Shoulder and Arm Conditions Disability Benefits Questionnaire Instructions

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

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

Provide a brief summary of 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'.

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

Check this box if the Veteran has no scars or other skin disfigurement related to any diagnosed condition or its treatment.

Enter any additional comments about the Veteran’s scars or other skin disfigurement related to the diagnosed conditions or their treatment.

Check this box if the Veteran’s right upper extremity is affected such that remaining function is so diminished that an amputation with prosthesis would equally serve the Veteran. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran’s left upper extremity is affected such that remaining function is so diminished that an amputation with prosthesis would equally serve the Veteran. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran’s shoulder or arm condition causes functional impairment of an extremity so severe that an amputation with prosthesis would equally serve the Veteran.

Check this box if the Veteran’s shoulder or arm condition does not cause functional impairment so severe that an amputation with prosthesis would equally serve the Veteran.

For each extremity identified as having loss of effective function, describe the condition causing the loss of function, explain the loss of effective function, and provide specific examples. Fill only if 'Right upper', 'Left upper' is checked (any).

Provide a detailed narrative citing and discussing all procurable evidence supporting the repeated-use-over-time findings and any estimated additional functional loss. Fill only if 'No' is 'No'.

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

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

Check this box if pain is a factor that causes functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'.

Check this box if fatigability is a factor that causes functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'.

Check this box if weakness is a factor that causes functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'.

Check this box if lack of endurance is a factor that causes functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'.

Check this box if incoordination is a factor that causes functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'.

Check this box if another factor (not listed) causes functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'.

Describe the other factor (not listed) that causes functional loss with repeated use over time. Fill only if 'Other' is 'Yes'.

Check this box if no factors apply (i.e., none of the listed factors cause functional loss with repeated use over time). Fill only if 'Yes' is 'Yes'.

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

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

Enter the estimated flexion endpoint range of motion for the joint immediately after repeated use over time, expressed in degrees. Fill only if 'No' is 'No'.

Enter the estimated abduction endpoint range of motion for the joint immediately after repeated use over time, expressed in degrees. Fill only if 'No' is 'No'.

Enter the estimated internal rotation endpoint range of motion for the joint immediately after repeated use over time, expressed in degrees. Fill only if 'No' is 'No'.

Enter the estimated external rotation endpoint range of motion for the joint immediately after repeated use over time, expressed in degrees. Fill only if 'No' is 'No'.

Cite and discuss the specific evidence used to support the repeated-use-over-time findings for this joint, based on all procurable information. Fill only if 'No' is 'No'.

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

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

Check this box if pain is a factor that causes functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'.

Check this box if fatigability is a factor that causes functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'.

Check this box if weakness is a factor that causes functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'.

Check this box if lack of endurance is a factor that causes functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'.

Check this box if incoordination is a factor that causes functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'.

Check this box if another factor not listed is causing functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'.

Enter the other factor (not listed) that causes functional loss with repeated use over time. Fill only if 'Other' is 'Yes'.

Check this box if none of the listed factors apply as causes of functional loss with repeated use over time. Fill only if 'Yes' is 'Yes'.

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

Check this box if procured evidence (the Veteran’s statements) does not suggest pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability with repeated use over time.

Enter the estimated flexion endpoint range of motion for this joint immediately after repeated use over time, in degrees. Fill only if 'No' is 'No'.

Enter the estimated abduction endpoint range of motion for this joint immediately after repeated use over time, in degrees. Fill only if 'No' is 'No'.

Enter the estimated internal rotation endpoint range of motion for this joint immediately after repeated use over time, in degrees. Fill only if 'No' is 'No'.

Enter the estimated external rotation endpoint range of motion for this joint immediately after repeated use over time, in degrees. Fill only if 'No' is 'No'.

Check this box if the examination is being conducted during a flare-up.

Check this box if the examination is not being conducted during a flare-up.

Check this box if pain is a factor that causes functional loss during flare-ups. Fill only if 'Yes' is 'Yes'.

Check this box if fatigability is a factor that causes functional loss during flare-ups. Fill only if 'Yes' is 'Yes'.

Check this box if weakness is a factor that causes functional loss during flare-ups. Fill only if 'Yes' is 'Yes'.

Check this box if lack of endurance is a factor that causes functional loss during flare-ups. Fill only if 'Yes' is 'Yes'.

Check this box if incoordination is a factor that causes functional loss during flare-ups. Fill only if 'Yes' is 'Yes'.

Check this box if another factor not listed is causing functional loss during flare-ups. Fill only if 'Yes' is 'Yes'.

Enter the other factor (not listed) that causes functional loss during flare-ups. Fill only if 'Other' is 'Yes'.

Check this box if none of the listed factors cause functional loss during flare-ups. Fill only if 'Yes' is 'Yes'.

Check this box if procured evidence (e.g., Veteran statements) suggests pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability during flare-ups.

Check this box if procured evidence does not suggest pain, fatigability, weakness, lack of endurance, or incoordination that significantly limits functional ability during flare-ups.

Enter the estimated flexion endpoint range of motion during flare-ups in degrees based on all available evidence. Fill only if 'Exam during flare-up: No' is 'No'.

Enter the estimated abduction endpoint range of motion during flare-ups in degrees based on all available evidence. Fill only if 'Exam during flare-up: No' is 'No'.

Enter the estimated internal rotation endpoint range of motion during flare-ups in degrees based on all available evidence. Fill only if 'Exam during flare-up: No' is 'No'.

Enter the estimated external rotation endpoint range of motion during flare-ups in degrees based on all available evidence. Fill only if 'Exam during flare-up: No' is 'No'.

Check this box if the examination is being conducted during a flare-up.

Check this box if the examination is not being conducted during a flare-up.

Check this box if pain significantly limits functional ability during flare-ups. Fill only if 'Yes' is 'Yes'.

Check this box if fatigability significantly limits functional ability during flare-ups. Fill only if 'Yes' is 'Yes'.

Check this box if weakness significantly limits functional ability during flare-ups. Fill only if 'Yes' is 'Yes'.

Check this box if lack of endurance significantly limits functional ability during flare-ups. Fill only if 'Yes' is 'Yes'.

Check this box if incoordination significantly limits functional ability during flare-ups. Fill only if 'Yes' is 'Yes'.

Check this box if another factor (not listed) significantly limits functional ability during flare-ups. Fill only if 'Yes' is 'Yes'.

Enter the other factor (not listed) that causes functional loss during flare-ups. Fill only if 'Other' is 'Yes'.

Check this box if none of the listed factors cause functional loss during flare-ups. Fill only if 'Yes' is 'Yes'.

Check this box if procured evidence (including the Veteran’s statements) indicates that flare-ups significantly limit functional ability (e.g., due to pain, fatigability, weakness, lack of endurance, or incoordination).

Check this box if procured evidence (including the Veteran’s statements) does not indicate that flare-ups significantly limit functional ability.

Enter the estimated flexion endpoint range of motion for this joint during flare-ups, in degrees. Fill only if 'Exam conducted during a flare-up - No' is 'No'.

Enter the estimated abduction endpoint range of motion for this joint during flare-ups, in degrees. Fill only if 'Exam conducted during a flare-up - No' is 'No'.

Enter the estimated internal rotation endpoint range of motion for this joint during flare-ups, in degrees. Fill only if 'Exam conducted during a flare-up - No' is 'No'.

Enter the estimated external rotation endpoint range of motion for this joint during flare-ups, in degrees. Fill only if 'Exam conducted during a flare-up - No' is 'No'.

Check this box if shoulder instability, dislocation, or labral pathology is suspected. Fill only if 'Crank Apprehension and Relocation Test' is 'Unable to test'.

Check this box if shoulder instability, dislocation, or labral pathology is not suspected. Fill only if 'Crank Apprehension and Relocation Test' is 'Unable to test'.

Describe the suspected shoulder instability, dislocation, or labral pathology (if testing could not be performed and suspicion is indicated). Fill only if 'Yes' is 'Yes'.

Check this box if shoulder instability, dislocation, or labral pathology is suspected. Fill only if 'Crank Apprehension and Relocation Test' is 'Unable to test'.

Check this box if shoulder instability, dislocation, or labral pathology is not suspected. Fill only if 'Crank Apprehension and Relocation Test' is 'Unable to test'.

Describe the suspected shoulder instability, dislocation, or labral pathology when the shoulder cannot be tested. Fill only if 'Yes' is 'Yes'.

Check this box if there is shoulder instability, dislocation, or labral pathology present.

Check this box if there is no shoulder instability, dislocation, or labral pathology present.

Check this box if there is shoulder instability, dislocation, or labral pathology.

Check this box if there is no shoulder instability, dislocation, or labral pathology.

Check this box if the Veteran has mechanical symptoms (e.g., clicking, catching, etc.).

Check this box if the Veteran does not have mechanical symptoms (e.g., clicking, catching, etc.).

Check this box if the Veteran has mechanical symptoms (e.g., clicking, catching).

Check this box if the Veteran does not have mechanical symptoms (e.g., clicking, catching).

Check this box if there are current residuals of recurrent dislocation (subluxation) of the glenohumeral (scapulohumeral) joint.

Check this box if there are no current residuals of recurrent dislocation (subluxation) of the glenohumeral (scapulohumeral) joint.

Check this box if recurrent dislocation residuals involve infrequent episodes with guarding of movement only at shoulder level (flexion and/or abduction at 90°). Fill only if 'Current residuals of recurrent dislocation (subluxation) – Yes' is 'Yes'.

Check this box if recurrent dislocation residuals involve frequent episodes with guarding of all arm movements. Fill only if 'Current residuals of recurrent dislocation (subluxation) – Yes' is 'Yes'.

Check this box if the recurrent dislocation residuals affect the shoulder’s range of motion. Fill only if 'Current residuals of recurrent dislocation (subluxation) – Yes' is 'Yes'.

Check this box if the recurrent dislocation residuals do not affect the shoulder’s range of motion. Fill only if 'Current residuals of recurrent dislocation (subluxation) – Yes' is 'Yes'.

Check this box if there are current residuals of recurrent dislocation (subluxation) of the glenohumeral (scapulohumeral) joint.

Check this box if there are no current residuals of recurrent dislocation (subluxation) of the glenohumeral (scapulohumeral) joint.

Check this box if, due to recurrent dislocation/subluxation, the Veteran has infrequent episodes and guards movement only at shoulder level (flexion and/or abduction at 90°). Fill only if 'Current residuals of recurrent dislocation (subluxation) - Yes' is 'Yes'.

Check this box if, due to recurrent dislocation/subluxation, the Veteran has frequent episodes and guards all arm movements. Fill only if 'Current residuals of recurrent dislocation (subluxation) - Yes' is 'Yes'.

Check this box if the recurrent dislocation/subluxation residuals affect range of motion. Fill only if 'Current residuals of recurrent dislocation (subluxation) - Yes' is 'Yes'.

Check this box if the recurrent dislocation/subluxation residuals do not affect range of motion. Fill only if 'Current residuals of recurrent dislocation (subluxation) - Yes' is 'Yes'.

Check this box if the cross-body adduction test is positive (pain occurs, suggesting possible AC joint pathology).

Check this box if the cross-body adduction test is negative (no pain and no indication of AC joint pathology).

Check this box if the cross-body adduction test could not be performed for any reason.

Check this box if the cross-body adduction test is not applicable to the exam or patient.

Check this box if the cross-body adduction test is positive (pain indicates possible acromioclavicular joint pathology).

Check this box if the cross-body adduction test is negative (no finding suggesting acromioclavicular joint pathology).

Check this box if the cross-body adduction test could not be performed.

Check this box if the cross-body adduction test is not applicable.

Check this box if, because the test cannot be performed, a clavicle, scapula, acromioclavicular (AC) joint, or sternoclavicular (SC) joint condition is suspected.

Check this box if, despite being unable to perform the test, a clavicle, scapula, acromioclavicular (AC) joint, or sternoclavicular (SC) joint condition is not suspected.

Describe the suspected clavicle, scapula, acromioclavicular (AC) joint, or sternoclavicular (SC) joint condition if the cross-body adduction test could not be performed. Fill only if 'Yes' is 'Yes'.

Check this box if, because you are unable to test, a clavicle, scapula, acromioclavicular (AC) joint, or sternoclavicular (SC) joint condition is suspected.

Check this box if, despite being unable to test, a clavicle, scapula, acromioclavicular (AC) joint, or sternoclavicular (SC) joint condition is not suspected.

Provide details describing the suspected clavicle, scapula, acromioclavicular (AC) joint, or sternoclavicular (SC) joint condition if the cross-body adduction test could not be performed. Fill only if 'Yes' is 'Yes'.

Check this box if there is a clavicle, scapula, acromioclavicular (AC) joint, sternoclavicular joint condition, or other impairment.

Check this box if there is no clavicle, scapula, acromioclavicular (AC) joint, sternoclavicular joint condition, or other impairment.

Check this box if the impairment is a malunion of the clavicle or scapula. Fill only if 'Yes' is 'Yes'.

Check this box if the impairment is a nonunion of the clavicle or scapula without loose movement. Fill only if 'Yes' is 'Yes'.

Check this box if the impairment is a nonunion of the clavicle or scapula with loose movement. Fill only if 'Yes' is 'Yes'.

Check this box if the impairment is a dislocation, including acromioclavicular (AC) separation or sternoclavicular dislocation. Fill only if 'Yes' is 'Yes'.

Check this box if the impairment is another clavicle/scapula/AC/SC condition not listed, and provide a description. Fill only if 'Yes' is 'Yes'.

Describe the other clavicle, scapula, acromioclavicular (AC) joint, or sternoclavicular joint condition/impairment selected under “Other (describe)”. Fill only if 'Other (describe)' is 'Yes'.

Check this box if there is a clavicle, scapula, acromioclavicular (AC) joint, or sternoclavicular joint condition or other impairment.

Check this box if there is no clavicle, scapula, acromioclavicular (AC) joint, or sternoclavicular joint condition or other impairment.

Check this box if the condition involves malunion of the clavicle or scapula. Fill only if '8C Condition/impairment present – Yes' is 'Yes'.

Check this box if there is nonunion of the clavicle or scapula and there is no loose movement. Fill only if '8C Condition/impairment present – Yes' is 'Yes'.

Check this box if there is nonunion of the clavicle or scapula with loose movement. Fill only if '8C Condition/impairment present – Yes' is 'Yes'.

Check this box if the condition involves dislocation, including acromioclavicular (AC) separation or sternoclavicular dislocation. Fill only if '8C Condition/impairment present – Yes' is 'Yes'.

Check this box if the impairment type is something other than the listed options and you will describe it. Fill only if '8C Condition/impairment present – Yes' is 'Yes'.

Describe the other clavicle, scapula, acromioclavicular (AC), or sternoclavicular (SC) joint condition or impairment when 'Other (describe)' is selected in item 8C. Fill only if 'Other (describe)' is 'Yes'.

Describe how any abnormal diagnostic test findings relate to the diagnosed condition(s), including which finding corresponds to which diagnosis and the clinical significance.

Enter any additional shoulder and/or arm diagnoses not already listed above, including relevant details such as diagnosis name, affected side, ICD code, and date of diagnosis if known.

Check this box if imaging studies document degenerative (osteoarthritis) or post-traumatic arthritis. Fill only if 'Yes' is 'Yes'.

Check this box if imaging studies do not document degenerative (osteoarthritis) or post-traumatic arthritis. Fill only if 'Yes' is 'Yes'.

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

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

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

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

Check this box if the Veteran uses the brace occasionally. Fill only if 'Brace' is 'Yes'.

Check this box if the Veteran uses the brace on a regular basis. Fill only if 'Brace' is 'Yes'.

Check this box if the Veteran uses the brace constantly. Fill only if 'Brace' is 'Yes'.

Check this box if the Veteran uses an assistive device not listed elsewhere, and provide a description of the device. Fill only if 'Yes' is 'Yes'.

Enter a description of any assistive device the Veteran uses that is not listed (e.g., other than a brace). Fill only if 'Other (describe)' is 'Yes'.

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

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

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

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

List all claimed shoulder and/or arm condition(s) that this questionnaire addresses.

Check this box if the Veteran has a current diagnosis of shoulder strain.

Check this box if the diagnosed shoulder strain affects the right shoulder.

Check this box if the diagnosed shoulder strain affects the left shoulder.

Check this box if the diagnosed shoulder strain affects both shoulders.

Enter the ICD diagnosis code for the shoulder strain diagnosis. Fill only if 'Shoulder strain - Side affected: Right', 'Shoulder strain - Side affected: Left', 'Shoulder strain - Side affected: Both' is 'Yes' (any fields selection).

Enter the date the right-side shoulder strain was diagnosed. Fill only if 'Shoulder strain - Side affected: Right', 'Shoulder strain - Side affected: Both' is 'Yes' (any fields selection).

Enter the date the left-side shoulder strain was diagnosed. Fill only if 'Shoulder strain - Side affected: Left', 'Shoulder strain - Side affected: Both' is 'Yes' (any fields selection).

Check this box if the Veteran has a diagnosis of acromioclavicular (AC) joint osteoarthritis related to the claimed shoulder/arm condition.

Check this box if the acromioclavicular joint osteoarthritis affects the right shoulder.

Check this box if the acromioclavicular joint osteoarthritis affects the left shoulder.

Check this box if the acromioclavicular joint osteoarthritis affects both shoulders.

Enter the ICD diagnostic code for acromioclavicular joint osteoarthritis. Fill only if 'Right (side affected) - Acromioclavicular joint osteoarthritis', 'Left (side affected) - Acromioclavicular joint osteoarthritis', 'Both (sides affected) - Acromioclavicular joint osteoarthritis' is 'Yes' (any fields selection).

Enter the date the right-side acromioclavicular joint osteoarthritis was diagnosed. Fill only if 'Right (side affected) - Acromioclavicular joint osteoarthritis', 'Both (sides affected) - Acromioclavicular joint osteoarthritis' is 'Yes' (any fields selection).

Enter the date the left-side acromioclavicular joint osteoarthritis was diagnosed. Fill only if 'Left (side affected) - Acromioclavicular joint osteoarthritis', 'Both (sides affected) - Acromioclavicular joint osteoarthritis' is 'Yes' (any fields selection).

Check this box if the Veteran is diagnosed with ankylosis of the glenohumeral (shoulder) joint.

Check this box if the ankylosis affects the right shoulder.

Check this box if the ankylosis affects the left shoulder.

Check this box if the ankylosis affects both shoulders.

Enter the ICD diagnostic code for ankylosis of the glenohumeral articulations (shoulder joint). Fill only if 'Side affected: Right', 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

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

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

Check this box if the Veteran has a diagnosis of glenohumeral (shoulder) joint instability.

Check this box if the glenohumeral joint instability affects the right shoulder.

Check this box if the glenohumeral joint instability affects the left shoulder.

Check this box if the glenohumeral joint instability affects both shoulders.

Enter the ICD diagnosis code for the Veteran’s glenohumeral joint instability. Fill only if 'Side affected - Right', 'Side affected - Left', 'Side affected - Both' is 'Yes' (any fields selection).

Enter the date the right shoulder glenohumeral joint instability was diagnosed. Fill only if 'Side affected - Right', 'Side affected - Both' is 'Yes' (any fields selection).

Enter the date the left shoulder glenohumeral joint instability was diagnosed. Fill only if 'Side affected - Left', 'Side affected - Both' is 'Yes' (any fields selection).

Check this box if the Veteran has a diagnosis of glenohumeral (shoulder) joint dislocation or recurrent dislocation.

Check this box if the glenohumeral joint dislocation/recurrent dislocation affects the right shoulder.

Check this box if the glenohumeral joint dislocation/recurrent dislocation affects the left shoulder.

Check this box if the glenohumeral joint dislocation/recurrent dislocation affects both shoulders.

Enter the ICD diagnosis code for glenohumeral joint dislocation/recurrent dislocation. Fill only if 'Side affected: Right', 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

Provide the date the right shoulder glenohumeral joint dislocation/recurrent dislocation was diagnosed. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any fields selection).

Provide the date the left shoulder glenohumeral joint dislocation/recurrent dislocation was diagnosed. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

Check this box if the Veteran has a diagnosis/history of shoulder joint replacement (total shoulder arthroplasty or hemiarthroplasty).

Check this box if the shoulder joint replacement applies to the right shoulder.

Check this box if the shoulder joint replacement applies to the left shoulder.

Check this box if the shoulder joint replacement applies to both shoulders.

Enter the ICD diagnosis code for the shoulder joint replacement (total/hemiarthroplasty) condition. Fill only if 'Side affected: Right', 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

Provide the date of diagnosis for the right-side shoulder joint replacement (total/hemiarthroplasty). Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any fields selection).

Provide the date of diagnosis for the left-side shoulder joint replacement (total/hemiarthroplasty). Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

Check this box if the Veteran has a diagnosis of acromioclavicular (AC) joint separation associated with the claimed condition(s).

Check this box if the acromioclavicular joint separation affects the right side only.

Check this box if the acromioclavicular joint separation affects the left side only.

Check this box if the acromioclavicular joint separation affects both the right and left sides.

Enter the ICD diagnosis code for the acromioclavicular joint separation. Fill only if 'Acromioclavicular joint separation – Right', 'Acromioclavicular joint separation – Left', 'Acromioclavicular joint separation – Both' is 'Yes' (any fields selection).

Enter the date the acromioclavicular joint separation was diagnosed for the right side. Fill only if 'Acromioclavicular joint separation – Right', 'Acromioclavicular joint separation – Both' is 'Yes' (any fields selection).

Enter the date the acromioclavicular joint separation was diagnosed for the left side. Fill only if 'Acromioclavicular joint separation – Left', 'Acromioclavicular joint separation – Both' is 'Yes' (any fields selection).

Check this box if the Veteran has a diagnosis of degenerative arthritis that is not due to trauma (posttraumatic).

Check this box if the degenerative arthritis (other than posttraumatic) affects the right shoulder/arm.

Check this box if the degenerative arthritis (other than posttraumatic) affects the left shoulder/arm.

Check this box if the degenerative arthritis (other than posttraumatic) affects both the right and left shoulders/arms.

Enter the ICD diagnosis code for degenerative arthritis (other than posttraumatic). Fill only if 'Side affected: Right', 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

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

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

Check this box if the Veteran has a current diagnosis of gonorrheal arthritis related to the claimed shoulder/arm condition.

Check this box if the gonorrheal arthritis diagnosis affects the right shoulder/arm.

Check this box if the gonorrheal arthritis diagnosis affects the left shoulder/arm.

Check this box if the gonorrheal arthritis diagnosis affects both the right and left shoulders/arms.

Enter the ICD diagnostic code for the condition "Arthritis, gonorrheal." Fill only if 'Side affected: Right', 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

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

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

Check this box if the Veteran has a diagnosis of pneumococcal arthritis associated with the claimed condition.

Check this box if the pneumococcal arthritis affects the right side.

Check this box if the pneumococcal arthritis affects the left side.

Check this box if the pneumococcal arthritis affects both sides.

Enter the ICD diagnosis code for pneumococcic arthritis. Fill only if 'Side affected: Right', 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

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

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

Check this box if the Veteran has a current diagnosis of streptococcic arthritis.

Check this box if the streptococcic arthritis affects the Veteran’s right shoulder/arm.

Check this box if the streptococcic arthritis affects the Veteran’s left shoulder/arm.

Check this box if the streptococcic arthritis affects both the right and left shoulders/arms.

Enter the ICD diagnosis code for streptococcic arthritis. Fill only if 'Side affected: Right', 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

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

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

Check this box if the Veteran has a current diagnosis of shoulder impingement syndrome.

Check this box if shoulder impingement syndrome affects the right shoulder only.

Check this box if shoulder impingement syndrome affects the left shoulder only.

Check this box if shoulder impingement syndrome affects both shoulders.

Enter the ICD diagnostic code for the shoulder impingement syndrome diagnosis. Fill only if 'Side affected - Right', 'Side affected - Left', 'Side affected - Both' is 'Yes' (any fields selection).

Enter the date the right shoulder impingement syndrome was diagnosed. Fill only if 'Side affected - Right', 'Side affected - Both' is 'Yes' (any fields selection).

Enter the date the left shoulder impingement syndrome was diagnosed. Fill only if 'Side affected - Left', 'Side affected - Both' is 'Yes' (any fields selection).

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

Select this option if the syphilitic arthritis affects the right shoulder/arm only.

Select this option if the syphilitic arthritis affects the left shoulder/arm only.

Select this option if the syphilitic arthritis affects both the right and left shoulders/arms.

Enter the ICD diagnostic code for syphilitic arthritis. Fill only if 'Side affected: Right', 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

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

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

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

Check this box if the rheumatoid arthritis (multi-joints) affects the right side.

Check this box if the rheumatoid arthritis (multi-joints) affects the left side.

Check this box if the rheumatoid arthritis (multi-joints) affects both the right and left sides.

Enter the ICD diagnosis code for arthritis, rheumatoid (multi-joints). Fill only if 'Arthritis, rheumatoid (multi-joints) - Right', 'Arthritis, rheumatoid (multi-joints) - Left', 'Arthritis, rheumatoid (multi-joints) - Both' is 'Yes' (any fields selection).

Enter the date arthritis, rheumatoid (multi-joints) was diagnosed for the right side. Fill only if 'Arthritis, rheumatoid (multi-joints) - Right', 'Arthritis, rheumatoid (multi-joints) - Both' is 'Yes' (any fields selection).

Enter the date arthritis, rheumatoid (multi-joints) was diagnosed for the left side. Fill only if 'Arthritis, rheumatoid (multi-joints) - Left', 'Arthritis, rheumatoid (multi-joints) - Both' is 'Yes' (any fields selection).

Check this box if the Veteran has a diagnosis of post-traumatic arthritis related to the claimed condition.

Check this box if the post-traumatic arthritis affects the right side.

Check this box if the post-traumatic arthritis affects the left side.

Check this box if the post-traumatic arthritis affects both sides.

Enter the ICD diagnosis code for the post-traumatic arthritis condition. Fill only if 'Post-traumatic arthritis - Right', 'Post-traumatic arthritis - Left', 'Post-traumatic arthritis - Both' is 'Yes' (any fields selection).

Enter the date the post-traumatic arthritis was diagnosed for the right side. Fill only if 'Post-traumatic arthritis - Right', 'Post-traumatic arthritis - Both' is 'Yes' (any fields selection).

Enter the date the post-traumatic arthritis was diagnosed for the left side. Fill only if 'Post-traumatic arthritis - Left', 'Post-traumatic arthritis - Both' is 'Yes' (any fields selection).

Check this box if the Veteran has a diagnosis of typhoid arthritis related to the claimed condition(s).

Check this box if the typhoid arthritis affects the right shoulder/arm.

Check this box if the typhoid arthritis affects the left shoulder/arm.

Check this box if the typhoid arthritis affects both the right and left shoulders/arms.

Enter the ICD diagnosis code for typhoid arthritis. Fill only if 'Side affected: Right', 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

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

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

Check this box if the Veteran has a diagnosis of another specified form of arthropathy (not gout) that should be listed for this claim (and specify the condition).

Enter the specific diagnosis for the other specified form of arthropathy (excluding gout). Fill only if 'Side affected: Right', 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

Check this box if this arthropathy affects the right side only.

Check this box if this arthropathy affects the left side only.

Check this box if this arthropathy affects both the right and left sides.

Enter the ICD code corresponding to the specified arthropathy diagnosis. Fill only if 'Side affected: Right', 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

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

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

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

Check this box if the osteoporosis residuals affect the right side only.

Check this box if the osteoporosis residuals affect the left side only.

Check this box if the osteoporosis residuals affect both the right and left sides.

Enter the ICD diagnosis code for osteoporosis, residuals of. Fill only if 'Side affected: Right', 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

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

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

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

Check this box if the osteomalacia residuals affect the right shoulder/arm.

Check this box if the osteomalacia residuals affect the left shoulder/arm.

Check this box if the osteomalacia residuals affect both shoulders/arms.

Enter the ICD diagnosis code corresponding to osteomalacia, residuals of. Fill only if 'Side affected: Right', 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

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

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

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

Check this box if the benign bone neoplasm affects the right side.

Check this box if the benign bone neoplasm affects the left side.

Check this box if the benign bone neoplasm affects both the right and left sides.

Enter the ICD diagnosis code for the benign bone neoplasm diagnosis. Fill only if 'Bones, neoplasm, benign - Side affected: Right', 'Bones, neoplasm, benign - Side affected: Left', 'Bones, neoplasm, benign - Side affected: Both' is 'Yes' (any fields selection).

Enter the date this benign bone neoplasm was diagnosed on the right side. Fill only if 'Bones, neoplasm, benign - Side affected: Right', 'Bones, neoplasm, benign - Side affected: Both' is 'Yes' (any fields selection).

Enter the date this benign bone neoplasm was diagnosed on the left side. Fill only if 'Bones, neoplasm, benign - Side affected: Left', 'Bones, neoplasm, benign - Side affected: Both' is 'Yes' (any fields selection).

Check this box if the veteran has a diagnosis of osteitis deformans associated with the claimed shoulder/arm condition.

Check this box if the osteitis deformans affects the right side.

Check this box if the osteitis deformans affects the left side.

Check this box if the osteitis deformans affects both sides.

Enter the ICD diagnostic code for osteitis deformans. Fill only if 'Osteitis deformans - Right', 'Osteitis deformans - Left', 'Osteitis deformans - Both' is 'Yes' (any fields selection).

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

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

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

Check this box if the gout affects the right side/shoulder/arm.

Check this box if the gout affects the left side/shoulder/arm.

Check this box if the gout affects both the right and left sides/shoulders/arms.

Enter the ICD diagnostic code for the gout diagnosis. Fill only if 'Side affected - Right', 'Side affected - Left', 'Side affected - Both' is 'Yes' (any fields selection).

Enter the date the gout diagnosis was first made for the right side. Fill only if 'Side affected - Right', 'Side affected - Both' is 'Yes' (any fields selection).

Enter the date the gout diagnosis was first made for the left side. Fill only if 'Side affected - Left', 'Side affected - Both' is 'Yes' (any fields selection).

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

Select this option if the bicipital tendonitis affects the right side only.

Select this option if the bicipital tendonitis affects the left side only.

Select this option if the bicipital tendonitis affects both the right and left sides.

Enter the ICD diagnostic code corresponding to the bicipital tendonitis diagnosis. Fill only if 'Bicipital tendonitis - Right', 'Bicipital tendonitis - Left', 'Bicipital tendonitis - Both' is 'Yes' (any fields selection).

Enter the date the bicipital tendonitis was diagnosed for the right side. Fill only if 'Bicipital tendonitis - Right', 'Bicipital tendonitis - Both' is 'Yes' (any fields selection).

Enter the date the bicipital tendonitis was diagnosed for the left side. Fill only if 'Bicipital tendonitis - Left', 'Bicipital tendonitis - Both' is 'Yes' (any fields selection).

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

Check this box if the bursitis affects the right side.

Check this box if the bursitis affects the left side.

Check this box if the bursitis affects both the right and left sides.

Enter the ICD diagnosis code associated with the bursitis diagnosis. Fill only if 'Bursitis - Right', 'Bursitis - Left', 'Bursitis - Both' is 'Yes' (any fields selection).

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

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

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

Check this box if the diagnosed myositis affects the right side.

Check this box if the diagnosed myositis affects the left side.

Check this box if the diagnosed myositis affects both sides.

Enter the ICD diagnosis code for the myositis condition. Fill only if 'Myositis - Side affected: Right', 'Myositis - Side affected: Left', 'Myositis - Side affected: Both' is 'Yes' (any fields selection).

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

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

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

Check this box if the heterotopic ossification affects the right side.

Check this box if the heterotopic ossification affects the left side.

Check this box if the heterotopic ossification affects both sides.

Enter the ICD diagnosis code for the heterotopic ossification condition. Fill only if 'Side affected: Right', 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

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

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

Check this box if the claimed condition includes a diagnosis of tendinopathy (or if a more specific option below is not known).

Check this box if the tendinopathy diagnosis affects the right side.

Check this box if the tendinopathy diagnosis affects the left side.

Check this box if the tendinopathy diagnosis affects both sides.

Enter the ICD diagnosis code for the tendinopathy diagnosis (if known). Fill only if 'Tendinopathy — Right', 'Tendinopathy — Left', 'Tendinopathy — Both' is 'Yes' (any fields selection).

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

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

Check this box if the diagnosis is specifically tendinitis.

Check this box if the tendinitis diagnosis affects the right side.

Check this box if the tendinitis diagnosis affects the left side.

Check this box if the tendinitis diagnosis affects both sides.

Enter the ICD diagnosis code for the tendinitis diagnosis (if known). Fill only if 'Tendinitis — Right', 'Tendinitis — Left', 'Tendinitis — Both' is 'Yes' (any fields selection).

Enter the date the tendinitis diagnosis was made for the right side. Fill only if 'Tendinitis — Right', 'Tendinitis — Both' is 'Yes' (any fields selection).

Enter the date the tendinitis diagnosis was made for the left side. Fill only if 'Tendinitis — Left', 'Tendinitis — Both' is 'Yes' (any fields selection).

Check this box if the diagnosis is specifically tendinosis.

Check this box if the tendinosis diagnosis affects the right side.

Check this box if the tendinosis diagnosis affects the left side.

Check this box if the tendinosis diagnosis affects both sides.

Enter the ICD diagnosis code for the tendinosis diagnosis (if known). Fill only if 'Tendinosis — Right', 'Tendinosis — Left', 'Tendinosis — Both' is 'Yes' (any fields selection).

Enter the date the tendinosis diagnosis was made for the right side. Fill only if 'Tendinosis — Right', 'Tendinosis — Both' is 'Yes' (any fields selection).

Enter the date the tendinosis diagnosis was made for the left side. Fill only if 'Tendinosis — Left', 'Tendinosis — Both' is 'Yes' (any fields selection).

Check this box if the diagnosis is specifically tenosynovitis.

Check this box if the tenosynovitis diagnosis affects the right side.

Check this box if the tenosynovitis diagnosis affects the left side.

Check this box if the tenosynovitis diagnosis affects both sides.

Enter the ICD diagnosis code for the tenosynovitis diagnosis (if known). Fill only if 'Tenosynovitis — Right', 'Tenosynovitis — Left', 'Tenosynovitis — Both' is 'Yes' (any fields selection).

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

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

Check this box if the veteran has an inflammatory condition of another type not listed elsewhere and you will specify the diagnosis.

Enter the specific inflammatory condition diagnosis being claimed if it is not otherwise listed. Fill only if 'Side affected: Right', 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

Check this box if the inflammatory condition affects the right side.

Check this box if the inflammatory condition affects the left side.

Check this box if the inflammatory condition affects both the right and left sides.

Enter the ICD diagnostic code corresponding to the specified inflammatory condition. Fill only if 'Side affected: Right', 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

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

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

Check this box if the Veteran has a diagnosis of a bicipital tendon tear.

Check this box if the bicipital tendon tear affects the right shoulder/arm.

Check this box if the bicipital tendon tear affects the left shoulder/arm.

Check this box if the bicipital tendon tear affects both shoulders/arms.

Enter the ICD diagnosis code associated with the bicipital tendon tear. Fill only if 'Side affected: Right', 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

Enter the date the bicipital tendon tear was diagnosed for the right side. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any fields selection).

Enter the date the bicipital tendon tear was diagnosed for the left side. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

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

Check this box if the Veteran’s rotator cuff tendonitis affects the right shoulder.

Check this box if the Veteran’s rotator cuff tendonitis affects the left shoulder.

Check this box if the Veteran’s rotator cuff tendonitis affects both shoulders.

Enter the ICD diagnostic code associated with the Veteran’s rotator cuff tendonitis. Fill only if 'Rotator cuff tendonitis - Right', 'Rotator cuff tendonitis - Left', 'Rotator cuff tendonitis - Both' is 'Yes' (any fields selection).

Enter the date rotator cuff tendonitis was diagnosed for the right side. Fill only if 'Rotator cuff tendonitis - Right', 'Rotator cuff tendonitis - Both' is 'Yes' (any fields selection).

Enter the date rotator cuff tendonitis was diagnosed for the left side. Fill only if 'Rotator cuff tendonitis - Left', 'Rotator cuff tendonitis - Both' is 'Yes' (any fields selection).

Check this box if the Veteran has a current diagnosis of a rotator cuff tear.

Check this box if the diagnosed rotator cuff tear affects the right shoulder.

Check this box if the diagnosed rotator cuff tear affects the left shoulder.

Check this box if the diagnosed rotator cuff tear affects both shoulders.

Enter the ICD diagnostic code for the rotator cuff tear. Fill only if 'Rotator cuff tear - Side affected: Right', 'Rotator cuff tear - Side affected: Left', 'Rotator cuff tear - Side affected: Both' is 'Yes' (any fields selection).

Enter the date the rotator cuff tear was diagnosed for the right side. Fill only if 'Rotator cuff tear - Side affected: Right', 'Rotator cuff tear - Side affected: Both' is 'Yes' (any fields selection).

Enter the date the rotator cuff tear was diagnosed for the left side. Fill only if 'Rotator cuff tear - Side affected: Left', 'Rotator cuff tear - Side affected: Both' is 'Yes' (any fields selection).

Check this box if the Veteran has a diagnosis of a labral tear/SLAP lesion associated with the claimed condition(s).

Check this box if the diagnosed labral tear/SLAP lesion affects the right shoulder.

Check this box if the diagnosed labral tear/SLAP lesion affects the left shoulder.

Check this box if the diagnosed labral tear/SLAP lesion affects both shoulders.

Enter the ICD diagnosis code for the labral tear (including SLAP) condition. Fill only if 'Side affected: Right', 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

Enter the date the labral tear (including SLAP) was diagnosed for the right shoulder. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any fields selection).

Enter the date the labral tear (including SLAP) was diagnosed for the left shoulder. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

Check this box if subacromial/subdeltoid bursitis is a current diagnosis associated with the claimed shoulder/arm condition.

Check this box if the subacromial/subdeltoid bursitis affects the right side.

Check this box if the subacromial/subdeltoid bursitis affects the left side.

Check this box if the subacromial/subdeltoid bursitis affects both sides.

Enter the ICD diagnosis code for Subacromial/subdeltoid bursitis. Fill only if 'Subacromial/subdeltoid bursitis - Right', 'Subacromial/subdeltoid bursitis - Left', 'Subacromial/subdeltoid bursitis - Both' is 'Yes' (any fields selection).

Enter the date Subacromial/subdeltoid bursitis was diagnosed for the right shoulder. Fill only if 'Subacromial/subdeltoid bursitis - Right', 'Subacromial/subdeltoid bursitis - Both' is 'Yes' (any fields selection).

Enter the date Subacromial/subdeltoid bursitis was diagnosed for the left shoulder. Fill only if 'Subacromial/subdeltoid bursitis - Left', 'Subacromial/subdeltoid bursitis - Both' is 'Yes' (any fields selection).

Check this box if the Veteran has a diagnosis of glenohumeral joint osteoarthritis related to the claimed shoulder/arm condition(s).

Check this box if the glenohumeral joint osteoarthritis affects the right shoulder only.

Check this box if the glenohumeral joint osteoarthritis affects the left shoulder only.

Check this box if the glenohumeral joint osteoarthritis affects both shoulders.

Enter the ICD code for the diagnosis of glenohumeral joint osteoarthritis. Fill only if 'Side affected: Right', 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

Enter the date the right-side glenohumeral joint osteoarthritis was diagnosed. Fill only if 'Side affected: Right', 'Side affected: Both' is 'Yes' (any fields selection).

Enter the date the left-side glenohumeral joint osteoarthritis was diagnosed. Fill only if 'Side affected: Left', 'Side affected: Both' is 'Yes' (any fields selection).

Check this box if the Veteran’s dominant hand is the right hand.

Check this box if the Veteran’s dominant hand is the left hand.

Check this box if the Veteran uses both hands equally as the dominant hand.

Check this box if you did not review any medical or other records as part of this examination.

Check this box if you reviewed any records (e.g., service treatment records, VA treatment records, or private treatment records) for this examination.

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

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

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

Enter the Veteran’s own words describing any functional loss or functional impairment of the joint or extremity being evaluated, including any effects after repeated use over time. Fill only if 'Yes' is 'Yes'.

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

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

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

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

Check this box if the Veteran was not examined in person for this evaluation (and the exam was conducted by another method).

Describe how the Veteran's examination was conducted if it was not performed in person (for example, telephone, video visit, or records review). Fill only if 'Examined in person – No' is 'Yes'.

Enter the flexion degree endpoint where motion is limited (if different than the flexion endpoint listed above). Fill only if 'Undamaged' is 'Yes'.

Enter the abduction degree endpoint where motion is limited (if different than the abduction endpoint listed above). Fill only if 'Undamaged' is 'Yes'.

Enter the internal rotation degree endpoint where motion is limited (if different than the internal rotation endpoint listed above). Fill only if 'Undamaged' is 'Yes'.

Enter the external rotation degree endpoint where motion is limited (if different than the external rotation endpoint listed above). Fill only if 'Undamaged' is 'Yes'.

Describe any left active range of motion limitations attributable to pain, weakness, fatigability, incoordination, or other factors and note the degrees/endpoints affected if applicable. Fill only if 'Undamaged' is 'Yes'.

Enter the measured active flexion endpoint range of motion for the left joint in degrees. Fill only if 'Undamaged' is 'Yes'.

Enter the measured active abduction endpoint range of motion for the left joint in degrees. Fill only if 'Undamaged' is 'Yes'.

Enter the measured active internal rotation endpoint range of motion for the left joint in degrees. Fill only if 'Undamaged' is 'Yes'.

Enter the measured active external rotation endpoint range of motion for the left joint in degrees. Fill only if 'Undamaged' is 'Yes'.

Check this box if flexion was painful during active range of motion testing of the left joint. Fill only if 'Undamaged' is 'Yes'.

Check this box if abduction was painful during active range of motion testing of the left joint. Fill only if 'Undamaged' is 'Yes'.

Check this box if internal rotation was painful during active range of motion testing of the left joint. Fill only if 'Undamaged' is 'Yes'.

Check this box if external rotation was painful during active range of motion testing of the left joint. Fill only if 'Undamaged' is 'Yes'.

Check this box if the Veteran has had arthroscopic surgery or any other shoulder surgery (other than total shoulder joint replacement).

Enter the date the arthroscopic or other shoulder surgery was performed. Fill only if 'Arthroscopic or other shoulder surgery' is 'Yes'.

Enter the type of arthroscopic or other shoulder surgery performed (procedure name/description). Fill only if 'Arthroscopic or other shoulder surgery' is 'Yes'.

Describe any current residual symptoms, limitations, or complications resulting from the arthroscopic or other shoulder surgery. Fill only if 'Arthroscopic or other shoulder surgery' is 'Yes'.

Check this box if the Veteran has not had any surgical procedures related to the shoulder condition.

Check this box if the Veteran has had a total shoulder joint replacement surgery.

Enter the date the Veteran underwent the total shoulder joint replacement surgery. Fill only if 'Total shoulder joint replacement' is 'Yes'.

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

Check this box if the Veteran has intermediate (not severe) ongoing weakness, pain, or limitation of shoulder motion after the total shoulder joint replacement. Fill only if 'Total shoulder joint replacement' is 'Yes'.

Check this box if the Veteran has chronic, severe painful motion and/or severe weakness following the total shoulder joint replacement. Fill only if 'Total shoulder joint replacement' is 'Yes'.

Check this box if the Veteran has residuals after the total shoulder joint replacement that are not captured by the other options and will be described in the space provided. Fill only if 'Total shoulder joint replacement' is 'Yes'.

Describe any other residual symptoms or complications the Veteran has following the total shoulder joint replacement. Fill only if 'Residuals: Other residuals (describe)' is 'Yes'.

Check this box if the clavicle or scapula condition affects range of motion of the shoulder (glenohumeral joint). Fill only if '8C. Is there a clavicle, scapula, acromioclavicular (AC) joint, sternoclavicular joint condition or other impairment?' is 'Yes'.

Check this box if the clavicle or scapula condition does not affect range of motion of the shoulder (glenohumeral joint). Fill only if '8C. Is there a clavicle, scapula, acromioclavicular (AC) joint, sternoclavicular joint condition or other impairment?' is 'Yes'.

Check this box if the Veteran has loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus.

Check this box if the Veteran does not have loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus.

Check this box if the Veteran has loss of head of the humerus (flail shoulder). Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran has nonunion of the humerus (false flail shoulder). Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran has fibrous union of the humerus. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran has malunion of the humerus with moderate or marked deformity.

Check this box if the Veteran does not have malunion of the humerus with moderate or marked deformity.

Check this box if malunion of the humerus is present and the deformity is moderate. Fill only if 'Malunion with deformity - Yes' is 'Yes'.

Check this box if malunion of the humerus is present and the deformity is marked. Fill only if 'Malunion with deformity - Yes' is 'Yes'.

Check this box if the humerus condition affects the shoulder (glenohumeral joint) range of motion. Fill only if 'Yes' is 'Yes'.

Check this box if the humerus condition does not affect the shoulder (glenohumeral joint) range of motion. Fill only if 'Yes' is 'Yes'.

Check this box if the left Crank Apprehension and Relocation Test is positive (pain and/or a sense of instability/apprehension with further external rotation).

Check this box if the left Crank Apprehension and Relocation Test is negative (no pain and no sense of instability/apprehension).

Check this box if the left Crank Apprehension and Relocation Test could not be performed or completed.

Check this box if the left Crank Apprehension and Relocation Test is not applicable for this evaluation.

Check this box if the left Empty Can Test is positive (weakness or pain indicating possible supraspinatus tendinopathy or tear).

Check this box if the left Empty Can Test is negative (no weakness or pain with the test).

Check this box if you could not perform the left Empty Can Test (e.g., due to pain, limited motion, or other inability to complete the maneuver).

Check this box if the left Empty Can Test is not applicable and was not performed for that reason.

Check this box if the left external rotation/infraspinatus strength test is positive (e.g., weakness or pain suggesting infraspinatus tendinopathy or tear).

Check this box if the left external rotation/infraspinatus strength test is negative (no abnormal weakness or pain on resisted external rotation).

Check this box if the left external rotation/infraspinatus strength test could not be performed for any reason.

Check this box if the left external rotation/infraspinatus strength test is not applicable.

Check this box if the left Hawkins' Impingement Test is positive (pain with internal rotation during the test).

Check this box if the left Hawkins' Impingement Test is negative (no pain with internal rotation during the test).

Check this box if you were unable to perform the left Hawkins' Impingement Test.

Check this box if the left Hawkins' Impingement Test is not applicable.

Check this box if the left lift-off subscapularis test is positive (e.g., weakness/pain indicating possible subscapularis tendinopathy or tear).

Check this box if the left lift-off subscapularis test is negative (no pain or weakness).

Check this box if the left lift-off subscapularis test could not be performed or completed.

Check this box if the left lift-off subscapularis test is not applicable and was not performed for that reason.

Enter the left joint passive flexion endpoint in degrees if it is different than the value listed above. Fill only if 'Undamaged' is 'Yes'.

Enter the left joint passive abduction endpoint in degrees if it is different than the value listed above. Fill only if 'Undamaged' is 'Yes'.

Enter the left joint passive internal rotation endpoint in degrees if it is different than the value listed above. Fill only if 'Undamaged' is 'Yes'.

Enter the left joint passive external rotation endpoint in degrees if it is different than the value listed above. Fill only if 'Undamaged' is 'Yes'.

Describe the factors (e.g., pain, weakness, fatigability, incoordination, or other) that limit the left joint’s passive range of motion and explain how they affect movement. Fill only if 'Undamaged' is 'Yes'.

Enter the measured passive range-of-motion endpoint for left-side flexion in degrees. Fill only if 'Undamaged', 'Flexion passive ROM same as active ROM' is 'Yes' and 17 is 'No' (all).

Check this box if the passive flexion range of motion is the same as the active flexion range of motion. Fill only if 'Undamaged' is 'Yes'.

Enter the measured passive range-of-motion endpoint for left-side abduction in degrees. Fill only if 'Undamaged', 'Abduction passive ROM same as active ROM' is 'Yes' and 19 is 'No' (all).

Check this box if the passive abduction range of motion is the same as the active abduction range of motion. Fill only if 'Undamaged' is 'Yes'.

Enter the measured passive range-of-motion endpoint for left-side internal rotation in degrees. Fill only if 'Undamaged', 'Internal rotation passive ROM same as active ROM' is 'Yes' and 21 is 'No' (all).

Check this box if the passive internal rotation range of motion is the same as the active internal rotation range of motion. Fill only if 'Undamaged' is 'Yes'.

Enter the measured passive range-of-motion endpoint for left-side external rotation in degrees. Fill only if 'Undamaged', 'External rotation passive ROM same as active ROM' is 'Yes' and 23 is 'No' (all).

Check this box if the passive external rotation range of motion is the same as the active external rotation range of motion. Fill only if 'Undamaged' is 'Yes'.

Check this box if passive range-of-motion flexion of the left joint exhibited pain on examination. Fill only if 'Undamaged' is 'Yes'.

Check this box if passive range-of-motion abduction of the left joint exhibited pain on examination. Fill only if 'Undamaged' is 'Yes'.

Check this box if passive range-of-motion internal rotation of the left joint exhibited pain on examination. Fill only if 'Undamaged' is 'Yes'.

Check this box if passive range-of-motion external rotation of the left joint exhibited pain on examination. Fill only if 'Undamaged' is 'Yes'.

Check this box if the left rotator cuff tests could not be performed and you suspect a left rotator cuff condition. Fill only if 'Hawkins' Impingement Test - Unable to test (Left)', 'Unable to test', 'Left external rotation/infraspinatus strength test - Unable to test', 'Unable to test' is 'Unable to test' (any).

Check this box if the left rotator cuff tests could not be performed but you do not suspect a left rotator cuff condition. Fill only if 'Hawkins' Impingement Test - Unable to test (Left)', 'Unable to test', 'Left external rotation/infraspinatus strength test - Unable to test', 'Unable to test' is 'Unable to test' (any).

Describe the suspected left rotator cuff condition when testing cannot be performed, including relevant symptoms, findings, or suspected diagnosis. Fill only if 'Yes' is 'Yes'.

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

Check this box if the left shoulder condition contributes to difficulty or limitation with standing.

Check this box if the left shoulder condition contributes to an altered gait or other problems with walking/moving around.

Check this box if the left shoulder has reduced range of motion compared to normal.

Check this box if the left shoulder shows weakness or reduced strength during movement.

Check this box if the left shoulder condition contributes to unsteadiness or poor stability while standing or moving.

Check this box if the left shoulder condition contributes to difficulty or limitation with sitting.

Check this box if swelling is present in or around the left shoulder and contributes to disability.

Check this box if there is visible or palpable deformity of the left shoulder that contributes to disability.

Check this box if the left shoulder has excessive motion (e.g., hypermobility/looseness) compared to normal.

Check this box if there is muscle atrophy related to reduced use of the left shoulder.

Check this box if another contributing factor not listed applies, and provide details in the 'Other, describe' area.

Enter a description of any other additional factor contributing to the left shoulder disability if 'Other' is selected. Fill only if 'Other (describe)' is 'Yes'.

Provide details describing the additional factors that contribute to the left shoulder disability.

Check this box if there is ankylosis of the scapulohumeral (glenohumeral) articulation of the left shoulder (scapula and humerus move as one piece).

Check this box if there is no ankylosis of the scapulohumeral (glenohumeral) articulation of the left shoulder.

Check this box if left shoulder ankylosis is present and abduction is up to 60 degrees with ability to reach the mouth and head. Fill only if 'Ankylosis present (Yes)' is 'Yes'.

Check this box if left shoulder ankylosis is present and abduction falls between the favorable and unfavorable positions. Fill only if 'Ankylosis present (Yes)' is 'Yes'.

Check this box if left shoulder ankylosis is present and abduction is 25 degrees or less from the side. Fill only if 'Ankylosis present (Yes)' is 'Yes'.

Enter the angle of left shoulder ankylosis measured in degrees of abduction. Fill only if 'Ankylosis present (Yes)' is 'Yes'.

Check this box if, with left shoulder ankylosis, there is involvement of Muscle Group I and/or II (as listed on the form). Fill only if 'Ankylosis present (Yes)' is 'Yes'.

Check this box if, with left shoulder ankylosis, there is no involvement of Muscle Group I or II. Fill only if 'Ankylosis present (Yes)' is 'Yes'.

Check this box if the left shoulder muscle atrophy is due to the claimed condition listed in the diagnosis section. Fill only if 'Yes (muscle atrophy present)' is 'Yes'.

Check this box if the left shoulder muscle atrophy is not due to the claimed condition listed in the diagnosis section. Fill only if 'Yes (muscle atrophy present)' is 'Yes'.

Provide the medical rationale explaining whether the left shoulder muscle atrophy is due to the claimed condition listed in the diagnosis section, including supporting clinical reasoning. Fill only if 'No' is 'Yes'.

Check this box if the Veteran has muscle atrophy of the left shoulder.

Check this box if the Veteran does not have muscle atrophy of the left shoulder.

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

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

Check this box if initial left shoulder ROM testing could not be performed.

Check this box if initial left shoulder ROM measurements are not indicated for this evaluation.

Explain why left shoulder initial range of motion testing was unable to be performed or was not indicated. Fill only if 'Unable to test', 'Not indicated' is 'Yes' for any fields selection.

Describe why the left shoulder range of motion is outside the normal range but is considered normal for the Veteran (for reasons unrelated to a shoulder/arm condition). Fill only if 'Abnormal or outside of normal range' is 'Yes'.

Check this box if the abnormal left shoulder range of motion itself contributes to functional loss.

Check this box if the abnormal left shoulder range of motion itself does not contribute to functional loss.

If the left shoulder range of motion is abnormal and contributes to functional loss, explain how it contributes to the functional loss. Fill only if 'ROM contributes to functional loss – Yes' is 'Yes'.

Check this box if the required left shoulder testing can be performed.

Check this box if the required left shoulder testing cannot be performed.

If left shoulder testing cannot be performed, provide the reason testing could not be completed. Fill only if 'Can testing be performed? No' is 'No'.

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

Check this box if there is additional loss of function or range of motion after three repetitions (left side).

Check this box if there is no additional loss of function or range of motion after three repetitions (left side).

Enter the left-side flexion range-of-motion endpoint measured after three repetitions, in degrees. Fill only if 'Yes' is 'Yes'.

Enter the left-side abduction range-of-motion endpoint measured after three repetitions, in degrees. Fill only if 'Yes' is 'Yes'.

Enter the left-side internal rotation range-of-motion endpoint measured after three repetitions, in degrees. Fill only if 'Yes' is 'Yes'.

Enter the left-side external rotation range-of-motion endpoint measured after three repetitions, in degrees. Fill only if 'Yes' is 'Yes'.

Check this box if there is objective evidence of crepitus on the left side.

Check this box if there is no objective evidence of crepitus on the left side.

Check this box if pain is a factor causing the left side functional loss after repetitive use (three repetitions). Fill only if 'Yes' is 'Yes'.

Check this box if fatigability is a factor causing the left side functional loss after repetitive use (three repetitions). Fill only if 'Yes' is 'Yes'.

Check this box if weakness is a factor causing the left side functional loss after repetitive use (three repetitions). Fill only if 'Yes' is 'Yes'.

Check this box if lack of endurance is a factor causing the left side functional loss after repetitive use (three repetitions). Fill only if 'Yes' is 'Yes'.

Check this box if incoordination is a factor causing the left side functional loss after repetitive use (three repetitions). Fill only if 'Yes' is 'Yes'.

Check this box if another factor (not listed) causes the left side functional loss after repetitive use (three repetitions). Fill only if 'Yes' is 'Yes'.

Describe any other factor (not already listed) that contributes to functional loss of the left side. Fill only if 'Other' is 'Yes'.

Check this box if none of the listed factors cause the left side functional loss after repetitive use (three repetitions). Fill only if 'Yes' is 'Yes'.

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

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

Describe any objective evidence of localized tenderness or pain on palpation on the left side, including the location, severity, and its relationship to the condition(s). Fill only if 'Yes' is 'Yes'.

Check this box if there is evidence of left-side pain.

Check this box if there is no evidence of left-side pain.

Check this box if the left-side pain is present during weight-bearing. Fill only if 'Yes (evidence of pain)' is 'Yes'.

Check this box if the left-side pain is present during nonweight-bearing. Fill only if 'Yes (evidence of pain)' is 'Yes'.

Check this box if the left-side pain occurs with active motion. Fill only if 'Yes (evidence of pain)' is 'Yes'.

Check this box if the left-side pain occurs with passive motion. Fill only if 'Yes (evidence of pain)' is 'Yes'.

Check this box if the left-side pain is present at rest or with no movement. Fill only if 'Yes (evidence of pain)' is 'Yes'.

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

Check this box if the left-side pain does not result in or cause functional loss. Fill only if 'Yes (evidence of pain)' is 'Yes'.

Enter any comments describing the evidence of pain on the left side, including the types of pain observed and any related functional loss details. Fill only if 'Causes functional loss' is 'Yes'.

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

Check this box if the Veteran is not able to perform repetitive-use testing with at least three repetitions (left side), and then explain the reason in the space provided.

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

Check this box if the unclaimed joint is damaged.

Check this box if the unclaimed joint is undamaged.

Check this box if the muscle atrophy being measured is in the left upper extremity, and then specify the measurement location (e.g., “10 cm above the anterior elbow crease”). Fill only if 'Yes (muscle atrophy present)' is 'Yes'.

Enter the specific location on the left upper extremity where the circumference measurement was taken (for example, a set distance above the anterior elbow crease). Fill only if 'Yes (muscle atrophy present)' is 'Yes'.

Enter the circumference measurement of the more normal side, in centimeters, taken at the specified measurement location. Fill only if 'Yes (muscle atrophy present)' is 'Yes'.

Enter the circumference measurement of the atrophied side, in centimeters, taken at the specified measurement location. Fill only if 'Yes (muscle atrophy present)' is 'Yes'.

Check this box if the Veteran does not currently have a diagnosis associated with any of the claimed conditions listed above.

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

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

Enter the type of any other significant diagnostic test reviewed, the date performed, and a brief summary of the findings/results related to the claimed condition(s) or diagnosis(es). Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran has a shoulder/arm diagnosis not listed above and you will specify it in the “Other diagnosis #1/#2” section.

Enter the name of the first other shoulder/arm diagnosis not listed above. Fill only if 'Other (specify)' is 'Yes'.

Check this box if Other diagnosis #1 affects the right side only. Fill only if 'Other (specify)' is 'Yes'.

Check this box if Other diagnosis #1 affects the left side only. Fill only if 'Other (specify)' is 'Yes'.

Check this box if Other diagnosis #1 affects both the right and left sides. Fill only if 'Other (specify)' is 'Yes'.

Enter the ICD code corresponding to Other diagnosis #1. Fill only if 'Other diagnosis #1 – Side affected: Right', 'Other diagnosis #1 – Side affected: Left', 'Other diagnosis #1 – Side affected: Both' is 'Yes' (any fields selection).

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

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

Enter the name of the second other shoulder/arm diagnosis not listed above. Fill only if 'Other (specify)' is 'Yes'.

Check this box if Other diagnosis #2 affects the right side only. Fill only if 'Other (specify)' is 'Yes'.

Check this box if Other diagnosis #2 affects the left side only. Fill only if 'Other (specify)' is 'Yes'.

Check this box if Other diagnosis #2 affects both the right and left sides. Fill only if 'Other (specify)' is 'Yes'.

Enter the ICD code corresponding to Other diagnosis #2. Fill only if 'Other diagnosis #2 – Side affected: Right', 'Other diagnosis #2 – Side affected: Left', 'Other diagnosis #2 – Side affected: Both' is 'Yes' (any fields selection).

Enter the date Other diagnosis #2 was diagnosed for the right side. Fill only if 'Other diagnosis #2 – Side affected: Right', 'Other diagnosis #2 – Side affected: Both' is 'Yes' (any fields selection).

Enter the date Other diagnosis #2 was diagnosed for the left side. Fill only if 'Other diagnosis #2 – Side affected: Left', 'Other diagnosis #2 – Side affected: Both' is 'Yes' (any fields selection).

Enter the full name of the patient/veteran.

Enter the patient/veteran’s Social Security Number.

Enter the date on which the examination was performed.

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

Check this box if a third party (not the Veteran) requested the questionnaire and you will list the requesting organization(s) or individual(s).

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

Check this box if the request came from another source not listed above and you will describe who requested it.

Describe the other person or entity requesting completion of this disability benefits questionnaire. Fill only if 'Other (please describe)' is 'Yes'.

Enter the flexion limitation degree endpoint if it differs from the active ROM value recorded above. Fill only if 'Undamaged' is 'Yes'.

Enter the abduction limitation degree endpoint if it differs from the active ROM value recorded above. Fill only if 'Undamaged' is 'Yes'.

Enter the internal rotation limitation degree endpoint if it differs from the active ROM value recorded above. Fill only if 'Undamaged' is 'Yes'.

Enter the external rotation limitation degree endpoint if it differs from the active ROM value recorded above. Fill only if 'Undamaged' is 'Yes'.

Describe any limitation of right-side active range of motion, including the contributing factors (e.g., pain, weakness, fatigability, incoordination) and the degrees at which the limitation occurs. Fill only if 'Undamaged' is 'Yes'.

Enter the measured right-side active range of motion endpoint for flexion in degrees. Fill only if 'Undamaged' is 'Yes'.

Enter the measured right-side active range of motion endpoint for abduction in degrees. Fill only if 'Undamaged' is 'Yes'.

Enter the measured right-side active range of motion endpoint for internal rotation in degrees. Fill only if 'Undamaged' is 'Yes'.

Enter the measured right-side active range of motion endpoint for external rotation in degrees. Fill only if 'Undamaged' is 'Yes'.

Check this box if right active ROM flexion was painful on examination. Fill only if 'Undamaged' is 'Yes'.

Check this box if right active ROM abduction was painful on examination. Fill only if 'Undamaged' is 'Yes'.

Check this box if right active ROM internal rotation was painful on examination. Fill only if 'Undamaged' is 'Yes'.

Check this box if right active ROM external rotation was painful on examination. Fill only if 'Undamaged' is 'Yes'.

Check this box if the Veteran has had arthroscopic or any other (non-replacement) shoulder surgery performed.

Enter the date the arthroscopic or other shoulder surgery was performed. Fill only if 'Arthroscopic or other shoulder surgery' is 'Yes'.

Specify the type of arthroscopic or other shoulder surgery performed. Fill only if 'Arthroscopic or other shoulder surgery' is 'Yes'.

Describe any residual symptoms or functional limitations remaining after the arthroscopic or other shoulder surgery. Fill only if 'Arthroscopic or other shoulder surgery' is 'Yes'.

Check this box if the Veteran has not had any surgical procedures for the shoulder condition.

Check this box if the Veteran has had a total shoulder joint replacement surgery.

Enter the date on which the Veteran’s total shoulder joint replacement surgery was performed. Fill only if 'Total shoulder joint replacement' is 'Yes'.

Check this option if the Veteran has no residuals following the total shoulder joint replacement. Fill only if 'Total shoulder joint replacement' is 'Yes'.

Check this option if the Veteran has intermediate residual weakness, pain, or limitation of motion after the total shoulder joint replacement. Fill only if 'Total shoulder joint replacement' is 'Yes'.

Check this option if the Veteran has chronic residuals with severe painful motion or weakness after the total shoulder joint replacement. Fill only if 'Total shoulder joint replacement' is 'Yes'.

Check this box if the Veteran has other residuals after the total shoulder joint replacement that should be described in the provided space. Fill only if 'Total shoulder joint replacement' is 'Yes'.

Describe any other residuals from the total shoulder joint replacement not covered by the listed residual options. Fill only if 'Residuals: Other residuals (describe)' is 'Yes'.

Check this box if the clavicle or scapula condition affects the shoulder’s range of motion (glenohumeral joint). Fill only if '8C. Is there a clavicle, scapula, acromioclavicular (AC) joint, sternoclavicular joint condition or other impairment?' is 'Yes'.

Check this box if the clavicle or scapula condition does not affect the shoulder’s range of motion (glenohumeral joint). Fill only if '8C. Is there a clavicle, scapula, acromioclavicular (AC) joint, sternoclavicular joint condition or other impairment?' is 'Yes'.

Check this box if the Veteran has loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus.

Check this box if the Veteran does not have loss of head (flail shoulder), nonunion (false flail shoulder), or fibrous union of the humerus.

Check this box if the Veteran has loss of head of the humerus (flail shoulder). Fill only if '9A: Yes' is 'Yes'.

Check this box if the Veteran has nonunion of the humerus (false flail shoulder). Fill only if '9A: Yes' is 'Yes'.

Check this box if the Veteran has fibrous union of the humerus. Fill only if '9A: Yes' is 'Yes'.

Check this box if the Veteran has malunion of the humerus with moderate or marked deformity.

Check this box if the Veteran does not have malunion of the humerus with moderate or marked deformity.

Check this box if malunion of the humerus is present and the deformity severity is moderate. Fill only if 'Yes' is 'Yes'.

Check this box if malunion of the humerus is present and the deformity severity is marked. Fill only if 'Yes' is 'Yes'.

Check this box if the humerus condition affects range of motion of the shoulder (glenohumeral joint). Fill only if '9A: Yes' is 'Yes'.

Check this box if the humerus condition does not affect range of motion of the shoulder (glenohumeral joint). Fill only if '9A: Yes' is 'Yes'.

Check this box if the Right Crank Apprehension and Relocation Test is positive (pain and/or sense of instability with further external rotation).

Check this box if the Right Crank Apprehension and Relocation Test is negative (no pain or sense of instability with the maneuver).

Check this box if the Right Crank Apprehension and Relocation Test could not be performed.

Check this box if the Right Crank Apprehension and Relocation Test is not applicable.

Check this box if the right Empty Can Test is positive (weakness/pain indicating possible supraspinatus tendinopathy or tear).

Check this box if the right Empty Can Test is negative (no findings suggesting rotator cuff pathology).

Check this box if the right Empty Can Test could not be performed or completed.

Check this box if the right Empty Can Test is not applicable.

Check this box if the right external rotation/infraspinatus strength test is positive (weakness/pain suggesting infraspinatus tendinopathy or tear).

Check this box if the right external rotation/infraspinatus strength test is negative (normal strength without a positive finding).

Check this box if the right external rotation/infraspinatus strength test could not be performed or completed.

Check this box if the right external rotation/infraspinatus strength test is not applicable.

Check this box if the right Hawkins’ Impingement Test is positive (pain with internal rotation in the Hawkins position).

Check this box if the right Hawkins’ Impingement Test is negative (no pain reproduced with internal rotation in the Hawkins position).

Check this box if you were unable to perform the right Hawkins’ Impingement Test.

Check this box if the right Hawkins’ Impingement Test is not applicable and was not performed for a non-clinical reason.

Check this box if the right lift-off subscapularis test is positive (weakness/pain indicating possible subscapularis tendinopathy or tear).

Check this box if the right lift-off subscapularis test is negative (no weakness or pain with the maneuver).

Check this box if the right lift-off subscapularis test could not be performed or assessed.

Check this box if the right lift-off subscapularis test is not applicable and should not be recorded.

Enter the flexion degree endpoint if the limitation endpoint differs from the passive ROM endpoint reported above. Fill only if 'Undamaged' is 'Yes'.

Enter the abduction degree endpoint if the limitation endpoint differs from the passive ROM endpoint reported above. Fill only if 'Undamaged' is 'Yes'.

Enter the internal rotation degree endpoint if the limitation endpoint differs from the passive ROM endpoint reported above. Fill only if 'Undamaged' is 'Yes'.

Enter the external rotation degree endpoint if the limitation endpoint differs from the passive ROM endpoint reported above. Fill only if 'Undamaged' is 'Yes'.

Describe any factors (e.g., pain, weakness, fatigability, incoordination, or other) that specifically limit the right shoulder passive range of motion and explain the limitation. Fill only if 'Undamaged' is 'Yes'.

Enter the measured right-side passive flexion endpoint value in degrees. Fill only if 'Undamaged', 'Flexion passive ROM same as active ROM' is 'Yes' and 49 is 'No' (all).

Check this box if the passive flexion endpoint (degrees) is the same as the active flexion ROM value. Fill only if 'Undamaged' is 'Yes'.

Enter the measured right-side passive abduction endpoint value in degrees. Fill only if 'Undamaged', 'Abduction passive ROM same as active ROM' is 'Yes' and 51 is 'No' (all).

Check this box if the passive abduction endpoint (degrees) is the same as the active abduction ROM value. Fill only if 'Undamaged' is 'Yes'.

Enter the measured right-side passive internal rotation endpoint value in degrees. Fill only if 'Undamaged', 'Internal rotation passive ROM same as active ROM' is 'Yes' and 53 is 'No' (all).

Check this box if the passive internal rotation endpoint (degrees) is the same as the active internal rotation ROM value. Fill only if 'Undamaged' is 'Yes'.

Enter the measured right-side passive external rotation endpoint value in degrees. Fill only if 'Undamaged', 'External rotation passive ROM same as active ROM' is 'Yes' and 55 is 'No' (all).

Check this box if the passive external rotation endpoint (degrees) is the same as the active external rotation ROM value. Fill only if 'Undamaged' is 'Yes'.

Check this box if passive flexion range of motion was painful on examination. Fill only if 'Undamaged' is 'Yes'.

Check this box if passive abduction range of motion was painful on examination. Fill only if 'Undamaged' is 'Yes'.

Check this box if passive internal rotation range of motion was painful on examination. Fill only if 'Undamaged' is 'Yes'.

Check this box if passive external rotation range of motion was painful on examination. Fill only if 'Undamaged' is 'Yes'.

Check this box if the patient is unable to be tested and you suspect a right rotator cuff condition. Fill only if 'Unable to test', 'Empty Can Test (Right) - Unable to test', 'Unable to test', 'Lift-off Subscapularis Test (Right) - Unable to test' is 'Unable to test' (any).

Check this box if the patient is unable to be tested and you do not suspect a right rotator cuff condition. Fill only if 'Unable to test', 'Empty Can Test (Right) - Unable to test', 'Unable to test', 'Lift-off Subscapularis Test (Right) - Unable to test' is 'Unable to test' (any).

Describe the suspected right rotator cuff condition and the clinical findings or reasons supporting this suspicion when testing could not be performed. Fill only if 'Yes' is 'Yes'.

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

Check this box if the right shoulder condition interferes with the ability to stand as part of normal activities.

Check this box if the right shoulder condition causes difficulty with walking or general movement from place to place.

Check this box if the right shoulder has reduced movement/limited range of motion compared with normal.

Check this box if the right shoulder shows weakness or reduced strength during movement.

Check this box if the right shoulder condition contributes to unsteadiness or instability when maintaining posture or position.

Check this box if the right shoulder condition interferes with the ability to sit comfortably or maintain a seated position.

Check this box if swelling is present in or around the right shoulder due to the condition.

Check this box if there is visible or palpable deformity of the right shoulder related to the condition.

Check this box if the right shoulder has excessive motion (e.g., laxity/hypermobility) compared with normal.

Check this box if there is muscle wasting/atrophy from reduced use of the right shoulder or arm.

Check this box if there are other additional contributing factors not listed, and provide details in the adjacent description field.

Enter a brief description of any other right shoulder contributing factor not listed in the options above. Fill only if 'Other (describe)' is 'Yes'.

Provide details describing the additional contributing factors of disability related to the right shoulder.

Check this box if there is ankylosis of the shoulder joint (scapula and humerus move as one piece).

Check this box if there is no ankylosis of the shoulder joint.

Check this box if shoulder ankylosis allows abduction up to 60 degrees and the person can reach the mouth and head. Fill only if 'Ankylosis of scapulohumeral (glenohumeral) articulation - Yes' is 'Yes'.

Check this box if shoulder ankylosis is between favorable and unfavorable severity. Fill only if 'Ankylosis of scapulohumeral (glenohumeral) articulation - Yes' is 'Yes'.

Check this box if shoulder ankylosis limits abduction to 25 degrees or less from the side. Fill only if 'Ankylosis of scapulohumeral (glenohumeral) articulation - Yes' is 'Yes'.

Enter the measured angle of right shoulder ankylosis in degrees of abduction. Fill only if 'Ankylosis of scapulohumeral (glenohumeral) articulation - Yes' is 'Yes'.

Check this box if ankylosis involves Muscle Groups I (e.g., trapezius/levator scapulae/serratus magnus) and II (e.g., pectoralis major II/latissimus dorsi/teres major/pectoralis minor/rhomboid). Fill only if 'Ankylosis of scapulohumeral (glenohumeral) articulation - Yes' is 'Yes'.

Check this box if ankylosis does not involve Muscle Groups I and II. Fill only if 'Ankylosis of scapulohumeral (glenohumeral) articulation - Yes' is 'Yes'.

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

Check this box if the Veteran’s right shoulder muscle atrophy is not due to the claimed condition listed in the diagnosis section (and provide the rationale). Fill only if 'Yes' is 'Yes'.

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

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

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

Check this box if the Veteran’s right shoulder initial range of motion measurements are all normal.

Check this box if any right shoulder initial range of motion measurement is abnormal or outside the normal range.

Check this box if you are unable to perform initial range of motion testing for the right shoulder.

Check this box if initial right shoulder range of motion testing is not indicated for this examination.

Explain why the right shoulder initial range-of-motion testing is marked as unable to test or not indicated. Fill only if 'Right shoulder ROM: Unable to test', 'Right shoulder ROM: Not indicated' is 'Yes' for any fields selection.

Describe why the right shoulder range of motion is outside the normal range but is considered normal for the Veteran due to other factors or conditions. Fill only if 'Right shoulder ROM: Abnormal or outside of normal range' is 'Yes'.

Check this box if the abnormal right shoulder range of motion itself contributes to functional loss.

Check this box if the abnormal right shoulder range of motion itself does not contribute to functional loss.

If abnormal right shoulder range of motion contributes to functional loss, explain how it contributes. Fill only if 'Abnormal ROM contributes to functional loss: Yes' is 'Yes'.

Check this box if right shoulder range of motion testing can be performed.

Check this box if right shoulder range of motion testing cannot be performed.

If right shoulder testing cannot be performed, provide the reason it cannot be done. Fill only if 'Right shoulder ROM testing can be performed: No' is 'No'.

Provide a narrative citing and discussing all procurable evidence used to estimate the right shoulder range of motion (including the Veteran’s statements, relevant medical records, and examiner judgment), or explain why an estimate cannot be provided. Fill only if 'Does procured evidence (statements from the Veteran) suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability with repeated use over time?' is 'Yes'.

Check this box if, on the right side, there is additional loss of function or range of motion after three repetitions during repetitive-use testing.

Check this box if, on the right side, there is no additional loss of function or range of motion after three repetitions during repetitive-use testing.

Enter the right-side flexion range-of-motion endpoint after completing three repetitions, in degrees. Fill only if 'Yes – Additional loss after three repetitions (Right)' is 'Yes'.

Enter the right-side abduction range-of-motion endpoint after completing three repetitions, in degrees. Fill only if 'Yes – Additional loss after three repetitions (Right)' is 'Yes'.

Enter the right-side internal rotation range-of-motion endpoint after completing three repetitions, in degrees. Fill only if 'Yes – Additional loss after three repetitions (Right)' is 'Yes'.

Enter the right-side external rotation range-of-motion endpoint after completing three repetitions, in degrees. Fill only if 'Yes – Additional loss after three repetitions (Right)' is 'Yes'.

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

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

Check this box if pain is a factor that causes the right-side functional loss after repetitive use. Fill only if 'Yes – Additional loss after three repetitions (Right)' is 'Yes'.

Check this box if fatigability is a factor that causes the right-side functional loss after repetitive use. Fill only if 'Yes – Additional loss after three repetitions (Right)' is 'Yes'.

Check this box if weakness is a factor that causes the right-side functional loss after repetitive use. Fill only if 'Yes – Additional loss after three repetitions (Right)' is 'Yes'.

Check this box if lack of endurance is a factor that causes the right-side functional loss after repetitive use. Fill only if 'Yes – Additional loss after three repetitions (Right)' is 'Yes'.

Check this box if incoordination is a factor that causes the right-side functional loss after repetitive use. Fill only if 'Yes – Additional loss after three repetitions (Right)' is 'Yes'.

Check this box if another factor (not listed) causes the right-side functional loss after repetitive use. Fill only if 'Yes – Additional loss after three repetitions (Right)' is 'Yes'.

Enter the other factor(s) (not listed) that contribute to functional loss after repetitive use testing. Fill only if 'Other' is 'Yes'.

Check this box if none of the listed factors cause right-side functional loss after repetitive use. Fill only if 'Yes – Additional loss after three repetitions (Right)' is 'Yes'.

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

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

Explain any objective evidence of localized tenderness or pain on palpation on the right side, including the location, severity, and relationship to the condition(s). Fill only if 'Localized tenderness/pain on palpation (Right) - Yes' is 'Yes'.

Check this box if there is evidence of pain on the right side.

Check this box if there is no evidence of pain on the right side.

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

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

Check this box if pain is evident during active motion on the right side. Fill only if 'Evidence of pain: Yes' is 'Yes'.

Check this box if pain is evident during passive motion on the right side. Fill only if 'Evidence of pain: Yes' is 'Yes'.

Check this box if pain is evident at rest or with no movement on the right side. Fill only if 'Evidence of pain: Yes' is 'Yes'.

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

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

Enter any comments describing the evidence of pain on the right side, including the types of pain observed and any related functional loss details. Fill only if 'Pain causes functional loss' is 'Yes'.

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

Check this box if the Veteran is not able to perform repetitive-use testing with at least three repetitions (right side) and provide an explanation in the space below.

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

Check this box if the unclaimed joint is damaged.

Check this box if the unclaimed joint is undamaged.

Check this box if the Veteran has muscle atrophy of the right upper extremity and you will provide the specific measurement location and circumference measurements in Section 4C. Fill only if 'Yes' is 'Yes'.

Specify the anatomical location where the upper-extremity circumference was measured (e.g., a set distance above a landmark such as the anterior elbow crease). Fill only if 'Yes' is 'Yes'.

Enter the circumference measurement of the more normal (unaffected) side at maximum muscle bulk for the specified measurement location. Fill only if 'Yes' is 'Yes'.

Enter the circumference measurement of the atrophied (affected) side at maximum muscle bulk for the specified measurement location. Fill only if 'Yes' is 'Yes'.

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

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

Describe how the diagnosed condition(s) affect the Veteran's ability to perform occupational tasks, providing one or more examples (e.g., standing, walking, lifting, sitting). Fill only if 'Yes' is 'Yes'.

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

Enter the examiner's signature.

Enter the examiner’s printed name and professional title/credentials (e.g., MD, DO, NP, PA-C).

Enter the examiner’s area of practice or specialty (e.g., Cardiology, Orthopedics, Psychology/Psychiatry, General Practice).

Enter the date the examiner signed the certification.

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

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

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

Enter the examiner’s mailing address.

Describe the history of the Veteran's shoulder and/or arm condition, including onset and course, as a brief summary.

Check this box if the Veteran reports experiencing flare-ups of the shoulder and/or arm condition.

Check this box if the Veteran does not report any flare-ups of the shoulder and/or arm condition.

If the Veteran reports flare-ups, describe them including frequency, duration, characteristics, precipitating and alleviating factors, and any severity or functional impairment during flare-ups. Fill only if 'Yes' is 'Yes'.

Check this box if the Veteran uses any assistive devices.

Check this box if the Veteran does not use any assistive devices.

Check this box if you are a VA Healthcare provider.

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

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

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