Fillable Va Form 21-0960c-7 - Fibromyalgia Disability Benefits Questionnaire printable pdf download

Va Form 21-0960c-7 - Fibromyalgia Disability Benefits Questionnaire

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OMB Approved No. 2900-0781

Respondent Burden: 15 Minutes

Expiration Date: 09/30/2019

FIBROMYALGIA DISABILITY BENEFITS QUESTIONNAIRE

IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE

PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN BEFORE

COMPLETING FORM.

(First, Middle Initial, Last)

NAME OF PATIENT/VETERAN

PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

NOTE TO PHYSICIAN - Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you

provide on this questionnaire as part of their evaluation in processing the veteran's claim. VA reserves the right to confirm the authenticity of ALL DBQs completed by

private health care providers.

SECTION I - DIAGNOSIS

NOTE - Fibromyalgia may also be called fibrositis or primary fibromyalgia syndrome.

(This is the condition the veteran is claiming or for which an

1A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER BEEN DIAGNOSED WITH FIBROMYALGIA?

exam has been requested)

(If "Yes," complete Item 1B)

YES

NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed above. If there is no diagnosis, if the diagnosis is different

from a previous diagnosis for this condition, or if there is a diagnosis of a complication due to the claimed condition, explain your findings and reasons in the "Remarks"

section. Date of diagnosis can be the date of the evaluation if the clinician is making the initial diagnosis, or an appropriate date determined through record review or

reported history.

(check all that apply)

1B. SELECT THE VETERAN'S CONDITION

FIBROMYALGIA

ICD CODE:

DATE OF DIAGNOSIS:

(specify)

OTHER

OTHER DIAGNOSIS #1

ICD CODE:

DATE OF DIAGNOSIS:

OTHER DIAGNOSIS #2