checkbox	Check this box if the condition causes unsteadiness or instability while standing or maintaining posture.
Other, describe	Checkbox	Check this box if there are other additional contributing factors not listed and you will describe them.
Additional Knee Condition Diagnoses (Free Text)
Additional Knee Condition Diagnoses	Text	Enter any additional knee-related diagnoses not already listed above, using the same format as the prior diagnosis entries.
Brace Use and Frequency
Brace	Checkbox	Check this box if the Veteran uses a brace as an assistive device for locomotion. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Brace frequency: Occasional	Radiobutton	Check this box if the Veteran uses a brace occasionally. Fill only if 'Yes', 'Brace' is 'Yes' and all. Depends on: Yes, Brace
Brace frequency: Regular	Radiobutton	Check this box if the Veteran uses a brace regularly. Fill only if 'Yes', 'Brace' is 'Yes' and all. Depends on: Yes, Brace
Brace frequency: Constant	Radiobutton	Check this box if the Veteran uses a brace constantly. Fill only if 'Yes', 'Brace' is 'Yes' and all. Depends on: Yes, Brace
Cane(s) Use and Frequency
Cane(s)	Checkbox	Check this box if the Veteran uses a cane or canes as an assistive device for locomotion. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Cane(s) frequency: Occasional	Radiobutton	Check this box if the Veteran uses a cane or canes occasionally. Fill only if 'Yes', 'Cane(s)' is 'Yes' and all. Depends on: Yes, Cane(s)
Cane(s) frequency: Regular	Radiobutton	Check this box if the Veteran uses a cane or canes on a regular basis. Fill only if 'Yes', 'Cane(s)' is 'Yes' and all. Depends on: Yes, Cane(s)
Cane(s) frequency: Constant	Radiobutton	Check this box if the Veteran uses a cane or canes constantly. Fill only if 'Yes', 'Cane(s)' is 'Yes' and all. Depends on: Yes, Cane(s)
Claimed Condition(s) List
Claimed Condition(s)	Text	Enter the claimed medical condition(s) that pertain to this Knee and Lower Leg Disability Benefits Questionnaire.
Crutches Use and Frequency
Crutches	Checkbox	Check this box if the Veteran uses crutches as an assistive device for locomotion. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Crutches frequency: Occasional	Radiobutton	Check this box if the Veteran uses crutches occasionally. Fill only if 'Yes', 'Crutches' is 'Yes' and all. Depends on: Yes, Crutches
Crutches frequency: Regular	Radiobutton	Check this box if the Veteran uses crutches on a regular basis. Fill only if 'Yes', 'Crutches' is 'Yes' and all. Depends on: Yes, Crutches
Crutches frequency: Constant	Radiobutton	Check this box if the Veteran uses crutches constantly. Fill only if 'Yes', 'Crutches' is 'Yes' and all. Depends on: Yes, Crutches
Diagnosis Row - Arthritis, Gonorrheal
Arthritis, gonorrheal	Checkbox	Check this box if the Veteran has a diagnosis of gonorrheal arthritis associated with the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Check this box if the gonorrheal arthritis affects the right knee/lower leg only. Fill only if 'Arthritis, gonorrheal' is 'Yes'. Depends on: Arthritis, gonorrheal
Side affected: Left	Radiobutton	Check this box if the gonorrheal arthritis affects the left knee/lower leg only. Fill only if 'Arthritis, gonorrheal' is 'Yes'. Depends on: Arthritis, gonorrheal
Side affected: Both	Radiobutton	Check this box if the gonorrheal arthritis affects both the right and left knees/lower legs. Fill only if 'Arthritis, gonorrheal' is 'Yes'. Depends on: Arthritis, gonorrheal
ICD Code (Arthritis, gonorrheal)	Text	Enter the ICD diagnostic code for the gonorrheal arthritis diagnosis. Fill only if 'Arthritis, gonorrheal' is 'Yes'. Depends on: Arthritis, gonorrheal
Date of Diagnosis - Right (Arthritis, gonorrheal)	Date	Enter the date the gonorrheal arthritis was diagnosed for the right side. Fill only if 'Arthritis, gonorrheal' is 'Yes'. Depends on: Arthritis, gonorrheal
Date of Diagnosis - Left (Arthritis, gonorrheal)	Date	Enter the date the gonorrheal arthritis was diagnosed for the left side. Fill only if 'Arthritis, gonorrheal' is 'Yes'. Depends on: Arthritis, gonorrheal
Diagnosis Row - Arthritis, Pneumococcic
Arthritis, pneumococcic	Checkbox	Check this box if the Veteran has a diagnosis of pneumococcal arthritis associated with the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Check this box if the pneumococcal arthritis affects the right side only. Fill only if 'Arthritis, pneumococcic' is 'Yes'. Depends on: Arthritis, pneumococcic
Side affected: Left	Radiobutton	Check this box if the pneumococcal arthritis affects the left side only. Fill only if 'Arthritis, pneumococcic' is 'Yes'. Depends on: Arthritis, pneumococcic
Side affected: Both	Radiobutton	Check this box if the pneumococcal arthritis affects both the right and left sides. Fill only if 'Arthritis, pneumococcic' is 'Yes'. Depends on: Arthritis, pneumococcic
Arthritis, pneumococcic - ICD Code	Text	Enter the ICD diagnosis code for pneumococcal arthritis. Fill only if 'Arthritis, pneumococcic' is 'Yes'. Depends on: Arthritis, pneumococcic
Arthritis, pneumococcic - Date of Diagnosis (Right)	Date	Enter the date the pneumococcal arthritis was diagnosed for the right side. Fill only if 'Arthritis, pneumococcic' is 'Yes'. Depends on: Arthritis, pneumococcic
Arthritis, pneumococcic - Date of Diagnosis (Left)	Date	Enter the date the pneumococcal arthritis was diagnosed for the left side. Fill only if 'Arthritis, pneumococcic' is 'Yes'. Depends on: Arthritis, pneumococcic
Diagnosis Row - Arthritis, Rheumatoid (Multi-joints)
Arthritis, rheumatoid (multi-joints)	Checkbox	Check this box if the Veteran has a diagnosis of rheumatoid arthritis affecting multiple joints related to the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Check this box if the rheumatoid arthritis (multi-joints) affects the right side. Fill only if 'Arthritis, rheumatoid (multi-joints)' is 'Yes'. Depends on: Arthritis, rheumatoid (multi-joints)
Side affected: Left	Radiobutton	Check this box if the rheumatoid arthritis (multi-joints) affects the left side. Fill only if 'Arthritis, rheumatoid (multi-joints)' is 'Yes'. Depends on: Arthritis, rheumatoid (multi-joints)
Side affected: Both	Radiobutton	Check this box if the rheumatoid arthritis (multi-joints) affects both the right and left sides. Fill only if 'Arthritis, rheumatoid (multi-joints)' is 'Yes'. Depends on: Arthritis, rheumatoid (multi-joints)
ICD Code (Rheumatoid Arthritis, Multi-joints)	Text	Enter the ICD diagnostic code for rheumatoid arthritis (multi-joints). Fill only if 'Arthritis, rheumatoid (multi-joints)' is 'Yes'. Depends on: Arthritis, rheumatoid (multi-joints)
Date of Diagnosis (Right Side)	Date	Enter the date when rheumatoid arthritis (multi-joints) was diagnosed for the right side. Fill only if 'Arthritis, rheumatoid (multi-joints)' is 'Yes'. Depends on: Arthritis, rheumatoid (multi-joints)
Date of Diagnosis (Left Side)	Date	Enter the date when rheumatoid arthritis (multi-joints) was diagnosed for the left side. Fill only if 'Arthritis, rheumatoid (multi-joints)' is 'Yes'. Depends on: Arthritis, rheumatoid (multi-joints)
Diagnosis Row - Arthritis, Streptococcic
Arthritis, streptococcic	Checkbox	Check this box if the Veteran has a diagnosis of streptococcic arthritis associated with the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Check this box if the streptococcic arthritis affects the right knee/lower leg. Fill only if 'Arthritis, streptococcic' is 'Yes'. Depends on: Arthritis, streptococcic
Side affected: Left	Radiobutton	Check this box if the streptococcic arthritis affects the left knee/lower leg. Fill only if 'Arthritis, streptococcic' is 'Yes'. Depends on: Arthritis, streptococcic
Side affected: Both	Radiobutton	Check this box if the streptococcic arthritis affects both knees/lower legs. Fill only if 'Arthritis, streptococcic' is 'Yes'. Depends on: Arthritis, streptococcic
Arthritis, streptococcic ICD code	Text	Enter the ICD diagnostic code for the streptococcic arthritis condition. Fill only if 'Arthritis, streptococcic' is 'Yes'. Depends on: Arthritis, streptococcic
Arthritis, streptococcic date of diagnosis (Right)	Date	Provide the date when streptococcic arthritis was diagnosed for the right side. Fill only if 'Arthritis, streptococcic' is 'Yes'. Depends on: Arthritis, streptococcic
Arthritis, streptococcic date of diagnosis (Left)	Date	Provide the date when streptococcic arthritis was diagnosed for the left side. Fill only if 'Arthritis, streptococcic' is 'Yes'. Depends on: Arthritis, streptococcic
Diagnosis Row - Arthritis, Syphilitic
Arthritis, syphilitic	Checkbox	Check this box if the veteran has a diagnosis of syphilitic arthritis related to the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Check this box if the syphilitic arthritis affects the right side/knee. Fill only if 'Arthritis, syphilitic' is 'Yes'. Depends on: Arthritis, syphilitic
Side affected: Left	Radiobutton	Check this box if the syphilitic arthritis affects the left side/knee. Fill only if 'Arthritis, syphilitic' is 'Yes'. Depends on: Arthritis, syphilitic
Side affected: Both	Radiobutton	Check this box if the syphilitic arthritis affects both sides/knees. Fill only if 'Arthritis, syphilitic' is 'Yes'. Depends on: Arthritis, syphilitic
Arthritis, syphilitic - ICD Code	Text	Enter the ICD code associated with the diagnosis of syphilitic arthritis. Fill only if 'Arthritis, syphilitic' is 'Yes'. Depends on: Arthritis, syphilitic
Arthritis, syphilitic - Date of Diagnosis (Right)	Date	Enter the date the syphilitic arthritis diagnosis was made for the right side. Fill only if 'Arthritis, syphilitic' is 'Yes'. Depends on: Arthritis, syphilitic
Arthritis, syphilitic - Date of Diagnosis (Left)	Date	Enter the date the syphilitic arthritis diagnosis was made for the left side. Fill only if 'Arthritis, syphilitic' is 'Yes'. Depends on: Arthritis, syphilitic
Diagnosis Row - Arthritis, Typhoid
Arthritis, typhoid	Checkbox	Check this box if the Veteran has a diagnosis of typhoid arthritis associated with the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Check this box if typhoid arthritis affects the right side/knee/leg only. Fill only if 'Arthritis, typhoid' is 'Yes'. Depends on: Arthritis, typhoid
Side affected: Left	Radiobutton	Check this box if typhoid arthritis affects the left side/knee/leg only. Fill only if 'Arthritis, typhoid' is 'Yes'. Depends on: Arthritis, typhoid
Side affected: Both	Radiobutton	Check this box if typhoid arthritis affects both sides/knees/legs. Fill only if 'Arthritis, typhoid' is 'Yes'. Depends on: Arthritis, typhoid
Arthritis, Typhoid - ICD Code	Text	Enter the ICD diagnostic code corresponding to the diagnosis of arthritis, typhoid. Fill only if 'Arthritis, typhoid' is 'Yes'. Depends on: Arthritis, typhoid
Arthritis, Typhoid - Date of Diagnosis (Right)	Date	Enter the date the arthritis, typhoid diagnosis was made for the right side. Fill only if 'Arthritis, typhoid' is 'Yes'. Depends on: Arthritis, typhoid
Arthritis, Typhoid - Date of Diagnosis (Left)	Date	Enter the date the arthritis, typhoid diagnosis was made for the left side. Fill only if 'Arthritis, typhoid' is 'Yes'. Depends on: Arthritis, typhoid
Diagnosis Row - Bone, Neoplasm, Benign
Bones, neoplasm, benign	Checkbox	Check this box if the veteran has a current diagnosis of a benign bone neoplasm associated with the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Select this option if the benign bone neoplasm affects the right side only. Fill only if 'Bones, neoplasm, benign' is 'Yes'. Depends on: Bones, neoplasm, benign
Side affected: Left	Radiobutton	Select this option if the benign bone neoplasm affects the left side only. Fill only if 'Bones, neoplasm, benign' is 'Yes'. Depends on: Bones, neoplasm, benign
Side affected: Both	Radiobutton	Select this option if the benign bone neoplasm affects both the right and left sides. Fill only if 'Bones, neoplasm, benign' is 'Yes'. Depends on: Bones, neoplasm, benign
ICD Code	Text	Enter the ICD diagnostic code for the selected condition (Bones, neoplasm, benign). Fill only if 'Bones, neoplasm, benign' is 'Yes'. Depends on: Bones, neoplasm, benign
Date of Diagnosis (Right)	Date	Enter the date the condition was diagnosed for the right side. Fill only if 'Bones, neoplasm, benign' is 'Yes'. Depends on: Bones, neoplasm, benign
Date of Diagnosis (Left)	Date	Enter the date the condition was diagnosed for the left side. Fill only if 'Bones, neoplasm, benign' is 'Yes'. Depends on: Bones, neoplasm, benign
Diagnosis Row - Bursitis
Bursitis (diagnosis)	Checkbox	Check this box if bursitis is a current diagnosis associated with the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Bursitis - Right side affected	Radiobutton	Select this option if the bursitis affects the right side only. Fill only if 'Bursitis (diagnosis)' is 'Yes'. Depends on: Bursitis (diagnosis)
Bursitis - Left side affected	Radiobutton	Select this option if the bursitis affects the left side only. Fill only if 'Bursitis (diagnosis)' is 'Yes'. Depends on: Bursitis (diagnosis)
Bursitis - Both sides affected	Radiobutton	Select this option if the bursitis affects both the right and left sides. Fill only if 'Bursitis (diagnosis)' is 'Yes'. Depends on: Bursitis (diagnosis)
Bursitis ICD Code	Text	Enter the ICD diagnosis code corresponding to the bursitis diagnosis. Fill only if 'Bursitis (diagnosis)' is 'Yes'. Depends on: Bursitis (diagnosis)
Bursitis Date of Diagnosis (Right)	Date	Enter the date the bursitis was diagnosed for the right side. Fill only if 'Bursitis (diagnosis)' is 'Yes'. Depends on: Bursitis (diagnosis)
Bursitis Date of Diagnosis (Left)	Date	Enter the date the bursitis was diagnosed for the left side. Fill only if 'Bursitis (diagnosis)' is 'Yes'. Depends on: Bursitis (diagnosis)
Diagnosis Row - Degenerative Arthritis (Other Than Post Traumatic)
Degenerative arthritis, other than post traumatic	Checkbox	Check this box if the Veteran has a diagnosis of degenerative arthritis that is not post-traumatic for the claimed knee/lower leg condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected – Right	Radiobutton	Check this box if the degenerative arthritis (other than post traumatic) affects the right side. Fill only if 'Degenerative arthritis, other than post traumatic' is 'Yes'. Depends on: Degenerative arthritis, other than post traumatic
Side affected – Left	Radiobutton	Check this box if the degenerative arthritis (other than post traumatic) affects the left side. Fill only if 'Degenerative arthritis, other than post traumatic' is 'Yes'. Depends on: Degenerative arthritis, other than post traumatic
Side affected – Both	Radiobutton	Check this box if the degenerative arthritis (other than post traumatic) affects both the right and left sides. Fill only if 'Degenerative arthritis, other than post traumatic' is 'Yes'. Depends on: Degenerative arthritis, other than post traumatic
ICD Code (Degenerative arthritis, other than post traumatic)	Text	Enter the ICD diagnostic code for degenerative arthritis (other than post traumatic). Fill only if 'Degenerative arthritis, other than post traumatic' is 'Yes'. Depends on: Degenerative arthritis, other than post traumatic
Date of Diagnosis – Right (Degenerative arthritis)	Date	Enter the date degenerative arthritis (other than post traumatic) was diagnosed for the right side. Fill only if 'Degenerative arthritis, other than post traumatic' is 'Yes'. Depends on: Degenerative arthritis, other than post traumatic
Date of Diagnosis – Left (Degenerative arthritis)	Date	Enter the date degenerative arthritis (other than post traumatic) was diagnosed for the left side. Fill only if 'Degenerative arthritis, other than post traumatic' is 'Yes'. Depends on: Degenerative arthritis, other than post traumatic
Diagnosis Row - Gout
Gout	Checkbox	Check this box if gout is a current diagnosis associated with the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected - Right	Radiobutton	Check this box if the gout diagnosis affects the right side only. Fill only if 'Gout' is 'Yes'. Depends on: Gout
Side affected - Left	Radiobutton	Check this box if the gout diagnosis affects the left side only. Fill only if 'Gout' is 'Yes'. Depends on: Gout
Side affected - Both	Radiobutton	Check this box if the gout diagnosis affects both the right and left sides. Fill only if 'Gout' is 'Yes'. Depends on: Gout
Gout ICD Code	Text	Enter the ICD diagnosis code for the patient's gout. Fill only if 'Gout' is 'Yes'. Depends on: Gout
Gout Date of Diagnosis (Right)	Date	Enter the date the patient's gout was diagnosed for the right side. Fill only if 'Gout' is 'Yes'. Depends on: Gout
Gout Date of Diagnosis (Left)	Date	Enter the date the patient's gout was diagnosed for the left side. Fill only if 'Gout' is 'Yes'. Depends on: Gout
Diagnosis Row - Heterotopic Ossification
Heterotopic ossification	Checkbox	Check this box if the Veteran has a current diagnosis of heterotopic ossification associated with the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Select this option if the heterotopic ossification diagnosis affects the right side only. Fill only if 'Heterotopic ossification' is 'Yes'. Depends on: Heterotopic ossification
Side affected: Left	Radiobutton	Select this option if the heterotopic ossification diagnosis affects the left side only. Fill only if 'Heterotopic ossification' is 'Yes'. Depends on: Heterotopic ossification
Side affected: Both	Radiobutton	Select this option if the heterotopic ossification diagnosis affects both the right and left sides. Fill only if 'Heterotopic ossification' is 'Yes'. Depends on: Heterotopic ossification
Heterotopic Ossification ICD Code	Text	Enter the ICD diagnosis code for the heterotopic ossification diagnosis. Fill only if 'Heterotopic ossification' is 'Yes'. Depends on: Heterotopic ossification
Heterotopic Ossification Diagnosis Date (Right)	Date	Enter the date the heterotopic ossification diagnosis was made for the right side. Fill only if 'Heterotopic ossification' is 'Yes'. Depends on: Heterotopic ossification
Heterotopic Ossification Diagnosis Date (Left)	Date	Enter the date the heterotopic ossification diagnosis was made for the left side. Fill only if 'Heterotopic ossification' is 'Yes'. Depends on: Heterotopic ossification
Diagnosis Row - Inflammatory Other Types
Inflammatory other types	Checkbox	Check this box if the Veteran has an inflammatory condition of the knee/lower leg that is not otherwise listed on the form. Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Check this box if the inflammatory condition affects the right knee/lower leg. Fill only if 'Inflammatory other types' is 'Yes'. Depends on: Inflammatory other types
Side affected: Left	Radiobutton	Check this box if the inflammatory condition affects the left knee/lower leg. Fill only if 'Inflammatory other types' is 'Yes'. Depends on: Inflammatory other types
Side affected: Both	Radiobutton	Check this box if the inflammatory condition affects both the right and left knees/lower legs. Fill only if 'Inflammatory other types' is 'Yes'. Depends on: Inflammatory other types
Inflammatory Other Types ICD Code	Text	Enter the ICD diagnostic code for the selected inflammatory other type condition. Fill only if 'Inflammatory other types' is 'Yes'. Depends on: Inflammatory other types
Inflammatory Other Types Date of Diagnosis (Right)	Date	Enter the date the inflammatory other type condition was diagnosed for the right side. Fill only if 'Inflammatory other types' is 'Yes'. Depends on: Inflammatory other types
Inflammatory Other Types Date of Diagnosis (Left)	Date	Enter the date the inflammatory other type condition was diagnosed for the left side. Fill only if 'Inflammatory other types' is 'Yes'. Depends on: Inflammatory other types
Inflammatory Other Types Specification	Text	Specify the exact inflammatory condition/type being claimed or diagnosed for this row. Fill only if 'Inflammatory other types' is 'Yes'. Depends on: Inflammatory other types
Diagnosis Row - Knee Anterior Cruciate Ligament Tear
Knee anterior cruciate ligament tear	Checkbox	Check this box if the Veteran has a diagnosis of an anterior cruciate ligament (ACL) tear of the knee. Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Check this box if the ACL tear diagnosis affects the right knee only. Fill only if 'Knee anterior cruciate ligament tear' is 'Yes'. Depends on: Knee anterior cruciate ligament tear
Side affected: Left	Radiobutton	Check this box if the ACL tear diagnosis affects the left knee only. Fill only if 'Knee anterior cruciate ligament tear' is 'Yes'. Depends on: Knee anterior cruciate ligament tear
Side affected: Both	Radiobutton	Check this box if the ACL tear diagnosis affects both knees. Fill only if 'Knee anterior cruciate ligament tear' is 'Yes'. Depends on: Knee anterior cruciate ligament tear
ICD Code (Knee ACL Tear)	Text	Enter the ICD diagnosis code for the knee anterior cruciate ligament (ACL) tear. Fill only if 'Knee anterior cruciate ligament tear' is 'Yes'. Depends on: Knee anterior cruciate ligament tear
Date of Diagnosis – Right (Knee ACL Tear)	Date	Provide the date the right knee anterior cruciate ligament (ACL) tear was diagnosed. Fill only if 'Knee anterior cruciate ligament tear' is 'Yes'. Depends on: Knee anterior cruciate ligament tear
Date of Diagnosis – Left (Knee ACL Tear)	Date	Provide the date the left knee anterior cruciate ligament (ACL) tear was diagnosed. Fill only if 'Knee anterior cruciate ligament tear' is 'Yes'. Depends on: Knee anterior cruciate ligament tear
Diagnosis Row - Knee Cartilage Restoration Surgery
Knee cartilage restoration surgery	Checkbox	Check this box if the Veteran has a diagnosis/history of knee cartilage restoration surgery associated with the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected - Right	Radiobutton	Check this box if the knee cartilage restoration surgery/condition affects the right knee. Fill only if 'Knee cartilage restoration surgery' is 'Yes'. Depends on: Knee cartilage restoration surgery
Side affected - Left	Radiobutton	Check this box if the knee cartilage restoration surgery/condition affects the left knee. Fill only if 'Knee cartilage restoration surgery' is 'Yes'. Depends on: Knee cartilage restoration surgery
Side affected - Both	Radiobutton	Check this box if the knee cartilage restoration surgery/condition affects both knees. Fill only if 'Knee cartilage restoration surgery' is 'Yes'. Depends on: Knee cartilage restoration surgery
ICD Code (Knee Cartilage Restoration Surgery)	Text	Enter the ICD diagnosis code associated with the knee cartilage restoration surgery condition. Fill only if 'Knee cartilage restoration surgery' is 'Yes'. Depends on: Knee cartilage restoration surgery
Date of Diagnosis - Right Knee (Knee Cartilage Restoration Surgery)	Date	Enter the date the knee cartilage restoration surgery condition was diagnosed for the right knee. Fill only if 'Knee cartilage restoration surgery' is 'Yes'. Depends on: Knee cartilage restoration surgery
Date of Diagnosis - Left Knee (Knee Cartilage Restoration Surgery)	Date	Enter the date the knee cartilage restoration surgery condition was diagnosed for the left knee. Fill only if 'Knee cartilage restoration surgery' is 'Yes'. Depends on: Knee cartilage restoration surgery
Diagnosis Row - Knee Fracture (Including Patellar Fracture)
Knee fracture (including patellar fracture)	Checkbox	Check this box if the Veteran has a diagnosis of a knee fracture, including a patellar fracture. Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Check this box if the knee fracture diagnosis affects the right knee. Fill only if 'Knee fracture (including patellar fracture)' is 'Yes'. Depends on: Knee fracture (including patellar fracture)
Side affected: Left	Radiobutton	Check this box if the knee fracture diagnosis affects the left knee. Fill only if 'Knee fracture (including patellar fracture)' is 'Yes'. Depends on: Knee fracture (including patellar fracture)
Side affected: Both	Radiobutton	Check this box if the knee fracture diagnosis affects both knees. Fill only if 'Knee fracture (including patellar fracture)' is 'Yes'. Depends on: Knee fracture (including patellar fracture)
Knee Fracture ICD Code	Text	Enter the ICD code corresponding to the diagnosed knee fracture (including patellar fracture). Fill only if 'Knee fracture (including patellar fracture)' is 'Yes'. Depends on: Knee fracture (including patellar fracture)
Knee Fracture Diagnosis Date (Right)	Date	Enter the date the right knee fracture (including patellar fracture) was diagnosed. Fill only if 'Knee fracture (including patellar fracture)' is 'Yes'. Depends on: Knee fracture (including patellar fracture)
Knee Fracture Diagnosis Date (Left)	Date	Enter the date the left knee fracture (including patellar fracture) was diagnosed. Fill only if 'Knee fracture (including patellar fracture)' is 'Yes'. Depends on: Knee fracture (including patellar fracture)
Diagnosis Row - Knee Instability
Knee instability	Checkbox	Check this box if the Veteran has a current diagnosis of knee instability associated with the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Check this box if the knee instability diagnosis affects the right knee. Fill only if 'Knee instability' is 'Yes'. Depends on: Knee instability
Side affected: Left	Radiobutton	Check this box if the knee instability diagnosis affects the left knee. Fill only if 'Knee instability' is 'Yes'. Depends on: Knee instability
Side affected: Both	Radiobutton	Check this box if the knee instability diagnosis affects both knees. Fill only if 'Knee instability' is 'Yes'. Depends on: Knee instability
Knee Instability ICD Code	Text	Enter the ICD diagnostic code for the knee instability condition. Fill only if 'Knee instability' is 'Yes'. Depends on: Knee instability
Knee Instability Date of Diagnosis (Right)	Date	Provide the date the right knee instability was diagnosed. Fill only if 'Knee instability' is 'Yes'. Depends on: Knee instability
Knee Instability Date of Diagnosis (Left)	Date	Provide the date the left knee instability was diagnosed. Fill only if 'Knee instability' is 'Yes'. Depends on: Knee instability
Diagnosis Row - Knee Joint Ankylosis
Knee joint ankylosis	Checkbox	Check this box if the Veteran has a diagnosis of knee joint ankylosis associated with the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Check this option if the knee joint ankylosis affects the right knee only. Fill only if 'Knee joint ankylosis' is 'Yes'. Depends on: Knee joint ankylosis
Side affected: Left	Radiobutton	Check this option if the knee joint ankylosis affects the left knee only. Fill only if 'Knee joint ankylosis' is 'Yes'. Depends on: Knee joint ankylosis
Side affected: Both	Radiobutton	Check this option if the knee joint ankylosis affects both knees. Fill only if 'Knee joint ankylosis' is 'Yes'. Depends on: Knee joint ankylosis
Knee Joint Ankylosis ICD Code	Text	Enter the ICD diagnosis code for the Veteran's knee joint ankylosis. Fill only if 'Knee joint ankylosis' is 'Yes'. Depends on: Knee joint ankylosis
Knee Joint Ankylosis Date of Diagnosis (Right)	Date	Enter the date the Veteran was diagnosed with knee joint ankylosis affecting the right knee. Fill only if 'Knee joint ankylosis' is 'Yes'. Depends on: Knee joint ankylosis
Knee Joint Ankylosis Date of Diagnosis (Left)	Date	Enter the date the Veteran was diagnosed with knee joint ankylosis affecting the left knee. Fill only if 'Knee joint ankylosis' is 'Yes'. Depends on: Knee joint ankylosis
Diagnosis Row - Knee Joint Osteoarthritis
Knee joint osteoarthritis	Checkbox	Check this box if the Veteran has a diagnosis of knee joint osteoarthritis associated with the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Check this box if the knee joint osteoarthritis affects the Veteran’s right knee. Fill only if 'Knee joint osteoarthritis' is 'Yes'. Depends on: Knee joint osteoarthritis
Side affected: Left	Radiobutton	Check this box if the knee joint osteoarthritis affects the Veteran’s left knee. Fill only if 'Knee joint osteoarthritis' is 'Yes'. Depends on: Knee joint osteoarthritis
Side affected: Both	Radiobutton	Check this box if the knee joint osteoarthritis affects both knees. Fill only if 'Knee joint osteoarthritis' is 'Yes'. Depends on: Knee joint osteoarthritis
Knee Joint Osteoarthritis ICD Code	Text	Enter the ICD diagnosis code for the knee joint osteoarthritis diagnosis. Fill only if 'Knee joint osteoarthritis' is 'Yes'. Depends on: Knee joint osteoarthritis
Knee Joint Osteoarthritis Date of Diagnosis (Right)	Date	Enter the date the right knee joint osteoarthritis was diagnosed. Fill only if 'Knee joint osteoarthritis' is 'Yes'. Depends on: Knee joint osteoarthritis
Knee Joint Osteoarthritis Date of Diagnosis (Left)	Date	Enter the date the left knee joint osteoarthritis was diagnosed. Fill only if 'Knee joint osteoarthritis' is 'Yes'. Depends on: Knee joint osteoarthritis
Diagnosis Row - Knee Meniscal Tear
Knee meniscal tear	Checkbox	Check this box if the Veteran has a current diagnosis of a knee meniscal tear associated with the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Knee meniscal tear - Right	Radiobutton	Check this box if the knee meniscal tear affects the right knee. Fill only if 'Knee meniscal tear' is 'Yes'. Depends on: Knee meniscal tear
Knee meniscal tear - Left	Radiobutton	Check this box if the knee meniscal tear affects the left knee. Fill only if 'Knee meniscal tear' is 'Yes'. Depends on: Knee meniscal tear
Knee meniscal tear - Both	Radiobutton	Check this box if the knee meniscal tear affects both knees. Fill only if 'Knee meniscal tear' is 'Yes'. Depends on: Knee meniscal tear
Knee meniscal tear ICD code	Text	Enter the ICD diagnostic code for the knee meniscal tear diagnosis. Fill only if 'Knee meniscal tear' is 'Yes'. Depends on: Knee meniscal tear
Knee meniscal tear diagnosis date (Right)	Date	Enter the date the right knee meniscal tear was diagnosed. Fill only if 'Knee meniscal tear' is 'Yes'. Depends on: Knee meniscal tear
Knee meniscal tear diagnosis date (Left)	Date	Enter the date the left knee meniscal tear was diagnosed. Fill only if 'Knee meniscal tear' is 'Yes'. Depends on: Knee meniscal tear
Diagnosis Row - Knee Posterior Cruciate Ligament Tear
Knee posterior cruciate ligament tear	Checkbox	Check this box if the Veteran has a diagnosis of a knee posterior cruciate ligament (PCL) tear associated with the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Check this box if the diagnosed knee posterior cruciate ligament (PCL) tear affects the right knee. Fill only if 'Knee posterior cruciate ligament tear' is 'Yes'. Depends on: Knee posterior cruciate ligament tear
Side affected: Left	Radiobutton	Check this box if the diagnosed knee posterior cruciate ligament (PCL) tear affects the left knee. Fill only if 'Knee posterior cruciate ligament tear' is 'Yes'. Depends on: Knee posterior cruciate ligament tear
Side affected: Both	Radiobutton	Check this box if the diagnosed knee posterior cruciate ligament (PCL) tear affects both knees. Fill only if 'Knee posterior cruciate ligament tear' is 'Yes'. Depends on: Knee posterior cruciate ligament tear
ICD Code (Knee posterior cruciate ligament tear)	Text	Enter the ICD diagnosis code for the knee posterior cruciate ligament tear. Fill only if 'Knee posterior cruciate ligament tear' is 'Yes'. Depends on: Knee posterior cruciate ligament tear
Date of Diagnosis - Right Knee (PCL tear)	Date	Enter the date the right knee posterior cruciate ligament tear was diagnosed. Fill only if 'Knee posterior cruciate ligament tear' is 'Yes'. Depends on: Knee posterior cruciate ligament tear
Date of Diagnosis - Left Knee (PCL tear)	Date	Enter the date the left knee posterior cruciate ligament tear was diagnosed. Fill only if 'Knee posterior cruciate ligament tear' is 'Yes'. Depends on: Knee posterior cruciate ligament tear
Diagnosis Row - Knee Strain
Knee strain	Checkbox	Check this box if the Veteran has a diagnosis of knee strain associated with the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Check this box if the knee strain affects the right knee. Fill only if 'Knee strain' is 'Yes'. Depends on: Knee strain
Side affected: Left	Radiobutton	Check this box if the knee strain affects the left knee. Fill only if 'Knee strain' is 'Yes'. Depends on: Knee strain
Side affected: Both	Radiobutton	Check this box if the knee strain affects both knees. Fill only if 'Knee strain' is 'Yes'. Depends on: Knee strain
Knee Strain ICD Code	Text	Enter the ICD diagnosis code corresponding to the knee strain. Fill only if 'Knee strain' is 'Yes'. Depends on: Knee strain
Knee Strain Date of Diagnosis (Right)	Date	Enter the date the right knee strain was diagnosed. Fill only if 'Knee strain' is 'Yes'. Depends on: Knee strain
Knee Strain Date of Diagnosis (Left)	Date	Enter the date the left knee strain was diagnosed. Fill only if 'Knee strain' is 'Yes'. Depends on: Knee strain
Diagnosis Row - Myositis
Myositis	Checkbox	Check this box if the Veteran has a current diagnosis of myositis associated with the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Myositis - Side affected: Right	Radiobutton	Check this box if the diagnosed myositis affects the right side only. Fill only if 'Myositis' is 'Yes'. Depends on: Myositis
Myositis - Side affected: Left	Radiobutton	Check this box if the diagnosed myositis affects the left side only. Fill only if 'Myositis' is 'Yes'. Depends on: Myositis
Myositis - Side affected: Both	Radiobutton	Check this box if the diagnosed myositis affects both the right and left sides. Fill only if 'Myositis' is 'Yes'. Depends on: Myositis
Myositis ICD Code	Text	Enter the ICD diagnostic code for the myositis diagnosis. Fill only if 'Myositis' is 'Yes'. Depends on: Myositis
Myositis Date of Diagnosis (Right)	Date	Enter the date myositis was diagnosed for the right side. Fill only if 'Myositis' is 'Yes'. Depends on: Myositis
Myositis Date of Diagnosis (Left)	Date	Enter the date myositis was diagnosed for the left side. Fill only if 'Myositis' is 'Yes'. Depends on: Myositis
Diagnosis Row - Osteitis Deformans
Osteitis deformans	Checkbox	Check this box if the Veteran has a current diagnosis of osteitis deformans (Paget disease of bone) associated with the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Osteitis deformans - Right side	Radiobutton	Check this box if the osteitis deformans affects the right side only. Fill only if 'Osteitis deformans' is 'Yes'. Depends on: Osteitis deformans
Osteitis deformans - Left side	Radiobutton	Check this box if the osteitis deformans affects the left side only. Fill only if 'Osteitis deformans' is 'Yes'. Depends on: Osteitis deformans
Osteitis deformans - Both sides	Radiobutton	Check this box if the osteitis deformans affects both the right and left sides. Fill only if 'Osteitis deformans' is 'Yes'. Depends on: Osteitis deformans
Osteitis deformans ICD code	Text	Enter the ICD diagnosis code for osteitis deformans. Fill only if 'Osteitis deformans' is 'Yes'. Depends on: Osteitis deformans
Osteitis deformans date of diagnosis (Right)	Date	Enter the date osteitis deformans was diagnosed for the right side. Fill only if 'Osteitis deformans' is 'Yes'. Depends on: Osteitis deformans
Osteitis deformans date of diagnosis (Left)	Date	Enter the date osteitis deformans was diagnosed for the left side. Fill only if 'Osteitis deformans' is 'Yes'. Depends on: Osteitis deformans
Diagnosis Row - Osteomalacia, Residuals Of
Osteomalacia, residuals of	Checkbox	Check this box if the Veteran has a current diagnosis of residuals of osteomalacia related to the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Check this box if the residuals of osteomalacia affect the right knee/lower leg only. Fill only if 'Osteomalacia, residuals of' is 'Yes'. Depends on: Osteomalacia, residuals of
Side affected: Left	Radiobutton	Check this box if the residuals of osteomalacia affect the left knee/lower leg only. Fill only if 'Osteomalacia, residuals of' is 'Yes'. Depends on: Osteomalacia, residuals of
Side affected: Both	Radiobutton	Check this box if the residuals of osteomalacia affect both the right and left knees/lower legs. Fill only if 'Osteomalacia, residuals of' is 'Yes'. Depends on: Osteomalacia, residuals of
Osteomalacia Residuals ICD Code	Text	Enter the ICD diagnosis code for osteomalacia, residuals of. Fill only if 'Osteomalacia, residuals of' is 'Yes'. Depends on: Osteomalacia, residuals of
Osteomalacia Residuals Date of Diagnosis (Right)	Date	Enter the date of diagnosis for osteomalacia, residuals of, affecting the right side. Fill only if 'Osteomalacia, residuals of' is 'Yes'. Depends on: Osteomalacia, residuals of
Osteomalacia Residuals Date of Diagnosis (Left)	Date	Enter the date of diagnosis for osteomalacia, residuals of, affecting the left side. Fill only if 'Osteomalacia, residuals of' is 'Yes'. Depends on: Osteomalacia, residuals of
Diagnosis Row - Osteoporosis, Residuals Of
Osteoporosis, residuals of	Checkbox	Check this box if the Veteran has a diagnosis of osteoporosis with residuals related to the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Check this box if the osteoporosis residuals affect the right side. Fill only if 'Osteoporosis, residuals of' is 'Yes'. Depends on: Osteoporosis, residuals of
Side affected: Left	Radiobutton	Check this box if the osteoporosis residuals affect the left side. Fill only if 'Osteoporosis, residuals of' is 'Yes'. Depends on: Osteoporosis, residuals of
Side affected: Both	Radiobutton	Check this box if the osteoporosis residuals affect both the right and left sides. Fill only if 'Osteoporosis, residuals of' is 'Yes'. Depends on: Osteoporosis, residuals of
Osteoporosis Residuals ICD Code	Text	Enter the ICD diagnosis code for osteoporosis, residuals of. Fill only if 'Osteoporosis, residuals of' is 'Yes'. Depends on: Osteoporosis, residuals of
Osteoporosis Residuals Date of Diagnosis (Right)	Date	Enter the date of diagnosis for osteoporosis, residuals of, for the right side. Fill only if 'Osteoporosis, residuals of' is 'Yes'. Depends on: Osteoporosis, residuals of
Osteoporosis Residuals Date of Diagnosis (Left)	Date	Enter the date of diagnosis for osteoporosis, residuals of, for the left side. Fill only if 'Osteoporosis, residuals of' is 'Yes'. Depends on: Osteoporosis, residuals of
Diagnosis Row - Other Specified Forms of Arthropathy (Excluding Gout)
Other specified forms of arthropathy (excluding gout)	Checkbox	Check this box if the Veteran has a diagnosis of other specified forms of arthropathy (not gout) associated with the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Check this box if the arthropathy affects the right side only. Fill only if 'Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Other specified forms of arthropathy (excluding gout)
Side affected: Left	Radiobutton	Check this box if the arthropathy affects the left side only. Fill only if 'Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Other specified forms of arthropathy (excluding gout)
Side affected: Both	Radiobutton	Check this box if the arthropathy affects both the right and left sides. Fill only if 'Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Other specified forms of arthropathy (excluding gout)
ICD Code (Other Specified Arthropathy)	Text	Enter the ICD diagnosis code for the condition "Other specified forms of arthropathy (excluding gout)". Fill only if 'Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Other specified forms of arthropathy (excluding gout)
Date of Diagnosis (Right)	Date	Enter the date this condition was diagnosed for the right side. Fill only if 'Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Other specified forms of arthropathy (excluding gout)
Date of Diagnosis (Left)	Date	Enter the date this condition was diagnosed for the left side. Fill only if 'Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Other specified forms of arthropathy (excluding gout)
Specify Other Arthropathy Diagnosis	Text	Specify the exact arthropathy diagnosis being claimed or identified (excluding gout). Fill only if 'Other specified forms of arthropathy (excluding gout)' is 'Yes'. Depends on: Other specified forms of arthropathy (excluding gout)
Diagnosis Row - Patellar Instability
Patellar instability	Checkbox	Check this box if the Veteran has a diagnosis of patellar instability associated with the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Patellar instability - Side affected: Right	Radiobutton	Select this option if the patellar instability affects the right knee only. Fill only if 'Patellar instability' is 'Yes'. Depends on: Patellar instability
Patellar instability - Side affected: Left	Radiobutton	Select this option if the patellar instability affects the left knee only. Fill only if 'Patellar instability' is 'Yes'. Depends on: Patellar instability
Patellar instability - Side affected: Both	Radiobutton	Select this option if the patellar instability affects both knees. Fill only if 'Patellar instability' is 'Yes'. Depends on: Patellar instability
Patellar Instability ICD Code	Text	Enter the ICD diagnosis code corresponding to patellar instability. Fill only if 'Patellar instability' is 'Yes'. Depends on: Patellar instability
Patellar Instability Date of Diagnosis (Right)	Date	Provide the date patellar instability was diagnosed for the right knee. Fill only if 'Patellar instability' is 'Yes'. Depends on: Patellar instability
Patellar Instability Date of Diagnosis (Left)	Date	Provide the date patellar instability was diagnosed for the left knee. Fill only if 'Patellar instability' is 'Yes'. Depends on: Patellar instability
Diagnosis Row - Patellar or Quadriceps Tendon Rupture
Patellar or quadriceps tendon rupture	Checkbox	Check this box if the Veteran has a diagnosis of patellar or quadriceps tendon rupture associated with the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Check this box if the patellar or quadriceps tendon rupture affects the right knee/leg only. Fill only if 'Patellar or quadriceps tendon rupture' is 'Yes'. Depends on: Patellar or quadriceps tendon rupture
Side affected: Left	Radiobutton	Check this box if the patellar or quadriceps tendon rupture affects the left knee/leg only. Fill only if 'Patellar or quadriceps tendon rupture' is 'Yes'. Depends on: Patellar or quadriceps tendon rupture
Side affected: Both	Radiobutton	Check this box if the patellar or quadriceps tendon rupture affects both knees/legs. Fill only if 'Patellar or quadriceps tendon rupture' is 'Yes'. Depends on: Patellar or quadriceps tendon rupture
ICD Code (Patellar/Quadriceps Tendon Rupture)	Text	Enter the ICD diagnosis code for the patellar or quadriceps tendon rupture. Fill only if 'Patellar or quadriceps tendon rupture' is 'Yes'. Depends on: Patellar or quadriceps tendon rupture
Date of Diagnosis - Right (Patellar/Quadriceps Tendon Rupture)	Date	Enter the date the right-side patellar or quadriceps tendon rupture was diagnosed. Fill only if 'Patellar or quadriceps tendon rupture' is 'Yes'. Depends on: Patellar or quadriceps tendon rupture
Date of Diagnosis - Left (Patellar/Quadriceps Tendon Rupture)	Date	Enter the date the left-side patellar or quadriceps tendon rupture was diagnosed. Fill only if 'Patellar or quadriceps tendon rupture' is 'Yes'. Depends on: Patellar or quadriceps tendon rupture
Diagnosis Row - Patellofemoral Pain Syndrome
Patellofemoral pain syndrome	Checkbox	Check this box if the Veteran has a diagnosis of patellofemoral pain syndrome associated with the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Check this box if patellofemoral pain syndrome affects the right knee only. Fill only if 'Patellofemoral pain syndrome' is 'Yes'. Depends on: Patellofemoral pain syndrome
Side affected: Left	Radiobutton	Check this box if patellofemoral pain syndrome affects the left knee only. Fill only if 'Patellofemoral pain syndrome' is 'Yes'. Depends on: Patellofemoral pain syndrome
Side affected: Both	Radiobutton	Check this box if patellofemoral pain syndrome affects both knees. Fill only if 'Patellofemoral pain syndrome' is 'Yes'. Depends on: Patellofemoral pain syndrome
Patellofemoral Pain Syndrome ICD Code	Text	Enter the ICD diagnostic code for patellofemoral pain syndrome. Fill only if 'Patellofemoral pain syndrome' is 'Yes'. Depends on: Patellofemoral pain syndrome
Patellofemoral Pain Syndrome Date of Diagnosis (Right)	Date	Enter the date patellofemoral pain syndrome was diagnosed for the right side. Fill only if 'Patellofemoral pain syndrome' is 'Yes'. Depends on: Patellofemoral pain syndrome
Patellofemoral Pain Syndrome Date of Diagnosis (Left)	Date	Enter the date patellofemoral pain syndrome was diagnosed for the left side. Fill only if 'Patellofemoral pain syndrome' is 'Yes'. Depends on: Patellofemoral pain syndrome
Diagnosis Row - Post-traumatic Arthritis
Post-traumatic arthritis	Checkbox	Check this box if the Veteran has a diagnosis of post-traumatic arthritis related to the claimed knee/lower leg condition. Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Post-traumatic arthritis - Right	Radiobutton	Check this box if the post-traumatic arthritis affects the right side only. Fill only if 'Post-traumatic arthritis' is 'Yes'. Depends on: Post-traumatic arthritis
Post-traumatic arthritis - Left	Radiobutton	Check this box if the post-traumatic arthritis affects the left side only. Fill only if 'Post-traumatic arthritis' is 'Yes'. Depends on: Post-traumatic arthritis
Post-traumatic arthritis - Both	Radiobutton	Check this box if the post-traumatic arthritis affects both the right and left sides. Fill only if 'Post-traumatic arthritis' is 'Yes'. Depends on: Post-traumatic arthritis
Post-traumatic Arthritis ICD Code	Text	Enter the ICD diagnosis code for post-traumatic arthritis. Fill only if 'Post-traumatic arthritis' is 'Yes'. Depends on: Post-traumatic arthritis
Post-traumatic Arthritis Date of Diagnosis (Right)	Date	Enter the date the post-traumatic arthritis diagnosis was made for the right side. Fill only if 'Post-traumatic arthritis' is 'Yes'. Depends on: Post-traumatic arthritis
Post-traumatic Arthritis Date of Diagnosis (Left)	Date	Enter the date the post-traumatic arthritis diagnosis was made for the left side. Fill only if 'Post-traumatic arthritis' is 'Yes'. Depends on: Post-traumatic arthritis
Diagnosis Row - Recurrent Patellar Dislocation
Recurrent patellar dislocation	Checkbox	Check this box if the Veteran has a diagnosis of recurrent patellar dislocation associated with the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Check this box if the recurrent patellar dislocation affects the right knee. Fill only if 'Recurrent patellar dislocation' is 'Yes'. Depends on: Recurrent patellar dislocation
Side affected: Left	Radiobutton	Check this box if the recurrent patellar dislocation affects the left knee. Fill only if 'Recurrent patellar dislocation' is 'Yes'. Depends on: Recurrent patellar dislocation
Side affected: Both	Radiobutton	Check this box if the recurrent patellar dislocation affects both knees. Fill only if 'Recurrent patellar dislocation' is 'Yes'. Depends on: Recurrent patellar dislocation
ICD Code (Recurrent Patellar Dislocation)	Text	Enter the ICD diagnosis code for recurrent patellar dislocation. Fill only if 'Recurrent patellar dislocation' is 'Yes'. Depends on: Recurrent patellar dislocation
Date of Diagnosis - Right (Recurrent Patellar Dislocation)	Date	Enter the date recurrent patellar dislocation was diagnosed for the right knee. Fill only if 'Recurrent patellar dislocation' is 'Yes'. Depends on: Recurrent patellar dislocation
Date of Diagnosis - Left (Recurrent Patellar Dislocation)	Date	Enter the date recurrent patellar dislocation was diagnosed for the left knee. Fill only if 'Recurrent patellar dislocation' is 'Yes'. Depends on: Recurrent patellar dislocation
Diagnosis Row - Recurrent Subluxation
Recurrent subluxation	Checkbox	Check this box if the Veteran has a diagnosis of recurrent subluxation related to the claimed knee/lower leg condition. Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected - Right	Radiobutton	Check this box if the recurrent subluxation affects the right knee. Fill only if 'Recurrent subluxation' is 'Yes'. Depends on: Recurrent subluxation
Side affected - Left	Radiobutton	Check this box if the recurrent subluxation affects the left knee. Fill only if 'Recurrent subluxation' is 'Yes'. Depends on: Recurrent subluxation
Side affected - Both	Radiobutton	Check this box if the recurrent subluxation affects both knees. Fill only if 'Recurrent subluxation' is 'Yes'. Depends on: Recurrent subluxation
Recurrent Subluxation ICD Code	Text	Enter the ICD diagnosis code for the recurrent subluxation condition. Fill only if 'Recurrent subluxation' is 'Yes'. Depends on: Recurrent subluxation
Recurrent Subluxation Diagnosis Date (Right)	Date	Enter the date the recurrent subluxation diagnosis was made for the right side. Fill only if 'Recurrent subluxation' is 'Yes'. Depends on: Recurrent subluxation
Recurrent Subluxation Diagnosis Date (Left)	Date	Enter the date the recurrent subluxation diagnosis was made for the left side. Fill only if 'Recurrent subluxation' is 'Yes'. Depends on: Recurrent subluxation
Diagnosis Row - Shin Splints/Medial Tibial Stress Syndrome (MTSS)
Shin splints/medial tibial stress syndrome (MTSS)	Checkbox	Check this box if the Veteran has a diagnosis of shin splints/medial tibial stress syndrome (MTSS), including post-surgery or treatment. Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Check this box if the shin splints/MTSS affects the right lower leg only. Fill only if 'Shin splints/medial tibial stress syndrome (MTSS)' is 'Yes'. Depends on: Shin splints/medial tibial stress syndrome (MTSS)
Side affected: Left	Radiobutton	Check this box if the shin splints/MTSS affects the left lower leg only. Fill only if 'Shin splints/medial tibial stress syndrome (MTSS)' is 'Yes'. Depends on: Shin splints/medial tibial stress syndrome (MTSS)
Side affected: Both	Radiobutton	Check this box if the shin splints/MTSS affects both lower legs. Fill only if 'Shin splints/medial tibial stress syndrome (MTSS)' is 'Yes'. Depends on: Shin splints/medial tibial stress syndrome (MTSS)
MTSS ICD Code	Text	Enter the ICD diagnosis code for shin splints/medial tibial stress syndrome (MTSS). Fill only if 'Shin splints/medial tibial stress syndrome (MTSS)' is 'Yes'. Depends on: Shin splints/medial tibial stress syndrome (MTSS)
MTSS Date of Diagnosis (Right)	Date	Provide the date shin splints/medial tibial stress syndrome (MTSS) was diagnosed for the right side. Fill only if 'Shin splints/medial tibial stress syndrome (MTSS)' is 'Yes'. Depends on: Shin splints/medial tibial stress syndrome (MTSS)
MTSS Date of Diagnosis (Left)	Date	Provide the date shin splints/medial tibial stress syndrome (MTSS) was diagnosed for the left side. Fill only if 'Shin splints/medial tibial stress syndrome (MTSS)' is 'Yes'. Depends on: Shin splints/medial tibial stress syndrome (MTSS)
Diagnosis Row - Stress Fracture of Tibia
Stress fracture of tibia	Checkbox	Check this box if the Veteran has a diagnosis of a stress fracture of the tibia associated with the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Check this box if the stress fracture of the tibia affects the right leg. Fill only if 'Stress fracture of tibia' is 'Yes'. Depends on: Stress fracture of tibia
Side affected: Left	Radiobutton	Check this box if the stress fracture of the tibia affects the left leg. Fill only if 'Stress fracture of tibia' is 'Yes'. Depends on: Stress fracture of tibia
Side affected: Both	Radiobutton	Check this box if the stress fracture of the tibia affects both legs. Fill only if 'Stress fracture of tibia' is 'Yes'. Depends on: Stress fracture of tibia
ICD Code (Stress Fracture of Tibia)	Text	Enter the ICD diagnosis code for the stress fracture of the tibia. Fill only if 'Stress fracture of tibia' is 'Yes'. Depends on: Stress fracture of tibia
Date of Diagnosis - Right (Stress Fracture of Tibia)	Date	Enter the date the stress fracture of the tibia was diagnosed for the right side. Fill only if 'Stress fracture of tibia' is 'Yes'. Depends on: Stress fracture of tibia
Date of Diagnosis - Left (Stress Fracture of Tibia)	Date	Enter the date the stress fracture of the tibia was diagnosed for the left side. Fill only if 'Stress fracture of tibia' is 'Yes'. Depends on: Stress fracture of tibia
Diagnosis Row - Tendinitis
Tendinitis	Checkbox	Check this box if tendinitis is a current diagnosis associated with the claimed knee/lower-leg condition. Fill only if 'Tendinopathy (select one if known)' is 'Yes'. Depends on: Tendinopathy (select one if known)
Tendinitis - Side affected: Right	Radiobutton	Check this box if the diagnosed tendinitis affects the right side only. Fill only if 'Tendinitis' is 'Yes'. Depends on: Tendinitis
Tendinitis - Side affected: Left	Radiobutton	Check this box if the diagnosed tendinitis affects the left side only. Fill only if 'Tendinitis' is 'Yes'. Depends on: Tendinitis
Tendinitis - Side affected: Both	Radiobutton	Check this box if the diagnosed tendinitis affects both the right and left sides. Fill only if 'Tendinitis' is 'Yes'. Depends on: Tendinitis
Tendinitis ICD Code	Text	Enter the ICD diagnostic code corresponding to the tendinitis diagnosis. Fill only if 'Tendinitis' is 'Yes'. Depends on: Tendinitis
Tendinitis Date of Diagnosis (Right)	Date	Enter the date the tendinitis diagnosis was made for the right side. Fill only if 'Tendinitis' is 'Yes'. Depends on: Tendinitis
Tendinitis Date of Diagnosis (Left)	Date	Enter the date the tendinitis diagnosis was made for the left side. Fill only if 'Tendinitis' is 'Yes'. Depends on: Tendinitis
Diagnosis Row - Tendinopathy
Tendinopathy (select one if known)	Checkbox	Check this box if the Veteran has a current diagnosis of tendinopathy related to the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Tendinopathy side affected: Right	Radiobutton	Check this box if the tendinopathy affects the right side. Fill only if 'Tendinopathy (select one if known)' is 'Yes'. Depends on: Tendinopathy (select one if known)
Tendinopathy side affected: Left	Radiobutton	Check this box if the tendinopathy affects the left side. Fill only if 'Tendinopathy (select one if known)' is 'Yes'. Depends on: Tendinopathy (select one if known)
Tendinopathy side affected: Both	Radiobutton	Check this box if the tendinopathy affects both the right and left sides. Fill only if 'Tendinopathy (select one if known)' is 'Yes'. Depends on: Tendinopathy (select one if known)
Tendinopathy ICD Code	Text	Enter the ICD diagnosis code for the tendinopathy diagnosis, if known. Fill only if 'Tendinopathy (select one if known)' is 'Yes'. Depends on: Tendinopathy (select one if known)
Tendinopathy Date of Diagnosis (Right)	Date	Enter the date the tendinopathy was diagnosed for the right side. Fill only if 'Tendinopathy (select one if known)' is 'Yes'. Depends on: Tendinopathy (select one if known)
Tendinopathy Date of Diagnosis (Left)	Date	Enter the date the tendinopathy was diagnosed for the left side. Fill only if 'Tendinopathy (select one if known)' is 'Yes'. Depends on: Tendinopathy (select one if known)
Diagnosis Row - Tendinosis
Tendinosis	Checkbox	Check this box if the diagnosis for the claimed condition is tendinosis. Fill only if 'Tendinopathy (select one if known)' is 'Yes'. Depends on: Tendinopathy (select one if known)
Tendinosis - Right	Radiobutton	Check this box if the tendinosis affects the right side. Fill only if 'Tendinosis' is 'Yes'. Depends on: Tendinosis
Tendinosis - Left	Radiobutton	Check this box if the tendinosis affects the left side. Fill only if 'Tendinosis' is 'Yes'. Depends on: Tendinosis
Tendinosis - Both	Radiobutton	Check this box if the tendinosis affects both the right and left sides. Fill only if 'Tendinosis' is 'Yes'. Depends on: Tendinosis
Tendinosis ICD Code	Text	Enter the ICD diagnosis code for tendinosis. Fill only if 'Tendinosis' is 'Yes'. Depends on: Tendinosis
Tendinosis Date of Diagnosis (Right)	Date	Enter the date the right-side tendinosis was diagnosed. Fill only if 'Tendinosis' is 'Yes'. Depends on: Tendinosis
Tendinosis Date of Diagnosis (Left)	Date	Enter the date the left-side tendinosis was diagnosed. Fill only if 'Tendinosis' is 'Yes'. Depends on: Tendinosis
Diagnosis Row - Tenosynovitis
Tenosynovitis	Checkbox	Check this box if the Veteran has a current diagnosis of tenosynovitis related to the claimed condition. Fill only if 'Tendinopathy (select one if known)' is 'Yes'. Depends on: Tendinopathy (select one if known)
Tenosynovitis - Side affected: Right	Radiobutton	Check this box if the diagnosed tenosynovitis affects the right side only. Fill only if 'Tenosynovitis' is 'Yes'. Depends on: Tenosynovitis
Tenosynovitis - Side affected: Left	Radiobutton	Check this box if the diagnosed tenosynovitis affects the left side only. Fill only if 'Tenosynovitis' is 'Yes'. Depends on: Tenosynovitis
Tenosynovitis - Side affected: Both	Radiobutton	Check this box if the diagnosed tenosynovitis affects both the right and left sides. Fill only if 'Tenosynovitis' is 'Yes'. Depends on: Tenosynovitis
Tenosynovitis ICD Code	Text	Enter the ICD diagnostic code associated with the tenosynovitis diagnosis. Fill only if 'Tenosynovitis' is 'Yes'. Depends on: Tenosynovitis
Tenosynovitis Date of Diagnosis (Right)	Date	Enter the date the clinician diagnosed tenosynovitis in the right side. Fill only if 'Tenosynovitis' is 'Yes'. Depends on: Tenosynovitis
Tenosynovitis Date of Diagnosis (Left)	Date	Enter the date the clinician diagnosed tenosynovitis in the left side. Fill only if 'Tenosynovitis' is 'Yes'. Depends on: Tenosynovitis
Diagnosis Row - Tibia and/or Fibula Fracture
Tibia and/or fibula fracture	Checkbox	Check this box if the Veteran has a current diagnosis of a tibia and/or fibula fracture associated with the claimed condition(s). Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Side affected: Right	Radiobutton	Check this box if the tibia and/or fibula fracture affects the right leg. Fill only if 'Tibia and/or fibula fracture' is 'Yes'. Depends on: Tibia and/or fibula fracture
Side affected: Left	Radiobutton	Check this box if the tibia and/or fibula fracture affects the left leg. Fill only if 'Tibia and/or fibula fracture' is 'Yes'. Depends on: Tibia and/or fibula fracture
Side affected: Both	Radiobutton	Check this box if the tibia and/or fibula fracture affects both legs. Fill only if 'Tibia and/or fibula fracture' is 'Yes'. Depends on: Tibia and/or fibula fracture
ICD Code (Tibia/Fibula Fracture)	Text	Enter the ICD diagnosis code for the tibia and/or fibula fracture. Fill only if 'Tibia and/or fibula fracture' is 'Yes'. Depends on: Tibia and/or fibula fracture
Date of Diagnosis (Right Tibia/Fibula)	Date	Enter the date the right tibia and/or fibula fracture was diagnosed. Fill only if 'Tibia and/or fibula fracture' is 'Yes'. Depends on: Tibia and/or fibula fracture
Date of Diagnosis (Left Tibia/Fibula)	Date	Enter the date the left tibia and/or fibula fracture was diagnosed. Fill only if 'Tibia and/or fibula fracture' is 'Yes'. Depends on: Tibia and/or fibula fracture
Evidence Narrative (Left Column)
Evidence Narrative	Text	Provide a narrative that cites and discusses all procurable evidence specific to the case. 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'. Depends on: Repeated use over time functional loss: Yes
Evidence Narrative (Right Column)
Evidence Narrative	Text	Provide a detailed narrative citing and discussing all procurable evidence specific to the case. 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'. Depends on: Repeated use over time functional loss: Yes
EVIDENCE REVIEW
No records were reviewed	Radiobutton	Check this box if you did not review any records or evidence for this examination.
Records reviewed	Radiobutton	Check this box if you reviewed any records or evidence (e.g., service, VA, or private treatment records) for this examination.
Evidence Reviewed (Details and Date Range)	Text	List the evidence and records reviewed (e.g., service treatment records, VA treatment records, private treatment records) and include the applicable date range. Fill only if 'Records reviewed' is 'Yes'. Depends on: Records reviewed
Examiner Address
Examiner Address	Text	Enter the examiner's complete mailing address.
Examiner Contact and Credential Numbers
Examiner Phone/Fax Numbers	Text	Enter the examiner’s phone number and/or fax number where they can be contacted.
National Provider Identifier (NPI) Number	Number	Enter the examiner’s National Provider Identifier (NPI) number.
Medical License Number and State	Text	Enter the examiner’s medical license number along with the state that issued the license.
Examiner Is VA Healthcare Provider (Yes/No)
Yes	Radiobutton	Check this box if the examiner completing the questionnaire is a VA healthcare provider.
No	Radiobutton	Check this box if the examiner completing the questionnaire is not a VA healthcare provider.
Examiner Name, Title, and Specialty
Examiner Printed Name and Title	Text	Enter the examiner’s printed full name and professional title/credentials (e.g., MD, DO, DDS, DMD, PhD, PsyD, NP, PA-C).
Examiner Specialty/Area of Practice	Text	Enter the examiner’s area of practice or medical specialty (e.g., Cardiology, Orthopedics, Psychology/Psychiatry, General Practice).
Examiner Signature and Date
Examiner Signature	Text	Enter the examiner's signature to certify the information provided in this section.
Date Signed	Date	Enter the date on which the examiner signed this certification.
In-Person Examination and If Not, How Conducted
In-person examination: Yes	Radiobutton	Check this box if the Veteran was examined in person.
In-person examination: No	Radiobutton	Check this box if the Veteran was not examined in person (and then describe how the examination was conducted).
Examination Conducted If Not In Person	Text	Describe how the examination was conducted if the Veteran was not examined in person (e.g., telehealth, records review, phone interview). Fill only if 'In-person examination: No' is 'Yes'. Depends on: In-person examination: No
Left Joint - Active Range of Motion (AROM)
Unclaimed joint: Damaged	Radiobutton	Check this box if the left joint being evaluated is the unclaimed joint and it is damaged. Fill only if 'Side affected' is 'Right'. Depends on: Side affected: Right
Unclaimed joint: Undamaged	Radiobutton	Check this box if the left joint being evaluated is the unclaimed joint and it is undamaged. Fill only if 'Side affected' is 'Right'. Depends on: Side affected: Right
AROM Flexion Endpoint (Degrees)	Number	Enter the measured active flexion endpoint for the left joint in degrees. Fill only if 'Unclaimed joint: Undamaged' is 'Yes'. Depends on: Unclaimed joint: Undamaged
AROM Extension Endpoint (Degrees)	Number	Enter the measured active extension endpoint for the left joint in degrees. Fill only if 'Unclaimed joint: Undamaged' is 'Yes'. Depends on: Unclaimed joint: Undamaged
Pain with ROM: Flexion	Checkbox	Check this box if flexion active range of motion of the left joint exhibited pain on examination. Fill only if 'Unclaimed joint: Undamaged' is 'Yes'. Depends on: Unclaimed joint: Undamaged
Pain with ROM: Extension	Checkbox	Check this box if extension active range of motion of the left joint exhibited pain on examination. Fill only if 'Unclaimed joint: Undamaged' is 'Yes'. Depends on: Unclaimed joint: Undamaged
Pain/Limit Flexion Endpoint (Degrees, If Different)	Number	If flexion is specifically limited by pain, weakness, fatigability, incoordination, or other factors, enter the flexion degree endpoint where that limitation occurs (if different from the AROM value above). Fill only if 'AROM Flexion Endpoint (Degrees)' differs from above. Depends on: AROM Flexion Endpoint (Degrees)
Pain/Limit Extension Endpoint (Degrees, If Different)	Number	If extension is specifically limited by pain, weakness, fatigability, incoordination, or other factors, enter the extension degree endpoint where that limitation occurs (if different from the AROM value above). Fill only if 'AROM Extension Endpoint (Degrees)' differs from above. Depends on: AROM Extension Endpoint (Degrees)
AROM Limitation Factors Description	Text	Describe the factors (pain, weakness, fatigability, incoordination, or other) that specifically limit the left joint’s active range of motion and provide any relevant details. Fill only if 'Unclaimed joint: Undamaged' is 'Yes'. Depends on: Unclaimed joint: Undamaged
Left Joint - Evidence of Pain & Functional Impact
Yes	Radiobutton	Check this box if there is evidence of pain in the left joint.
No	Radiobutton	Check this box if there is no evidence of pain in the left joint.
Weight-bearing	Checkbox	If there is evidence of pain, check this box if the pain occurs with weight-bearing. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Nonweight-bearing	Checkbox	If there is evidence of pain, check this box if the pain occurs with nonweight-bearing. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Active motion	Checkbox	If there is evidence of pain, check this box if the pain occurs during active motion. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Passive motion	Checkbox	If there is evidence of pain, check this box if the pain occurs during passive motion. Fill only if 'Yes' is 'Yes'. Depends on: Yes
On rest/non-movement	Checkbox	If there is evidence of pain, check this box if the pain is present at rest or with no movement. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Does not result in/cause functional loss	Checkbox	If there is evidence of pain, check this box if the pain does not result in or cause functional loss. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Causes functional loss	Checkbox	If there is evidence of pain, check this box if the pain causes functional loss (and describe it in the comments box below). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left Joint - Passive Range of Motion (PROM)
PROM Flexion Endpoint	Text	Enter the left joint passive range of motion flexion endpoint value in degrees. Fill only if 'Flexion PROM same as active ROM' is 'No'. Depends on: Flexion PROM same as active ROM
Flexion PROM same as active ROM	Checkbox	Check this box if the passive flexion endpoint is the same as the active ROM flexion endpoint.
PROM Extension Endpoint	Text	Enter the left joint passive range of motion extension endpoint value in degrees. Fill only if 'Extension PROM same as active ROM' is 'No'. Depends on: Extension PROM same as active ROM
Extension PROM same as active ROM	Checkbox	Check this box if the passive extension endpoint is the same as the active ROM extension endpoint.
Passive ROM pain: Flexion	Checkbox	Check this box if pain was exhibited during passive flexion range of motion testing.
Passive ROM pain: Extension	Checkbox	Check this box if pain was exhibited during passive extension range of motion testing.
PROM Flexion Endpoint (Pain/Weakness/Fatigue Limitation)	Text	If passive flexion is specifically limited by pain, weakness, fatigability, incoordination, or other factors, enter the flexion degree endpoint attributable to those factors. Fill only if 'PROM Flexion Endpoint' differs from above. Depends on: PROM Flexion Endpoint
PROM Extension Endpoint (Pain/Weakness/Fatigue Limitation)	Text	If passive extension is specifically limited by pain, weakness, fatigability, incoordination, or other factors, enter the extension degree endpoint attributable to those factors. Fill only if 'PROM Extension Endpoint' differs from above. Depends on: PROM Extension Endpoint
PROM Additional Notes	Text	Provide any narrative details or explanations related to the left joint passive range of motion findings, including factors affecting limitation.
Left Knee - Ambulation Aids for Patellar Instability
Prescription required (Left knee): Yes	Radiobutton	Check this box if the Veteran requires a prescription from a medical provider for any ambulation aid due to left knee patellar instability. Fill only if 'Is there recurrent patellar instability?' is 'Yes'. Depends on: Yes
Prescription required (Left knee): No	Radiobutton	Check this box if the Veteran does not require a prescription from a medical provider for any ambulation aid due to left knee patellar instability. Fill only if 'Is there recurrent patellar instability?' is 'Yes'. Depends on: Yes
Cane(s)	Checkbox	Check this box if the Veteran requires a prescribed cane or canes for ambulation due to left knee patellar instability. Fill only if 'Prescription required (Left knee): Yes' is 'Yes'. Depends on: Prescription required (Left knee): Yes
Walker	Checkbox	Check this box if the Veteran requires a prescribed walker for ambulation due to left knee patellar instability. Fill only if 'Prescription required (Left knee): Yes' is 'Yes'. Depends on: Prescription required (Left knee): Yes
Crutches	Checkbox	Check this box if the Veteran requires prescribed crutches for ambulation due to left knee patellar instability. Fill only if 'Prescription required (Left knee): Yes' is 'Yes'. Depends on: Prescription required (Left knee): Yes
Brace(s)	Checkbox	Check this box if the Veteran requires prescribed brace(s) for ambulation due to left knee patellar instability. Fill only if 'Prescription required (Left knee): Yes' is 'Yes'. Depends on: Prescription required (Left knee): Yes
Left Knee - Describe checked boxes above
Left knee checked-box details	Text	Provide a detailed description for each item you checked above for the left knee. Fill only if 'Does the Veteran currently have or has the Veteran been diagnosed with a meniscus (semilunar cartilage) condition?' is 'Yes'. Depends on: Meniscus condition - Yes
Left Knee - Functional Loss Explanation
Left Knee ROM Functional Loss Explanation	Text	Provide an explanation of how the left knee range of motion limitation contributes to functional loss, including the specific ways it affects function. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left Knee - Initial ROM Measurement Selection
All normal	Radiobutton	Check this box if the left knee initial range of motion (ROM) measurements are within normal limits.
Abnormal or outside of normal range	Radiobutton	Check this box if the left knee initial range of motion (ROM) measurements are abnormal or outside the normal range.
Unable to test	Radiobutton	Check this box if you were unable to perform the left knee initial ROM measurement testing.
Not indicated	Radiobutton	Check this box if left knee initial ROM measurement testing was not indicated for this evaluation.
Left Knee - Leg Length Discrepancy Measurements and Description
Leg length discrepancy (shortening of any bones of the lower extremity)	Checkbox	Check this box if the Veteran has a leg length discrepancy due to shortening of any bones of the lower extremity. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left Leg Length Measurement	Number	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'. Depends on: Leg length discrepancy (shortening of any bones of the lower extremity)
Measurements unit: cm	Radiobutton	Check this box if the leg length discrepancy measurement is recorded in centimeters (cm). Fill only if 'Leg length discrepancy (shortening of any bones of the lower extremity)' is 'Yes'. Depends on: Leg length discrepancy (shortening of any bones of the lower extremity)
Measurements unit: inch	Radiobutton	Check this box if the leg length discrepancy measurement is recorded in inches (inch). Fill only if 'Leg length discrepancy (shortening of any bones of the lower extremity)' is 'Yes'. Depends on: Leg length discrepancy (shortening of any bones of the lower extremity)
Leg Length Discrepancy Relationship Description	Text	Describe how any leg length discrepancy relates to the left knee/lower-leg conditions listed in the diagnosis section above. Fill only if 'Leg length discrepancy (shortening of any bones of the lower extremity)' is 'Yes'. Depends on: Leg length discrepancy (shortening of any bones of the lower extremity)
Left Knee - Meniscal Condition and Symptom Frequency/Severity
Meniscus condition - Yes	Radiobutton	Check this box if the Veteran currently has, or has been diagnosed with, a left knee meniscus (semilunar cartilage) condition.
Meniscus condition - No	Radiobutton	Check this box if the Veteran does not currently have and has never been diagnosed with a left knee meniscus (semilunar cartilage) condition.
No current symptoms	Checkbox	Check this box if the Veteran has a left knee meniscus condition but currently has no symptoms. Fill only if 'Meniscus condition - Yes' is 'Yes'. Depends on: Meniscus condition - Yes
Meniscal dislocation	Checkbox	Check this box if the Veteran’s left knee meniscus condition includes a meniscal dislocation. Fill only if 'Meniscus condition - Yes' is 'Yes'. Depends on: Meniscus condition - Yes
Meniscal tear	Checkbox	Check this box if the Veteran’s left knee meniscus condition includes a meniscal tear. Fill only if 'Meniscus condition - Yes' is 'Yes'. Depends on: Meniscus condition - Yes
Frequent episodes of joint locking	Checkbox	Check this box if the Veteran frequently experiences episodes of the left knee “locking.” Fill only if 'Meniscus condition - Yes' is 'Yes'. Depends on: Meniscus condition - Yes
Frequent episodes of joint pain	Checkbox	Check this box if the Veteran frequently experiences left knee joint pain episodes related to the meniscus condition. Fill only if 'Meniscus condition - Yes' is 'Yes'. Depends on: Meniscus condition - Yes
Frequent episodes of joint effusion	Checkbox	Check this box if the Veteran frequently experiences episodes of left knee joint effusion (swelling/fluid in the joint). Fill only if 'Meniscus condition - Yes' is 'Yes'. Depends on: Meniscus condition - Yes
Left Knee - Outside Normal but Normal for Veteran Description
Left Knee Outside Normal but Normal for Veteran Description	Text	Describe why the left knee range of motion is outside the normal range but is considered normal for the Veteran (e.g., due to age, body habitus, or a neurologic condition unrelated to a knee/lower leg condition). Fill only if 'Abnormal or outside of normal range' is 'Yes'. Depends on: Abnormal or outside of normal range
Left Knee - ROM Contributes to Functional Loss (Yes/No)
Yes	Radiobutton	Check this box if the left knee range of motion (when abnormal) itself contributes to a functional loss.
No	Radiobutton	Check this box if the left knee range of motion (even if abnormal) does not itself contribute to a functional loss.
Left Knee - Testing Can Be Performed (Yes/No)
Yes	Radiobutton	Check this box if left knee testing can be performed.
No	Radiobutton	Check this box if left knee testing cannot be performed.
Left Knee - Testing Not Performed Explanation
Left Knee Testing Not Performed Explanation	Text	Explain why left knee testing cannot be performed if you answered "No" to whether testing can be performed. Fill only if 'No' is 'Yes'. Depends on: No
Left Knee - Tibial/Fibular Impairment Conditions and Symptoms
Yes	Radiobutton	Check this box if the Veteran currently has or has been diagnosed with a recurrent patellar dislocation, shin splints, stress fractures, or any other tibial or fibular impairment (left knee).
No	Radiobutton	Check this box if the Veteran does not currently have and has not been diagnosed with a recurrent patellar dislocation, shin splints, stress fractures, or any other tibial or fibular impairment (left knee).
Stress fracture of the lower leg	Checkbox	Check this box if the Veteran has a stress fracture of the lower leg as part of the left tibial/fibular impairment. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Current Symptoms Description	Text	Enter a description of the Veteran's current symptoms related to the left knee tibial or fibular impairment condition. Fill only if 'Stress fracture of the lower leg' is 'Yes'. Depends on: Stress fracture of the lower leg
Acquired and/or traumatic genu recurvatum	Checkbox	Check this box if the Veteran has acquired and/or traumatic genu recurvatum with objectively demonstrated weakness and insecurity in weight-bearing. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Recurrent patellar dislocation	Checkbox	Check this box if the Veteran has recurrent patellar dislocation as part of the left tibial/fibular impairment. Fill only if 'Yes' is 'Yes'. Depends on: Yes
"Shin Splints" (medial tibial stress syndrome - MTSS)	Checkbox	Check this box if the Veteran has shin splints (medial tibial stress syndrome/MTSS) as part of the left tibial/fibular impairment. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left Knee - Tibial/Fibular Impairment Response to Treatment
Responsive to surgery and/or treatment	Radiobutton	Check this box if the Veteran’s tibial/fibular impairment has improved or responded to surgery and/or treatment. Fill only if 'Treatment for less than 12 consecutive months', 'Requiring treatment for 12 consecutive months or more' is 'Yes' (any fields). Depends on: Treatment for less than 12 consecutive months, Requiring treatment for 12 consecutive months or more
Unresponsive to shoe orthotics or other conservative treatment	Radiobutton	Check this box if the Veteran’s tibial/fibular impairment did not respond to shoe orthotics or other conservative treatment. Fill only if 'Treatment for less than 12 consecutive months', 'Requiring treatment for 12 consecutive months or more' is 'Yes' (any fields). Depends on: Treatment for less than 12 consecutive months, Requiring treatment for 12 consecutive months or more
Unresponsive to surgery and to shoe orthotics or other conservative treatment	Radiobutton	Check this box if the Veteran’s tibial/fibular impairment did not respond to surgery and also did not respond to shoe orthotics or other conservative treatment. Fill only if 'Treatment for less than 12 consecutive months', 'Requiring treatment for 12 consecutive months or more' is 'Yes' (any fields). Depends on: Treatment for less than 12 consecutive months, Requiring treatment for 12 consecutive months or more
Left Knee - Tibial/Fibular Impairment Treatment Length
No treatment received	Radiobutton	Check this box if the Veteran has not received any treatment for the left knee tibial or fibular impairment. Fill only if '"Shin Splints" (medial tibial stress syndrome - MTSS)' is 'Yes'. Depends on: "Shin Splints" (medial tibial stress syndrome - MTSS)
Treatment for less than 12 consecutive months	Radiobutton	Check this box if the Veteran has received treatment for the left knee tibial or fibular impairment for less than 12 consecutive months. Fill only if '"Shin Splints" (medial tibial stress syndrome - MTSS)' is 'Yes'. Depends on: "Shin Splints" (medial tibial stress syndrome - MTSS)
Requiring treatment for 12 consecutive months or more	Radiobutton	Check this box if the Veteran has required treatment for the left knee tibial or fibular impairment for 12 consecutive months or more. Fill only if '"Shin Splints" (medial tibial stress syndrome - MTSS)' is 'Yes'. Depends on: "Shin Splints" (medial tibial stress syndrome - MTSS)
Left Knee - Unable to Test/Not Indicated Explanation
Left Knee Unable to Test/Not Indicated Explanation	Text	Explain why the left knee initial range of motion (ROM) testing was unable to be performed or was not indicated. Fill only if 'Unable to test', 'Not indicated' is 'Yes' (any). Depends on: Unable to test, Not indicated
Left Knee Additional Loss After Three Repetitions
Additional loss after three repetitions — Yes	Radiobutton	Check this box if there is additional loss of function or range of motion in the left knee after three repetitions.
Additional loss after three repetitions — No	Radiobutton	Check this box if there is no additional loss of function or range of motion in the left knee after three repetitions.
Left knee flexion endpoint after 3 repetitions	Number	Enter the left knee flexion endpoint measurement after completion of three repetitions. Fill only if 'Additional loss after three repetitions — Yes' is 'Yes'. Depends on: Additional loss after three repetitions — Yes
Left knee extension endpoint after 3 repetitions	Number	Enter the left knee extension endpoint measurement after completion of three repetitions. Fill only if 'Additional loss after three repetitions — Yes' is 'Yes'. Depends on: Additional loss after three repetitions — Yes
Pain	Checkbox	Check this box if pain is a factor causing the left knee’s additional functional loss after three repetitions. Fill only if 'Additional loss after three repetitions — Yes' is 'Yes'. Depends on: Additional loss after three repetitions — Yes
Fatigability	Checkbox	Check this box if fatigability is a factor causing the left knee’s additional functional loss after three repetitions. Fill only if 'Additional loss after three repetitions — Yes' is 'Yes'. Depends on: Additional loss after three repetitions — Yes
Weakness	Checkbox	Check this box if weakness is a factor causing the left knee’s additional functional loss after three repetitions. Fill only if 'Additional loss after three repetitions — Yes' is 'Yes'. Depends on: Additional loss after three repetitions — Yes
Lack of endurance	Checkbox	Check this box if lack of endurance is a factor causing the left knee’s additional functional loss after three repetitions. Fill only if 'Additional loss after three repetitions — Yes' is 'Yes'. Depends on: Additional loss after three repetitions — Yes
Incoordination	Checkbox	Check this box if incoordination is a factor causing the left knee’s additional functional loss after three repetitions. Fill only if 'Additional loss after three repetitions — Yes' is 'Yes'. Depends on: Additional loss after three repetitions — Yes
Other	Checkbox	Check this box if another factor (not listed) causes the left knee’s additional functional loss after three repetitions, and specify it in the provided line. Fill only if 'Additional loss after three repetitions — Yes' is 'Yes'. Depends on: Additional loss after three repetitions — Yes
Left knee other factor causing additional loss after 3 repetitions	Text	Describe any other factor(s) contributing to additional functional loss or range-of-motion loss in the left knee after three repetitions. Fill only if 'Additional loss after three repetitions — Yes', 'Other' is 'Yes' for all fields. Depends on: Additional loss after three repetitions — Yes, Other
N/A	Checkbox	Check this box if the listed factors do not apply (e.g., no applicable contributing factor to additional functional loss after three repetitions). Fill only if 'Additional loss after three repetitions — Yes' is 'Yes'. Depends on: Additional loss after three repetitions — Yes
Left Knee Ambulation Prescription and Devices (6D)
6D - Yes	Radiobutton	Check this box if the Veteran requires a prescription from a medical provider for an ambulation device.
6D - No	Radiobutton	Check this box if the Veteran does not require a prescription from a medical provider for any ambulation device.
Cane(s)	Checkbox	Check this box if a cane is prescribed/required for ambulation. Fill only if '6D - Yes' is 'Yes'. Depends on: 6D - Yes
Walker	Checkbox	Check this box if a walker is prescribed/required for ambulation. Fill only if '6D - Yes' is 'Yes'. Depends on: 6D - Yes
Crutches	Checkbox	Check this box if crutches are prescribed/required for ambulation. Fill only if '6D - Yes' is 'Yes'. Depends on: 6D - Yes
Brace(s)	Checkbox	Check this box if a brace is prescribed/required for ambulation. Fill only if '6D - Yes' is 'Yes'. Depends on: 6D - Yes
Left Knee Ankylosis Angle (5B)
Left Knee Ankylosis Angle (Degrees)	Number	Enter the angle of ankylosis for the left knee in degrees. Fill only if 'Yes' is 'Yes'. Depends on: Yes
N/A – no ankylosis of knee joint	Checkbox	Check this box if there is no ankylosis of the left knee joint (so the ankylosis angle does not apply). Fill only if 'No' is 'Yes'. Depends on: No
Left Knee Ankylosis Presence and Severity (5A)
Yes	Radiobutton	Check this box if there is ankylosis of the left knee and/or lower leg.
No	Radiobutton	Check this box if there is no ankylosis of the left knee and/or lower leg.
Favorable angle (full extension or slight flexion 0–10°)	Radiobutton	Check this box if left knee ankylosis is present and the knee is fixed in full extension or slight flexion between 0 and 10 degrees. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Flexion 10–20°	Radiobutton	Check this box if left knee ankylosis is present and the knee is fixed in flexion between 10 and 20 degrees. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Flexion 20–45°	Radiobutton	Check this box if left knee ankylosis is present and the knee is fixed in flexion between 20 and 45 degrees. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Extremely unfavorable (flexion ≥45°)	Radiobutton	Check this box if left knee ankylosis is present and the knee is fixed in flexion at an angle of 45 degrees or more. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left Knee Crepitus/Tenderness Comments
Left Knee Crepitus Comments	Text	Enter any comments or observations regarding crepitus in the left knee.
Objective evidence of crepitus - Yes	Radiobutton	Check this box if there is objective evidence of crepitus in the left knee.
Objective evidence of crepitus - No	Radiobutton	Check this box if there is no objective evidence of crepitus in the left knee.
Localized tenderness/pain on palpation - Yes	Radiobutton	Check this box if there is objective evidence of localized tenderness or pain on palpation of the left knee joint or associated soft tissue.
Localized tenderness/pain on palpation - No	Radiobutton	Check this box if there is no objective evidence of localized tenderness or pain on palpation of the left knee joint or associated soft tissue.
Left Knee Tenderness/Pain Explanation	Text	If localized tenderness or pain on palpation is present, describe the location, severity, and how it relates to the condition(s). Fill only if 'Localized tenderness/pain on palpation - Yes' is 'Yes'. Depends on: Localized tenderness/pain on palpation - Yes
Left Knee Examined Immediately After Repeated Use Over Time
Yes	Radiobutton	Check this box if the Veteran is being examined immediately after repeated use over time (left knee).
No	Radiobutton	Check this box if the Veteran is not being examined immediately after repeated use over time (left knee).
Left Knee Flare-ups Assessment (During Flare-up, Functional Loss & Factors)
Exam conducted during a flare-up — Yes	Radiobutton	Check this box if the left knee examination is being performed while the Veteran is experiencing a flare-up.
Exam conducted during a flare-up — No	Radiobutton	Check this box if the left knee examination is not being performed during a flare-up.
Evidence suggests functional limitation with flare-ups — Yes	Radiobutton	Check this box if the Veteran’s statements/evidence indicate pain, fatigability, weakness, lack of endurance, or incoordination significantly limits left knee functional ability during flare-ups.
Evidence suggests functional limitation with flare-ups — No	Radiobutton	Check this box if the Veteran’s statements/evidence do not indicate significant limitation of left knee functional ability during flare-ups.
Factor causing functional loss: Pain	Checkbox	Check this box if pain contributes to functional loss of the left knee during flare-ups. Fill only if 'Evidence suggests functional limitation with flare-ups — Yes' is 'Yes'. Depends on: Evidence suggests functional limitation with flare-ups — Yes
Factor causing functional loss: Fatigability	Checkbox	Check this box if fatigability contributes to functional loss of the left knee during flare-ups. Fill only if 'Evidence suggests functional limitation with flare-ups — Yes' is 'Yes'. Depends on: Evidence suggests functional limitation with flare-ups — Yes
Factor causing functional loss: Weakness	Checkbox	Check this box if weakness contributes to functional loss of the left knee during flare-ups. Fill only if 'Evidence suggests functional limitation with flare-ups — Yes' is 'Yes'. Depends on: Evidence suggests functional limitation with flare-ups — Yes
Factor causing functional loss: Lack of endurance	Checkbox	Check this box if lack of endurance contributes to functional loss of the left knee during flare-ups. Fill only if 'Evidence suggests functional limitation with flare-ups — Yes' is 'Yes'. Depends on: Evidence suggests functional limitation with flare-ups — Yes
Factor causing functional loss: Incoordination	Checkbox	Check this box if incoordination contributes to functional loss of the left knee during flare-ups. Fill only if 'Evidence suggests functional limitation with flare-ups — Yes' is 'Yes'. Depends on: Evidence suggests functional limitation with flare-ups — Yes
Factor causing functional loss: Other	Checkbox	Check this box if another factor (not listed) contributes to left knee functional loss during flare-ups and specify it in the provided space. Fill only if 'Evidence suggests functional limitation with flare-ups — Yes' is 'Yes'. Depends on: Evidence suggests functional limitation with flare-ups — Yes
Other Flare-up Functional Loss Factor (Left Knee)	Text	Enter any other factor not listed that causes functional loss of the left knee during flare-ups. Fill only if 'Evidence suggests functional limitation with flare-ups — Yes', 'Factor causing functional loss: Other' is 'Yes' for all fields selection. Depends on: Evidence suggests functional limitation with flare-ups — Yes, Factor causing functional loss: Other
Factor causing functional loss: N/A	Checkbox	Check this box if none of the listed factors cause functional loss of the left knee during flare-ups.
Left Knee Flare-ups ROM Estimates (Flexion/Extension)
Left Knee Flare-up Flexion Endpoint (Degrees)	Number	Enter the estimated left knee flexion endpoint during flare-ups, based on procured evidence and the Veteran’s statements. Fill only if 'Evidence suggests functional limitation with flare-ups — Yes' is 'Yes'. Depends on: Evidence suggests functional limitation with flare-ups — Yes
Left Knee Flare-up Extension Endpoint (Degrees)	Number	Enter the estimated left knee extension endpoint during flare-ups, based on procured evidence and the Veteran’s statements. Fill only if 'Evidence suggests functional limitation with flare-ups — Yes' is 'Yes'. Depends on: Evidence suggests functional limitation with flare-ups — Yes
Left Knee Ligament Tear and Type (6B)
Yes	Radiobutton	Check this box if there is or has been a left knee ligament tear (sprain).
No	Radiobutton	Check this box if there is not and has never been a left knee ligament tear (sprain).
Complete ligament tear	Radiobutton	Check this box if the left knee ligament tear was a complete tear. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Incomplete/partial ligament tear	Radiobutton	Check this box if the left knee ligament tear was incomplete or partial. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left Knee Ligament Tear Repaired and Outcome (6C)
Ligament tear repaired - Yes	Radiobutton	Check this box if the left knee ligament tear was repaired.
Ligament tear repaired - No	Radiobutton	Check this box if the left knee ligament tear was not repaired.
Complete tear repair - successful	Radiobutton	Check this box if the left knee had a complete ligament tear that was repaired and the repair was successful. Fill only if 'Ligament tear repaired - Yes' is 'Yes'. Depends on: Ligament tear repaired - Yes
Complete tear repair - failed	Radiobutton	Check this box if the left knee had a complete ligament tear that was repaired and the repair failed. Fill only if 'Ligament tear repaired - Yes' is 'Yes'. Depends on: Ligament tear repaired - Yes
Left Knee Muscle Group XIII Involvement (5C)
Yes	Radiobutton	Check this box if the left knee ankylosis involves Muscle Group XIII (posterior thigh/hamstring muscle group).
No	Radiobutton	Check this box if the left knee ankylosis does not involve Muscle Group XIII (posterior thigh/hamstring muscle group).
Left Knee Recurrent Patellar Instability (6E)
Yes	Radiobutton	Check this box if the Veteran has recurrent patellar instability in the left knee.
No	Radiobutton	Check this box if the Veteran does not have recurrent patellar instability in the left knee.
Left Knee Recurrent Subluxation or Persistent Instability (6A)
Yes	Radiobutton	Check this box if the left knee has recurrent subluxation or persistent instability.
No	Radiobutton	Check this box if the left knee does not have recurrent subluxation or persistent instability.
Left Knee Repeated Use Over Time Evidence Discussion
Repeated Use Over Time Evidence Discussion (Left Knee)	Text	Enter a narrative citing and discussing all procurable evidence regarding the Veteran’s left knee functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left Knee Repeated Use Over Time Functional Loss (Yes/No & Factors)
Yes	Radiobutton	Check this box if the procured evidence suggests pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits left knee functional ability with repeated use over time. Fill only if 'Is the Veteran being examined immediately after repeated use over time?' is 'No'. Depends on: No
No	Radiobutton	Check this box if the procured evidence does not suggest significant limitation of left knee functional ability with repeated use over time due to pain, fatigability, weakness, lack of endurance, or incoordination. Fill only if 'Is the Veteran being examined immediately after repeated use over time?' is 'No'. Depends on: No
Pain	Checkbox	Check this box if pain is a factor causing the left knee functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Fatigability	Checkbox	Check this box if fatigability is a factor causing the left knee functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Weakness	Checkbox	Check this box if weakness is a factor causing the left knee functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Lack of endurance	Checkbox	Check this box if lack of endurance is a factor causing the left knee functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Incoordination	Checkbox	Check this box if incoordination is a factor causing the left knee functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other	Checkbox	Check this box if another factor (not listed) causes the left knee functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other Functional Loss Factor	Text	Enter any other factor(s) causing functional loss with repeated use over time that are not listed (e.g., pain, fatigability, weakness, lack of endurance, incoordination). Fill only if 'Yes', 'Other' is 'Yes' for all fields selection. Depends on: Yes, Other
N/A	Checkbox	Check this box if selecting factors is not applicable (for example, because there is no functional loss with repeated use over time). Fill only if 'Is the Veteran being examined immediately after repeated use over time?' is 'No'. Depends on: No
Left Knee Repeated Use Over Time ROM Estimates (Flexion/Extension)
Flexion Endpoint After Repeated Use	Text	Enter the estimated left knee flexion endpoint in degrees immediately after repeated use over time. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Extension Endpoint After Repeated Use	Text	Enter the estimated left knee extension endpoint in degrees immediately after repeated use over time. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left Knee Repetitive-Use Testing (3+ repetitions)
Yes	Radiobutton	Check this box if the Veteran is able to perform repetitive-use testing with at least three repetitions for the left knee.
No	Radiobutton	Check this box if the Veteran is not able to perform repetitive-use testing with at least three repetitions for the left knee.
Explanation if Repetitive-Use Testing Not Performed	Text	Provide the reason the Veteran was not able to complete repetitive-use range of motion testing with at least three repetitions for the left knee. Fill only if 'No' is 'Yes'. Depends on: No
Left Knee Surgical Repair for Patellar Instability and Description (6F)
Yes	Radiobutton	Check this box if the Veteran has had surgical repair of the left knee for patellar instability.
No	Radiobutton	Check this box if the Veteran has not had surgical repair of the left knee for patellar instability.
Left Knee Patellar Instability Surgery Description	Text	Describe the surgical repair performed on the left knee for patellar instability, including the procedure details and any relevant notes. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left Lower Extremity Atrophy Details and Measurements (Right Column)
Left lower extremity (location of measurement)	Checkbox	Check this box when documenting muscle atrophy in the left lower extremity and you will specify the measurement location (e.g., “10 cm above or below knee”). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Left Lower Extremity Atrophy Location and Measurement Details	Text	Describe the specific location where the left lower extremity circumference was measured (e.g., how many cm above or below the knee) and any additional atrophy measurement details requested. Fill only if 'Left lower extremity (location of measurement)' is 'Yes'. Depends on: Left lower extremity (location of measurement)
Circumference of More Normal Side (Left Lower Extremity)	Number	Enter the circumference measurement of the more normal (less affected) side for comparison. Fill only if 'Left lower extremity (location of measurement)' is 'Yes'. Depends on: Left lower extremity (location of measurement)
Circumference of Atrophied Side (Left Lower Extremity)	Number	Enter the circumference measurement of the atrophied (more affected) side. Fill only if 'Left lower extremity (location of measurement)' is 'Yes'. Depends on: Left lower extremity (location of measurement)
Muscle Atrophy Due to Claimed Condition? + Rationale if No (Left Column)
Yes	Radiobutton	Check this box if the Veteran’s muscle atrophy is due to the claimed condition listed in the diagnosis section. Fill only if 'Yes' is 'Yes'. Depends on: Yes
No	Radiobutton	Check this box if the Veteran’s muscle atrophy is not due to the claimed condition listed in the diagnosis section (and provide a rationale). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Rationale if Muscle Atrophy Not Due to Claimed Condition	Text	Explain why the Veteran’s muscle atrophy is not due to the claimed condition listed in the diagnosis section, citing relevant medical evidence. Fill only if 'Yes', 'No' is 'Yes' for all fields selection. Depends on: Yes, No
Muscle Atrophy Due to Claimed Condition? + Rationale if No (Right Column)
Yes — Muscle atrophy due to claimed condition	Radiobutton	Check this box if the Veteran’s muscle atrophy is due to the claimed condition listed in the diagnosis section. Fill only if 'Yes' is 'Yes'. Depends on: Yes
No — Muscle atrophy not due to claimed condition	Radiobutton	Check this box if the Veteran’s muscle atrophy is not due to the claimed condition listed in the diagnosis section (and provide a rationale). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Rationale if Muscle Atrophy Not Due to Claimed Condition	Text	Provide the medical rationale explaining why the Veteran’s muscle atrophy is not due to the claimed condition listed in the diagnosis section. Fill only if 'Yes', 'No — Muscle atrophy not due to claimed condition' is 'Yes' for all fields selection. Depends on: Yes, No — Muscle atrophy not due to claimed condition
Muscle Atrophy Present? (Left Column)
Yes	Radiobutton	Check this box if the Veteran has muscle atrophy.
No	Radiobutton	Check this box if the Veteran does not have muscle atrophy.
Muscle Atrophy Present? (Right Column)
Yes	Radiobutton	Check this box if the Veteran has muscle atrophy.
No	Radiobutton	Check this box if the Veteran does not have muscle atrophy.
No Current Diagnosis Selected
No current diagnosis associated with any claimed condition	Checkbox	Check this box if the Veteran does not have a current diagnosis related to any of the claimed condition(s) listed above.
Other Assistive Device (Describe) and Frequency
Other (describe)	Checkbox	Check this box if the Veteran uses an assistive device not listed above, and write the device type on the line provided. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Other Assistive Device Description	Text	Enter a description of the other assistive device the Veteran uses (not listed above). Fill only if 'Yes', 'Other (describe)' is 'Yes' and all. Depends on: Yes, Other (describe)
Other device frequency: Occasional	Radiobutton	Check this box if the Veteran uses the other assistive device only occasionally. Fill only if 'Yes', 'Other (describe)' is 'Yes' and all. Depends on: Yes, Other (describe)
Other device frequency: Regular	Radiobutton	Check this box if the Veteran uses the other assistive device on a regular basis. Fill only if 'Yes', 'Other (describe)' is 'Yes' and all. Depends on: Yes, Other (describe)
Other device frequency: Constant	Radiobutton	Check this box if the Veteran uses the other assistive device constantly or nearly all the time. Fill only if 'Yes', 'Other (describe)' is 'Yes' and all. Depends on: Yes, Other (describe)
Other Diagnoses Section Indicator (Other - Specify)
Other (specify)	Checkbox	Check this box if the Veteran has a knee/lower leg diagnosis not listed above and you will specify the diagnosis in the space provided. Fill only if 'No current diagnosis associated with any claimed condition' is 'No'. Depends on: No current diagnosis associated with any claimed condition
Other Diagnosis #1 Row
Other Diagnosis #1	Text	Enter the name of the other diagnosis associated with the claimed condition. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other diagnosis #1 - Right	Radiobutton	Check this box if Other diagnosis #1 affects the right side only. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other diagnosis #1 - Left	Radiobutton	Check this box if Other diagnosis #1 affects the left side only. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other diagnosis #1 - Both	Radiobutton	Check this box if Other diagnosis #1 affects both the right and left sides. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other Diagnosis #1 ICD Code	Text	Enter the ICD diagnostic code for Other Diagnosis #1. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other Diagnosis #1 Date of Diagnosis (Right)	Date	Enter the date the right side diagnosis for Other Diagnosis #1 was made. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other Diagnosis #1 Date of Diagnosis (Left)	Date	Enter the date the left side diagnosis for Other Diagnosis #1 was made. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other Diagnosis #2 Row
Other diagnosis #2	Text	Enter the name of the additional knee/lower leg diagnosis (diagnosis #2). Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other diagnosis #2 - Right	Radiobutton	Check this box if the condition entered for Other diagnosis #2 affects the right side only. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other diagnosis #2 - Left	Radiobutton	Check this box if the condition entered for Other diagnosis #2 affects the left side only. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other diagnosis #2 - Both	Radiobutton	Check this box if the condition entered for Other diagnosis #2 affects both the right and left sides. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other diagnosis #2 ICD code	Text	Enter the ICD diagnostic code associated with other diagnosis #2. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other diagnosis #2 date of diagnosis (right)	Date	Enter the date this diagnosis was made for the right side. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other diagnosis #2 date of diagnosis (left)	Date	Enter the date this diagnosis was made for the left side. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other Diagnosis #3 Row
Other Diagnosis #3	Text	Enter the name of the third additional diagnosis related to the claimed knee/lower leg condition. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other diagnosis #3 - Right	Radiobutton	Check this box if Other diagnosis #3 affects the right knee/leg. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other diagnosis #3 - Left	Radiobutton	Check this box if Other diagnosis #3 affects the left knee/leg. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other diagnosis #3 - Both	Radiobutton	Check this box if Other diagnosis #3 affects both knees/legs. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other Diagnosis #3 ICD Code	Text	Enter the ICD diagnosis code associated with Other Diagnosis #3. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other Diagnosis #3 Date of Diagnosis (Right)	Date	Enter the date this diagnosis was made for the right side. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other Diagnosis #3 Date of Diagnosis (Left)	Date	Enter the date this diagnosis was made for the left side. Fill only if 'Other (specify)' is 'Yes'. Depends on: Other (specify)
Other Requestor Description
Other Requestor Description	Text	Describe who requested completion of this questionnaire if it was someone other than the Veteran/Claimant or a third party listed above. Fill only if 'Other' is 'Yes'. Depends on: Other
Patient/Veteran Identification
Patient/Veteran Name	Text	Enter the full name of the patient/veteran.
Patient/Veteran Social Security Number	Text	Enter the patient/veteran's Social Security number.
Date of Examination	Date	Enter the date the examination was performed.
Questionnaire Requested By (Select One)
Veteran/Claimant	Checkbox	Check this box if you are completing this Disability Benefits Questionnaire at the request of the Veteran/Claimant.
Third party	Checkbox	Check this box if a third party requested the questionnaire, and list the requesting organization(s) or individual(s).
Other	Checkbox	Check this box if the requestor is someone else not listed above, and describe who requested it.
Right Joint - Active Range of Motion (AROM)
Damaged	Radiobutton	Check this box if the unclaimed joint is damaged. Fill only if 'Side affected' is 'Left'. Depends on: Side affected: Left
Undamaged	Radiobutton	Check this box if the unclaimed joint is undamaged. Fill only if 'Side affected' is 'Left'. Depends on: Side affected: Left
AROM Flexion Endpoint (Degrees)	Number	Enter the active range of motion flexion endpoint measurement for the right joint in degrees. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
AROM Extension Endpoint (Degrees)	Number	Enter the active range of motion extension endpoint measurement for the right joint in degrees. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Flexion (pain)	Checkbox	Check this box if flexion range of motion exhibited pain on examination. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Extension (pain)	Checkbox	Check this box if extension range of motion exhibited pain on examination. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Flexion Pain-Limited Endpoint (Degrees)	Number	If flexion is limited by pain, weakness, fatigability, incoordination, or other factors, enter the flexion degree endpoint where the limitation occurs. Fill only if 'AROM Flexion Endpoint (Degrees)' differs from above. Depends on: AROM Flexion Endpoint (Degrees)
Extension Pain-Limited Endpoint (Degrees)	Number	If extension is limited by pain, weakness, fatigability, incoordination, or other factors, enter the extension degree endpoint where the limitation occurs. Fill only if 'AROM Extension Endpoint (Degrees)' differs from above. Depends on: AROM Extension Endpoint (Degrees)
AROM Limitation Explanation	Text	Describe any factors (pain, weakness, fatigability, incoordination, or other) that specifically limit active range of motion and provide relevant details. Fill only if 'Undamaged' is 'Yes'. Depends on: Undamaged
Right Joint - Evidence of Pain & Functional Impact
Evidence of pain - Yes	Radiobutton	Check this box if there is evidence of pain in the right joint on examination.
Evidence of pain - No	Radiobutton	Check this box if there is no evidence of pain in the right joint on examination.
Pain with weight-bearing	Checkbox	Check this box if pain is present during weight-bearing activities for the right joint. Fill only if 'Evidence of pain - Yes' is 'Yes'. Depends on: Evidence of pain - Yes
Pain with nonweight-bearing	Checkbox	Check this box if pain is present during nonweight-bearing use/positioning of the right joint. Fill only if 'Evidence of pain - Yes' is 'Yes'. Depends on: Evidence of pain - Yes
Pain with active motion	Checkbox	Check this box if pain is present when the patient actively moves the right joint. Fill only if 'Evidence of pain - Yes' is 'Yes'. Depends on: Evidence of pain - Yes
Pain with passive motion	Checkbox	Check this box if pain is present when the examiner passively moves the right joint. Fill only if 'Evidence of pain - Yes' is 'Yes'. Depends on: Evidence of pain - Yes
Pain at rest / non-movement	Checkbox	Check this box if pain is present at rest or without movement of the right joint. Fill only if 'Evidence of pain - Yes' is 'Yes'. Depends on: Evidence of pain - Yes
Pain does not result in/cause functional loss	Checkbox	Check this box if pain is present but does not result in or cause functional loss for the right joint. Fill only if 'Evidence of pain - Yes' is 'Yes'. Depends on: Evidence of pain - Yes
Pain causes functional loss	Checkbox	Check this box if pain results in or causes functional loss for the right joint (and describe it in the comments box). Fill only if 'Evidence of pain - Yes' is 'Yes'. Depends on: Evidence of pain - Yes
Right Joint - Passive Range of Motion (PROM)
PROM Flexion Endpoint (Degrees)	Number	Enter the passive range-of-motion flexion endpoint value in degrees for the right joint. Fill only if 'Flexion PROM same as active ROM' is 'No'. Depends on: Flexion PROM same as active ROM
Flexion PROM same as active ROM	Checkbox	Check this box if the passive flexion endpoint (PROM) is the same as the active flexion ROM value.
PROM Extension Endpoint (Degrees)	Number	Enter the passive range-of-motion extension endpoint value in degrees for the right joint. Fill only if 'Extension PROM same as active ROM' is 'No'. Depends on: Extension PROM same as active ROM
Extension PROM same as active ROM	Checkbox	Check this box if the passive extension endpoint (PROM) is the same as the active extension ROM value.
Passive ROM pain: Flexion	Checkbox	Check this box if passive flexion ROM exhibited pain during the examination.
Passive ROM pain: Extension	Checkbox	Check this box if passive extension ROM exhibited pain during the examination.
PROM Flexion Endpoint (If Different)	Number	If limitation is specifically attributable to pain, weakness, fatigability, incoordination, or other factors, enter the flexion endpoint in degrees attributable to those factors. Fill only if 'PROM Flexion Endpoint (Degrees)' differs from above. Depends on: PROM Flexion Endpoint (Degrees)
PROM Extension Endpoint (If Different)	Number	If limitation is specifically attributable to pain, weakness, fatigability, incoordination, or other factors, enter the extension endpoint in degrees attributable to those factors. Fill only if 'PROM Extension Endpoint (Degrees)' differs from above. Depends on: PROM Extension Endpoint (Degrees)
PROM Limitation Explanation	Text	Describe the factors (e.g., pain, weakness, fatigability, incoordination, or other) affecting passive range of motion and how they limit movement.
Right Knee - Ambulation Aids for Patellar Instability
Requires prescription for ambulation aid(s) - Yes	Radiobutton	Check this box if the Veteran requires a prescription from a medical provider for any ambulation aid due to right knee patellar instability. Fill only if 'Is there recurrent patellar instability?' is 'Yes'. Depends on: Yes
Requires prescription for ambulation aid(s) - No	Radiobutton	Check this box if the Veteran does not require a prescription from a medical provider for any ambulation aid due to right knee patellar instability. Fill only if 'Is there recurrent patellar instability?' is 'Yes'. Depends on: Yes
Cane(s)	Checkbox	Check this box if, for right knee patellar instability, the Veteran requires a prescribed cane or canes for ambulation. Fill only if 'Requires prescription for ambulation aid(s) - Yes' is 'Yes'. Depends on: Requires prescription for ambulation aid(s) - Yes
Walker	Checkbox	Check this box if, for right knee patellar instability, the Veteran requires a prescribed walker for ambulation. Fill only if 'Requires prescription for ambulation aid(s) - Yes' is 'Yes'. Depends on: Requires prescription for ambulation aid(s) - Yes
Crutches	Checkbox	Check this box if, for right knee patellar instability, the Veteran requires prescribed crutches for ambulation. Fill only if 'Requires prescription for ambulation aid(s) - Yes' is 'Yes'. Depends on: Requires prescription for ambulation aid(s) - Yes
Brace(s)	Checkbox	Check this box if, for right knee patellar instability, the Veteran requires prescribed brace(s) for ambulation. Fill only if 'Requires prescription for ambulation aid(s) - Yes' is 'Yes'. Depends on: Requires prescription for ambulation aid(s) - Yes
Right Knee - Describe checked boxes above
Right Knee Checked Box Details	Text	Describe the right knee condition details corresponding to any boxes checked above. Fill only if 'Does the Veteran currently have or has the Veteran been diagnosed with a meniscus (semilunar cartilage) condition?' is 'Yes'. Depends on: Meniscus condition - Yes
Right Knee - Functional Loss Explanation
Right Knee ROM Functional Loss Explanation	Text	Provide an explanation of how abnormal right knee range of motion contributes to functional loss, including the specific limitations it causes. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right Knee - Initial ROM Measurement Selection
All normal	Radiobutton	Check this box if the right knee initial range of motion (ROM) measurements are all within normal limits.
Abnormal or outside of normal range	Radiobutton	Check this box if any right knee initial ROM measurement is abnormal or outside the normal range.
Unable to test	Radiobutton	Check this box if you were unable to perform right knee initial ROM testing.
Not indicated	Radiobutton	Check this box if right knee initial ROM measurements were not indicated to be performed.
Right Knee - Leg Length Discrepancy Measurements and Description
Leg length discrepancy	Checkbox	Check this box if the Veteran has a leg length discrepancy (shortening of any bones of the lower extremity). Fill only if 'Yes (tibial/fibular impairment diagnosis)' is 'Yes'. Depends on: Yes (tibial/fibular impairment diagnosis)
Right Leg Length Measurement	Number	Enter the measured length of the Veteran's right lower extremity for leg length discrepancy assessment. Fill only if 'Leg length discrepancy' is 'Yes'. Depends on: Leg length discrepancy
Right leg measurement unit: cm	Radiobutton	Select this option if the right leg length measurement is being recorded in centimeters. Fill only if 'Leg length discrepancy' is 'Yes'. Depends on: Leg length discrepancy
Right leg measurement unit: inch	Radiobutton	Select this option if the right leg length measurement is being recorded in inches (to the nearest 1/4 inch). Fill only if 'Leg length discrepancy' is 'Yes'. Depends on: Leg length discrepancy
Right Leg Length Discrepancy Relationship Description	Text	Describe how any right leg length discrepancy relates to the tibial or fibular conditions listed in the diagnosis section above. Fill only if 'Leg length discrepancy' is 'Yes'. Depends on: Leg length discrepancy
Right Knee - Meniscal Condition and Symptom Frequency/Severity
Meniscus condition - Yes	Radiobutton	Check this box if the Veteran currently has, or has been diagnosed with, a right knee meniscus (semilunar cartilage) condition.
Meniscus condition - No	Radiobutton	Check this box if the Veteran does not currently have and has never been diagnosed with a right knee meniscus (semilunar cartilage) condition.
No current symptoms	Checkbox	Check this box if the Veteran has a right knee meniscal condition but has no current meniscal symptoms. Fill only if 'Meniscus condition - Yes' is 'Yes'. Depends on: Meniscus condition - Yes
Meniscal dislocation	Checkbox	Check this box if the Veteran has (or has had) right knee meniscal dislocation. Fill only if 'Meniscus condition - Yes' is 'Yes'. Depends on: Meniscus condition - Yes
Meniscal tear	Checkbox	Check this box if the Veteran has (or has had) a right knee meniscal tear. Fill only if 'Meniscus condition - Yes' is 'Yes'. Depends on: Meniscus condition - Yes
Frequent episodes of joint "locking"	Checkbox	Check this box if the Veteran frequently experiences right knee joint locking episodes due to the meniscal condition. Fill only if 'Meniscus condition - Yes' is 'Yes'. Depends on: Meniscus condition - Yes
Frequent episodes of joint pain	Checkbox	Check this box if the Veteran frequently experiences right knee joint pain episodes due to the meniscal condition. Fill only if 'Meniscus condition - Yes' is 'Yes'. Depends on: Meniscus condition - Yes
Frequent episodes of joint effusion	Checkbox	Check this box if the Veteran frequently experiences right knee joint effusion (swelling/fluid) episodes due to the meniscal condition. Fill only if 'Meniscus condition - Yes' is 'Yes'. Depends on: Meniscus condition - Yes
Right Knee - Outside Normal but Normal for Veteran Description
Right Knee Outside-Normal ROM Explanation	Text	Describe why the right knee range of motion is outside the normal range but is considered normal for the Veteran (e.g., due to age, body habitus, or a non-knee/leg condition). Fill only if 'Abnormal or outside of normal range' is 'Yes'. Depends on: Abnormal or outside of normal range
Right Knee - ROM Contributes to Functional Loss (Yes/No)
Yes	Radiobutton	Check this box if the right knee range of motion (ROM) itself contributes to a functional loss.
No	Radiobutton	Check this box if the right knee range of motion (ROM) itself does not contribute to a functional loss.
Right Knee - Testing Can Be Performed (Yes/No)
Yes	Radiobutton	Check this box if testing for the right knee can be performed.
No	Radiobutton	Check this box if testing for the right knee cannot be performed.
Right Knee - Testing Not Performed Explanation
Right Knee Testing Not Performed Explanation	Text	Provide the reason right knee testing cannot be performed, including any limiting factors such as pain, safety concerns, or medical contraindications. Fill only if 'No' is 'Yes'. Depends on: No
Right Knee - Tibial/Fibular Impairment Conditions and Symptoms
Yes (tibial/fibular impairment diagnosis)	Radiobutton	Check this box if the Veteran currently has, or has been diagnosed with, recurrent patellar dislocation, shin splints (MTSS), stress fractures, or another tibial or fibular impairment of the right knee/lower leg.
No (tibial/fibular impairment diagnosis)	Radiobutton	Check this box if the Veteran does not currently have and has never been diagnosed with recurrent patellar dislocation, shin splints (MTSS), stress fractures, or any other tibial or fibular impairment of the right knee/lower leg.
Stress fracture of the lower leg	Checkbox	Check this box if the Veteran has (or has had) a stress fracture of the right lower leg. Fill only if 'Yes (tibial/fibular impairment diagnosis)' is 'Yes'. Depends on: Yes (tibial/fibular impairment diagnosis)
Right knee tibial/fibular impairment symptoms description	Text	Describe the Veteran’s current right knee symptoms related to tibial or fibular impairment (e.g., pain, swelling, instability, functional limitations). Fill only if 'Stress fracture of the lower leg' is 'Yes'. Depends on: Stress fracture of the lower leg
Acquired/traumatic genu recurvatum with weakness/insecurity in weight-bearing	Checkbox	Check this box if the Veteran has acquired and/or traumatic genu recurvatum of the right knee with objectively demonstrated weakness and insecurity in weight-bearing. Fill only if 'Yes (tibial/fibular impairment diagnosis)' is 'Yes'. Depends on: Yes (tibial/fibular impairment diagnosis)
Recurrent patellar dislocation	Checkbox	Check this box if the Veteran has (or has had) recurrent dislocation of the right patella (kneecap). Fill only if 'Yes (tibial/fibular impairment diagnosis)' is 'Yes'. Depends on: Yes (tibial/fibular impairment diagnosis)
Shin splints (medial tibial stress syndrome - MTSS)	Checkbox	Check this box if the Veteran has (or has had) right-sided shin splints/medial tibial stress syndrome (MTSS). Fill only if 'Yes (tibial/fibular impairment diagnosis)' is 'Yes'. Depends on: Yes (tibial/fibular impairment diagnosis)
Right Knee - Tibial/Fibular Impairment Response to Treatment
Responsive to surgery and/or treatment	Radiobutton	Check this box if the Veteran underwent treatment for the right knee tibial/fibular impairment and the condition improved (was responsive) to surgery and/or other treatment. Fill only if 'Treatment for less than 12 consecutive months', 'Requiring treatment for 12 consecutive months or more' is 'Yes' (any fields). Depends on: Treatment for less than 12 consecutive months, Requiring treatment for 12 consecutive months or more
Unresponsive to shoe orthotics or other conservative treatment	Radiobutton	Check this box if the Veteran underwent conservative treatment (such as shoe orthotics) for the right knee tibial/fibular impairment and did not improve. Fill only if 'Treatment for less than 12 consecutive months', 'Requiring treatment for 12 consecutive months or more' is 'Yes' (any fields). Depends on: Treatment for less than 12 consecutive months, Requiring treatment for 12 consecutive months or more
Unresponsive to surgery and to shoe orthotics/other conservative treatment	Radiobutton	Check this box if the Veteran underwent surgery and also tried shoe orthotics or other conservative treatment for the right knee tibial/fibular impairment, and the condition did not improve with either. Fill only if 'Treatment for less than 12 consecutive months', 'Requiring treatment for 12 consecutive months or more' is 'Yes' (any fields). Depends on: Treatment for less than 12 consecutive months, Requiring treatment for 12 consecutive months or more
Right Knee - Tibial/Fibular Impairment Treatment Length
No treatment received	Radiobutton	Check this box if the Veteran has received no treatment for the right knee tibial/fibular impairment. Fill only if 'Shin splints (medial tibial stress syndrome - MTSS)' is 'Yes'. Depends on: Shin splints (medial tibial stress syndrome - MTSS)
Treatment for less than 12 consecutive months	Radiobutton	Check this box if the Veteran’s right knee tibial/fibular impairment has been treated for less than 12 consecutive months. Fill only if 'Shin splints (medial tibial stress syndrome - MTSS)' is 'Yes'. Depends on: Shin splints (medial tibial stress syndrome - MTSS)
Requiring treatment for 12 consecutive months or more	Radiobutton	Check this box if the Veteran’s right knee tibial/fibular impairment requires treatment for 12 consecutive months or more. Fill only if 'Shin splints (medial tibial stress syndrome - MTSS)' is 'Yes'. Depends on: Shin splints (medial tibial stress syndrome - MTSS)
Right Knee - Unable to Test/Not Indicated Explanation
Right Knee Unable to Test/Not Indicated Explanation	Text	Provide the explanation for why the right knee initial range of motion (ROM) measurements were unable to be tested or were not indicated. Fill only if 'Unable to test', 'Not indicated' is 'Yes' (any). Depends on: Unable to test, Not indicated
Right Knee Additional Loss After Three Repetitions
Yes – Additional loss after three repetitions	Radiobutton	Check this box if the right knee shows additional loss of function or range of motion after completing at least three repetitions.
No – Additional loss after three repetitions	Radiobutton	Check this box if the right knee does not show additional loss of function or range of motion after completing at least three repetitions.
Right Knee Flexion Endpoint After 3 Repetitions	Number	Enter the right knee flexion endpoint measured after completion of three repetitive-use repetitions. Fill only if 'Yes – Additional loss after three repetitions' is 'Yes'. Depends on: Yes – Additional loss after three repetitions
Right Knee Extension Endpoint After 3 Repetitions	Number	Enter the right knee extension endpoint measured after completion of three repetitive-use repetitions. Fill only if 'Yes – Additional loss after three repetitions' is 'Yes'. Depends on: Yes – Additional loss after three repetitions
Pain	Checkbox	Check this box if pain is a factor causing the additional functional loss after three repetitions in the right knee. Fill only if 'Yes – Additional loss after three repetitions' is 'Yes'. Depends on: Yes – Additional loss after three repetitions
Fatigability	Checkbox	Check this box if fatigability is a factor causing the additional functional loss after three repetitions in the right knee. Fill only if 'Yes – Additional loss after three repetitions' is 'Yes'. Depends on: Yes – Additional loss after three repetitions
Weakness	Checkbox	Check this box if weakness is a factor causing the additional functional loss after three repetitions in the right knee. Fill only if 'Yes – Additional loss after three repetitions' is 'Yes'. Depends on: Yes – Additional loss after three repetitions
Lack of endurance	Checkbox	Check this box if lack of endurance is a factor causing the additional functional loss after three repetitions in the right knee. Fill only if 'Yes – Additional loss after three repetitions' is 'Yes'. Depends on: Yes – Additional loss after three repetitions
Incoordination	Checkbox	Check this box if incoordination is a factor causing the additional functional loss after three repetitions in the right knee. Fill only if 'Yes – Additional loss after three repetitions' is 'Yes'. Depends on: Yes – Additional loss after three repetitions
Other	Checkbox	Check this box if another factor (not listed) causes the additional functional loss after three repetitions in the right knee, and specify it in the provided space. Fill only if 'Yes – Additional loss after three repetitions' is 'Yes'. Depends on: Yes – Additional loss after three repetitions
Other Factor Causing Additional Loss (Right Knee)	Text	Describe any other factor not listed that contributes to the additional functional loss after three repetitions for the right knee. Fill only if 'Yes – Additional loss after three repetitions', 'Other' is 'Yes' for all fields. Depends on: Yes – Additional loss after three repetitions, Other
N/A	Checkbox	Check this box if no factors apply because there is no additional functional loss after three repetitions in the right knee. Fill only if 'Yes – Additional loss after three repetitions' is 'Yes'. Depends on: Yes – Additional loss after three repetitions
Right Knee Ambulation Prescription and Devices (6D)
Prescription required for ambulation: Yes	Radiobutton	Check this box if the Veteran requires a prescription (by a medical provider) for any device to assist with ambulation (walking).
Prescription required for ambulation: No	Radiobutton	Check this box if the Veteran does not require a prescription (by a medical provider) for any ambulation-assist device.
Cane(s)	Checkbox	Check this box if a prescribed cane (one or more) is required for ambulation. Fill only if 'Prescription required for ambulation: Yes' is 'Yes'. Depends on: Prescription required for ambulation: Yes
Walker	Checkbox	Check this box if a prescribed walker is required for ambulation. Fill only if 'Prescription required for ambulation: Yes' is 'Yes'. Depends on: Prescription required for ambulation: Yes
Crutches	Checkbox	Check this box if prescribed crutches are required for ambulation. Fill only if 'Prescription required for ambulation: Yes' is 'Yes'. Depends on: Prescription required for ambulation: Yes
Brace(s)	Checkbox	Check this box if a prescribed knee brace (one or more) is required for ambulation. Fill only if 'Prescription required for ambulation: Yes' is 'Yes'. Depends on: Prescription required for ambulation: Yes
Right Knee Ankylosis Angle (5B)
Right Knee Ankylosis Angle (Degrees)	Number	Enter the measured angle of ankylosis for the right knee in degrees. Fill only if 'Yes — ankylosis present' is 'Yes'. Depends on: Yes — ankylosis present
N/A – no ankylosis of knee joint	Checkbox	Check this box if the right knee has no ankylosis (so an ankylosis angle in degrees does not apply). Fill only if 'No — ankylosis not present' is 'Yes'. Depends on: No — ankylosis not present
Right Knee Ankylosis Presence and Severity (5A)
Yes — ankylosis present	Radiobutton	Check this box if there is ankylosis of the right knee and/or lower leg.
No — ankylosis not present	Radiobutton	Check this box if there is no ankylosis of the right knee and/or lower leg.
Severity: Favorable (0–10°)	Radiobutton	Check this box if right knee ankylosis is at a favorable angle in full extension or slight flexion between 0 and 10 degrees. Fill only if 'Yes — ankylosis present' is 'Yes'. Depends on: Yes — ankylosis present
Severity: Flexion 10–20°	Radiobutton	Check this box if right knee ankylosis is in flexion between 10 and 20 degrees. Fill only if 'Yes — ankylosis present' is 'Yes'. Depends on: Yes — ankylosis present
Severity: Flexion 20–45°	Radiobutton	Check this box if right knee ankylosis is in flexion between 20 and 45 degrees. Fill only if 'Yes — ankylosis present' is 'Yes'. Depends on: Yes — ankylosis present
Severity: Extremely unfavorable (≥45°)	Radiobutton	Check this box if right knee ankylosis is extremely unfavorable, with flexion at an angle of 45 degrees or more. Fill only if 'Yes — ankylosis present' is 'Yes'. Depends on: Yes — ankylosis present
Right Knee Crepitus/Tenderness Comments
Right Knee Crepitus Comments	Text	Enter any comments describing the objective evidence of crepitus in the right knee.
Crepitus present (Yes)	Radiobutton	Check this box if there is objective evidence of crepitus in the right knee.
Crepitus present (No)	Radiobutton	Check this box if there is no objective evidence of crepitus in the right knee.
Localized tenderness/pain on palpation present (Yes)	Radiobutton	Check this box if there is objective evidence of localized tenderness or pain on palpation of the right knee joint or associated soft tissue.
Localized tenderness/pain on palpation present (No)	Radiobutton	Check this box if there is no objective evidence of localized tenderness or pain on palpation of the right knee joint or associated soft tissue.
Right Knee Tenderness/Pain on Palpation Explanation	Text	If localized tenderness or pain on palpation is present, explain the right knee findings including location, severity, and relationship to the condition(s). Fill only if 'Localized tenderness/pain on palpation present (Yes)' is 'Yes'. Depends on: Localized tenderness/pain on palpation present (Yes)
Right Knee Examined Immediately After Repeated Use Over Time
Yes	Radiobutton	Check this box if the Veteran is being examined immediately after repeated use over time (right knee).
No	Radiobutton	Check this box if the Veteran is not being examined immediately after repeated use over time (right knee).
Right Knee Flare-ups Assessment (During Flare-up, Functional Loss & Factors)
During flare-up: Yes	Radiobutton	Check this box if the right knee examination is being conducted during a flare-up.
During flare-up: No	Radiobutton	Check this box if the right knee examination is not being conducted during a flare-up.
Flare-ups cause significant functional limitation: Yes	Radiobutton	Check this box if procured evidence indicates flare-ups cause pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability.
Flare-ups cause significant functional limitation: No	Radiobutton	Check this box if procured evidence does not indicate flare-ups significantly limit functional ability due to pain, fatigability, weakness, lack of endurance, or incoordination.
Functional loss factor: Pain	Checkbox	Check this box if pain is a factor that causes the right knee functional loss during flare-ups. Fill only if 'Flare-ups cause significant functional limitation: Yes' is 'Yes'. Depends on: Flare-ups cause significant functional limitation: Yes
Functional loss factor: Fatigability	Checkbox	Check this box if fatigability is a factor that causes the right knee functional loss during flare-ups. Fill only if 'Flare-ups cause significant functional limitation: Yes' is 'Yes'. Depends on: Flare-ups cause significant functional limitation: Yes
Functional loss factor: Weakness	Checkbox	Check this box if weakness is a factor that causes the right knee functional loss during flare-ups. Fill only if 'Flare-ups cause significant functional limitation: Yes' is 'Yes'. Depends on: Flare-ups cause significant functional limitation: Yes
Functional loss factor: Lack of endurance	Checkbox	Check this box if lack of endurance is a factor that causes the right knee functional loss during flare-ups. Fill only if 'Flare-ups cause significant functional limitation: Yes' is 'Yes'. Depends on: Flare-ups cause significant functional limitation: Yes
Functional loss factor: Incoordination	Checkbox	Check this box if incoordination is a factor that causes the right knee functional loss during flare-ups. Fill only if 'Flare-ups cause significant functional limitation: Yes' is 'Yes'. Depends on: Flare-ups cause significant functional limitation: Yes
Functional loss factor: Other	Checkbox	Check this box if another factor not listed causes right knee functional loss during flare-ups, and provide details in the adjacent space. Fill only if 'Flare-ups cause significant functional limitation: Yes' is 'Yes'. Depends on: Flare-ups cause significant functional limitation: Yes
Other Functional Loss Factor (Right Knee Flare-ups)	Text	Enter the other factor(s) not listed that cause functional loss of the right knee during flare-ups. Fill only if 'Flare-ups cause significant functional limitation: Yes', 'Functional loss factor: Other' is 'Yes' for all fields selection. Depends on: Flare-ups cause significant functional limitation: Yes, Functional loss factor: Other
Functional loss factors: N/A	Checkbox	Check this box if none of the listed factors apply to right knee functional loss during flare-ups.
Right Knee Flare-ups ROM Estimates (Flexion/Extension)
Right Knee Flare-up Flexion Endpoint (Degrees)	Text	Enter the estimated right knee flexion endpoint in degrees during flare-ups based on available evidence and the Veteran’s statements. Fill only if 'Flare-ups cause significant functional limitation: Yes' is 'Yes'. Depends on: Flare-ups cause significant functional limitation: Yes
Right Knee Flare-up Extension Endpoint (Degrees)	Text	Enter the estimated right knee extension endpoint in degrees during flare-ups based on available evidence and the Veteran’s statements. Fill only if 'Flare-ups cause significant functional limitation: Yes' is 'Yes'. Depends on: Flare-ups cause significant functional limitation: Yes
Right Knee Ligament Tear and Type (6B)
Ligament tear (sprain) - Yes	Radiobutton	Check this box if the patient has had a ligament tear (sprain) in the right knee.
Ligament tear (sprain) - No	Radiobutton	Check this box if the patient has not had a ligament tear (sprain) in the right knee.
Tear type - Complete ligament tear	Radiobutton	Check this box if the right knee ligament tear was a complete tear. Fill only if 'Ligament tear (sprain) - Yes' is 'Yes'. Depends on: Ligament tear (sprain) - Yes
Tear type - Incomplete/partial ligament tear	Radiobutton	Check this box if the right knee ligament tear was incomplete or partial. Fill only if 'Ligament tear (sprain) - Yes' is 'Yes'. Depends on: Ligament tear (sprain) - Yes
Right Knee Ligament Tear Repaired and Outcome (6C)
Yes	Radiobutton	Check this box if the right knee ligament tear was repaired.
No	Radiobutton	Check this box if the right knee ligament tear was not repaired.
Complete tear repair – successful	Radiobutton	Check this box if the right knee had a complete ligament tear that was repaired and the repair was successful. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Complete tear repair – failed	Radiobutton	Check this box if the right knee had a complete ligament tear that was repaired but the repair failed. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right Knee Muscle Group XIII Involvement (5C)
Muscle Group XIII involvement (Yes)	Radiobutton	Check this box if the right knee is ankylosed and Muscle Group XIII (posterior thigh/hamstrings) is involved.
Muscle Group XIII involvement (No)	Radiobutton	Check this box if the right knee is ankylosed and Muscle Group XIII (posterior thigh/hamstrings) is not involved.
Right Knee Recurrent Patellar Instability (6E)
Yes	Radiobutton	Check this box if the right knee has recurrent patellar instability.
No	Radiobutton	Check this box if the right knee does not have recurrent patellar instability.
Right Knee Recurrent Subluxation or Persistent Instability (6A)
6A. Yes	Radiobutton	Check this box if the right knee has recurrent subluxation or persistent instability.
6A. No	Radiobutton	Check this box if the right knee does not have recurrent subluxation or persistent instability.
Right Knee Repeated Use Over Time Evidence Discussion
Right Knee Repeated Use Over Time Evidence Discussion	Text	Cite and discuss all procurable evidence supporting the estimated right knee functional loss and range of motion with repeated use over time, specific to the case. Fill only if 'Repeated use over time functional loss: Yes' is 'Yes'. Depends on: Repeated use over time functional loss: Yes
Right Knee Repeated Use Over Time Functional Loss (Yes/No & Factors)
Repeated use over time functional loss: Yes	Radiobutton	Check this box if procured evidence (including the Veteran’s statements) suggests pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability with repeated use over time. Fill only if 'Is the Veteran being examined immediately after repeated use over time?' is 'No'. Depends on: No
Repeated use over time functional loss: No	Radiobutton	Check this box if procured evidence does not suggest any significant limitation in functional ability with repeated use over time. Fill only if 'Is the Veteran being examined immediately after repeated use over time?' is 'No'. Depends on: No
Factor causing functional loss: Pain	Checkbox	Check this box if pain contributes to the functional loss with repeated use over time. Fill only if 'Repeated use over time functional loss: Yes' is 'Yes'. Depends on: Repeated use over time functional loss: Yes
Factor causing functional loss: Fatigability	Checkbox	Check this box if fatigability contributes to the functional loss with repeated use over time. Fill only if 'Repeated use over time functional loss: Yes' is 'Yes'. Depends on: Repeated use over time functional loss: Yes
Factor causing functional loss: Weakness	Checkbox	Check this box if weakness contributes to the functional loss with repeated use over time. Fill only if 'Repeated use over time functional loss: Yes' is 'Yes'. Depends on: Repeated use over time functional loss: Yes
Factor causing functional loss: Lack of endurance	Checkbox	Check this box if lack of endurance contributes to the functional loss with repeated use over time. Fill only if 'Repeated use over time functional loss: Yes' is 'Yes'. Depends on: Repeated use over time functional loss: Yes
Factor causing functional loss: Incoordination	Checkbox	Check this box if incoordination contributes to the functional loss with repeated use over time. Fill only if 'Repeated use over time functional loss: Yes' is 'Yes'. Depends on: Repeated use over time functional loss: Yes
Factor causing functional loss: Other	Checkbox	Check this box if another factor (not listed) contributes to the functional loss with repeated use over time. Fill only if 'Repeated use over time functional loss: Yes' is 'Yes'. Depends on: Repeated use over time functional loss: Yes
Other Functional Loss Factor	Text	Enter the other factor(s) causing functional loss with repeated use over time that are not listed (e.g., pain, fatigability, weakness, lack of endurance, incoordination). Fill only if 'Repeated use over time functional loss: Yes', 'Factor causing functional loss: Other' is 'Yes' for all fields selection. Depends on: Repeated use over time functional loss: Yes, Factor causing functional loss: Other
Factors causing functional loss: N/A	Checkbox	Check this box if no factors apply as causes of functional loss with repeated use over time. Fill only if 'Is the Veteran being examined immediately after repeated use over time?' is 'No'. Depends on: No
Right Knee Repeated Use Over Time ROM Estimates (Flexion/Extension)
Flexion Endpoint After Repeated Use Over Time	Number	Enter the estimated right knee flexion endpoint (in degrees) immediately after repeated use over time based on the available evidence. Fill only if 'Repeated use over time functional loss: Yes' is 'Yes'. Depends on: Repeated use over time functional loss: Yes
Extension Endpoint After Repeated Use Over Time	Number	Enter the estimated right knee extension endpoint (in degrees) immediately after repeated use over time based on the available evidence. Fill only if 'Repeated use over time functional loss: Yes' is 'Yes'. Depends on: Repeated use over time functional loss: Yes
Right Knee Repetitive-Use Testing (3+ repetitions)
Yes	Radiobutton	Check this box if the Veteran is able to perform repetitive-use testing with at least three repetitions for the right knee.
No	Radiobutton	Check this box if the Veteran is not able to perform repetitive-use testing with at least three repetitions for the right knee.
Unable to Perform Repetitive-Use Testing Explanation (Right Knee)	Text	Explain why the Veteran is unable to perform right-knee repetitive-use testing with at least three repetitions. Fill only if 'No' is 'Yes'. Depends on: No
Right Knee Surgical Repair for Patellar Instability and Description (6F)
Yes — Surgical repair for patellar instability (Right knee)	Radiobutton	Check this box if the Veteran has had surgical repair of the right knee for patellar instability.
No — Surgical repair for patellar instability (Right knee)	Radiobutton	Check this box if the Veteran has not had surgical repair of the right knee for patellar instability.
Right Knee Patellar Instability Surgery Description	Text	Describe the surgical repair procedure(s) performed on the right knee for patellar instability, including what was repaired and any relevant operative details. Fill only if 'Yes — Surgical repair for patellar instability (Right knee)' is 'Yes'. Depends on: Yes — Surgical repair for patellar instability (Right knee)
Right Lower Extremity Atrophy Details and Measurements (Left Column)
Right lower extremity (specify location of measurement)	Checkbox	Check this box if the muscle atrophy is in the right lower extremity and you will specify the measurement location (e.g., “10 cm above or below knee”). Fill only if 'Yes' is 'Yes'. Depends on: Yes
Right lower extremity atrophy measurement location	Text	Enter the specific location on the right lower extremity where the circumference measurements were taken (e.g., how many centimeters above or below the knee). Fill only if 'Right lower extremity (specify location of measurement)' is 'Yes'. Depends on: Right lower extremity (specify location of measurement)
Circumference of more normal side (cm)	Number	Enter the circumference measurement of the more normal (unaffected) side at the specified location. Fill only if 'Right lower extremity (specify location of measurement)' is 'Yes'. Depends on: Right lower extremity (specify location of measurement)
Circumference of atrophied side (cm)	Number	Enter the circumference measurement of the atrophied (affected) side at the specified location. Fill only if 'Right lower extremity (specify location of measurement)' is 'Yes'. Depends on: Right lower extremity (specify location of measurement)
Section 10A - Other Pertinent Physical Findings (Yes/No and Summary)
Yes	Radiobutton	Check this box if the Veteran has other pertinent physical findings, complications, conditions, signs, or symptoms related to the diagnosed condition(s).
No	Radiobutton	Check this box if the Veteran does not have any other pertinent physical findings, complications, conditions, signs, or symptoms related to the diagnosed condition(s).
Other Pertinent Physical Findings Summary	Text	Provide a brief summary describing any other pertinent physical findings, complications, conditions, signs, or symptoms related to the conditions listed in the diagnosis section. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Section 10B - Scars or Disfigurement (Yes/No)
Yes	Radiobutton	Check this box if the Veteran has any scars or other skin disfigurement related to any condition or to the treatment of any condition listed in the diagnosis section.
No	Radiobutton	Check this box if the Veteran does not have any scars or other skin disfigurement related to any condition or to the treatment of any condition listed in the diagnosis section.
SECTION 14 - FUNCTIONAL IMPACT
Yes	Radiobutton	Check this box if the diagnosed condition(s) impact the Veteran’s ability to perform any type of occupational task (e.g., standing, walking, lifting, sitting).
No	Radiobutton	Check this box if the diagnosed condition(s) do not impact the Veteran’s ability to perform occupational tasks.
Functional Impact Description	Text	Describe how the diagnosed condition(s) impact the veteran’s ability to perform occupational tasks (e.g., standing, walking, lifting, sitting), providing one or more examples. Fill only if 'Yes' is 'Yes'. Depends on: Yes
SECTION 15 - REMARKS
Remarks	Text	Enter any additional remarks or explanations, including the section number the remark relates to when applicable. Fill only if 'The Veteran does not have a current diagnosis associated with any claimed condition(s) listed above' is 'Yes'. Depends on: No current diagnosis associated with any claimed condition
Section 9 (Left Knee) - Surgical Procedures and Residuals
No surgery	Checkbox	Check this box if the Veteran has not had any surgical procedures on the left knee.
Knee joint resurfacing	Checkbox	Check this box if the Veteran has had a left knee joint resurfacing procedure.
Left Knee Joint Resurfacing Surgery Date	Date	Enter the date the left knee joint resurfacing surgery was performed. Fill only if 'Knee joint resurfacing' is checked. Depends on: Knee joint resurfacing
Total knee joint replacement	Checkbox	Check this box if the Veteran has had a total left knee joint replacement.
Left Total Knee Replacement Surgery Date	Date	Enter the date the left total knee joint replacement surgery was performed. Fill only if 'Total knee joint replacement' is checked. Depends on: Total knee joint replacement
Total knee joint replacement residuals: None	Checkbox	Check this box if the Veteran has no residuals from the total left knee joint replacement.
Total knee joint replacement residuals: Intermediate degrees of residual weakness, pain, or limitation of motion	Checkbox	Check this box if, after total left knee joint replacement, the Veteran has intermediate residual weakness, pain, or limitation of motion.
Total knee joint replacement residuals: Chronic residuals consisting of severe painful motion or weakness	Checkbox	Check this box if, after total left knee joint replacement, the Veteran has chronic residuals with severe painful motion or weakness.
Total knee joint replacement residuals: Other residuals (describe)	Checkbox	Check this box if the Veteran has residuals from the total left knee joint replacement that are not covered by the listed options and will be described.
Left Total Knee Replacement Other Residuals Description	Text	Describe any other residuals from the left total knee joint replacement not covered by the listed options. Fill only if 'Total knee joint replacement residuals: Other residuals (describe)' is checked. Depends on: Total knee joint replacement residuals: Other residuals (describe)
Meniscectomy	Checkbox	Check this box if the Veteran has had a left knee meniscectomy.
Left Meniscectomy Surgery Date	Date	Enter the date the left meniscectomy surgery was performed. Fill only if 'Meniscectomy' is checked. Depends on: Meniscectomy
Arthroscopic ligament repair	Checkbox	Check this box if the Veteran has had an arthroscopic ligament repair procedure on the left knee.
Left Arthroscopic Ligament Repair Surgery Date	Date	Enter the date the left arthroscopic ligament repair surgery was performed. Fill only if 'Arthroscopic ligament repair' is checked. Depends on: Arthroscopic ligament repair
Other surgery not described (specify below)	Checkbox	Check this box if the Veteran has had another left knee surgery not listed here and the type of surgery will be specified.
Left Other Knee Surgery Date	Date	Enter the date the other left knee surgery (not otherwise described on this form) was performed. Fill only if 'Other surgery not described (specify below)' is checked. Depends on: Other surgery not described (specify below)
Left Other Knee Surgery Type	Text	Specify the type of other left knee surgery performed that is not listed above. Fill only if 'Other surgery not described (specify below)' is checked. Depends on: Other surgery not described (specify below)
Residual signs or symptoms due to meniscectomy, arthroscopic ligament repair or other knee surgery not described above	Checkbox	Check this box if the Veteran has current residual signs or symptoms due to a left knee meniscectomy, arthroscopic ligament repair, or other left knee surgery not otherwise listed above.
Left Knee Surgery Residuals Description	Text	Describe any residual signs or symptoms due to left meniscectomy, arthroscopic ligament repair, or other left knee surgery not described above.
Section 9 (Right Knee) - Surgical Procedures and Residuals
No surgery	Checkbox	Check this box if the Veteran has not had any right knee surgery.
Knee joint resurfacing	Checkbox	Check this box if the Veteran has had right knee joint resurfacing surgery.
Knee Joint Resurfacing Surgery Date (Right Knee)	Date	Enter the date the Veteran had right knee joint resurfacing surgery. Fill only if 'Knee joint resurfacing' is checked. Depends on: Knee joint resurfacing
Total knee joint replacement	Checkbox	Check this box if the Veteran has had a total right knee joint replacement.
Total Knee Joint Replacement Surgery Date (Right Knee)	Date	Enter the date the Veteran had a total right knee joint replacement. Fill only if 'Total knee joint replacement' is checked. Depends on: Total knee joint replacement
Total knee joint replacement residuals: None	Checkbox	Check this box if there are no residual symptoms or functional limitations following the total right knee replacement.
Residuals: Intermediate degrees of residual weakness, pain, or limitation of motion	Checkbox	Check this box if the total right knee replacement resulted in intermediate (not severe) residual weakness, pain, or limitation of motion.
Residuals: Chronic residuals consisting of severe painful motion or weakness	Checkbox	Check this box if the total right knee replacement resulted in chronic severe painful motion or severe weakness.
Residuals: Other (describe)	Checkbox	Check this box if the total right knee replacement resulted in other residuals not listed, and provide a description.
Other Total Knee Replacement Residuals Description (Right Knee)	Text	Describe any other residuals from the Veteran’s total right knee replacement that are not covered by the listed residual options. Fill only if 'Residuals: Other (describe)' is checked. Depends on: Residuals: Other (describe)
Meniscectomy	Checkbox	Check this box if the Veteran has had a right knee meniscectomy.
Meniscectomy Surgery Date (Right Knee)	Date	Enter the date the Veteran had a right knee meniscectomy. Fill only if 'Meniscectomy' is checked. Depends on: Meniscectomy
Arthroscopic ligament repair	Checkbox	Check this box if the Veteran has had arthroscopic ligament repair surgery on the right knee.
Arthroscopic Ligament Repair Surgery Date (Right Knee)	Date	Enter the date the Veteran had right knee arthroscopic ligament repair surgery. Fill only if 'Arthroscopic ligament repair' is checked. Depends on: Arthroscopic ligament repair
Other surgery not described (specify below)	Checkbox	Check this box if the Veteran had another type of right knee surgery not listed and you will specify the type of surgery.
Other Knee Surgery Date (Right Knee)	Date	Enter the date of the other right knee surgery that is not otherwise described on the form. Fill only if 'Other surgery not described (specify below)' is checked. Depends on: Other surgery not described (specify below)
Type of Other Knee Surgery (Right Knee)	Text	Specify the type/name of the other right knee surgery performed. Fill only if 'Other surgery not described (specify below)' is checked. Depends on: Other surgery not described (specify below)
Residual signs or symptoms due to meniscectomy, arthroscopic ligament repair, or other knee surgery not described above	Checkbox	Check this box if the Veteran has residual signs or symptoms from a right knee meniscectomy, arthroscopic ligament repair, or other unlisted right knee surgery.
Residual Signs and Symptoms Description (Right Knee)	Text	Describe any residual signs or symptoms due to right knee meniscectomy, arthroscopic ligament repair, or other knee surgery not described above.
Third Party Requestor Name(s)
Third-Party Requestor Name(s)	Text	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' is 'Yes'. Depends on: Third party
Veteran Regularly Seen in Clinic (Yes/No)
Yes	Radiobutton	Check this box if the Veteran is regularly seen as a patient in your clinic.
No	Radiobutton	Check this box if the Veteran is not regularly seen as a patient in your clinic.
Walker Use and Frequency
Walker	Checkbox	Check this box if the Veteran uses a walker as an assistive device for locomotion. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Walker frequency: Occasional	Radiobutton	Check this box if the Veteran uses a walker occasionally. Fill only if 'Yes', 'Walker' is 'Yes' and all. Depends on: Yes, Walker
Walker frequency: Regular	Radiobutton	Check this box if the Veteran uses a walker on a regular basis. Fill only if 'Yes', 'Walker' is 'Yes' and all. Depends on: Yes, Walker
Walker frequency: Constant	Radiobutton	Check this box if the Veteran uses a walker constantly. Fill only if 'Yes', 'Walker' is 'Yes' and all. Depends on: Yes, Walker
Wheelchair Use and Frequency
Wheelchair	Checkbox	Check this box if the Veteran uses a wheelchair as an assistive device for locomotion. Fill only if 'Yes' is 'Yes'. Depends on: Yes
Wheelchair frequency of use: Occasional	Radiobutton	Check this box if the Veteran uses a wheelchair only occasionally. Fill only if 'Yes', 'Wheelchair' is 'Yes' and all. Depends on: Yes, Wheelchair
Wheelchair frequency of use: Regular	Radiobutton	Check this box if the Veteran uses a wheelchair on a regular basis but not constantly. Fill only if 'Yes', 'Wheelchair' is 'Yes' and all. Depends on: Yes, Wheelchair
Wheelchair frequency of use: Constant	Radiobutton	Check this box if the Veteran uses a wheelchair constantly as their normal mode of locomotion. Fill only if 'Yes', 'Wheelchair' is 'Yes' and all. Depends on: Yes, Wheelchair

Knee and Lower Leg Disability Benefits Questionnaire Instructions