Va Form 21-0960c-7 - Fibromyalgia Disability Benefits Questionnaire Page 2
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3PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION IV - FINDINGS, SIGNS, SYMPTOMS
4A. DOES THE VETERAN CURRENTLY HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO FIBROMYALGIA?
(If "Yes," complete items 4B & 4C)
YES
NO
NOTE: For VA purposes widespread musculoskeletal pain means that pain occurs in both sides of the body, both
WIDESPREAD MUSCULOSKELETAL PAIN (
above and below the waist and affecting both the axial skeleton (i.e., cervical spine, anterior chest, thoracic spine or low back) and the extremities)
STIFFNESS
MUSCLE WEAKNESS
FATIGUE
SLEEP DISTURBANCES
PARESTHESIAS
HEADACHE
DEPRESSION
ANXIETY
IRRITABLE BOWEL SYMPTOMS
RAYNAUD'S-LIKE SYMPTOMS
(describe):__________________________________________________________________________________________________________________
OTHER
(For all checked conditions, describe)_________________________________________________________________________________________________________
NOTE - If Mental Health conditions, such as depression due to fibromyalgia are identified, a VA Form 21-0960P-2, Mental Disorders (Other than PTSD) Disability
Benefits Questionnaire must ALSO be completed.
(check all that apply)
4B. FREQUENCY OF FIBROMYALGIA SYMPTOMS
NO SYMPTOMS
EPISODIC WITH EXACERBATIONS
PRESENT MORE THAN ONE-THIRD OF THE TIME
CONSTANT OR NEARLY CONSTANT
(If checked, describe):
OFTEN PRECIPITATED BY ENVIRONMENTAL OR EMOTIONAL STRESS OR OVEREXERTION
(describe):
OTHER
(trigger points)
(check all that apply)
4C. TENDER POINTS
FOR PAIN
None
All bilaterally
Low cervical region: at anterior aspect of the interspaces between
Right
Left
Both
(If checked, indicate side):
transverse processes of C5-C7
(If checked, indicate side):
Right
Left
Both
Second rib: at second costochondral junction
(If checked, indicate side):
Occiput: at suboccipital muscle insertion
Right
Left
Both
(If checked, indicate side):
Trapezius muscle: midpoint of upper border
Right
Left
Both
(If checked, indicate side):
Supraspinatus Muscle: above medial border of the scapular spine
Right
Left
Both
(If checked, indicate side):
Right
Left
Both
Lateral epicondyle: 2 cm distal to lateral epicondyle
(If checked, indicate side):
Right
Left
Both
Gluteal: at upper outer quadrant of buttocks
(If checked, indicate side):
Greater trochanter: posterior to greater trochanteric prominence
Right
Left
Both
(If checked, indicate side):
Knee: medial joint line
Right
Left
Both
:
(If checked, indicate side):
Other, specify
Right
Left
Both
SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
5. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN SECTION I, DIAGNOSIS?
(If "Yes," describe - brief summary):
YES
NO
SECTION VI - DIAGNOSTIC TESTING
NOTE - If diagnostic test results are in the medical record and reflect the veteran's current condition, repeat testing is not required.
6. ARE THERE ANY SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
(If "Yes," provide type of test or procedure, date and results (brief summary)):
YES
NO
Page 2
VA FORM 21-0960C-7, SEP 2016
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