Va Form 21-0960l-2 - Sleep Apnea Disability Benefits Questionnaire
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2OMB Control No. 2900-0778
Respondent Burden: 15 minutes
SLEEP APNEA 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 INFORMATION
BEFORE COMPLETING FORM.
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.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN HAVE OR HAS HE/SHE EVER HAD SLEEP APNEA?
(If "Yes," complete Item 1B)
YES
NO
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO SLEEP APNEA AND CHECK DIAGNOSTIC TYPE:
OBSTRUCTIVE
ICD Code:
Date of diagnosis:
CENTRAL
ICD Code:
Date of diagnosis:
MIXED, COMPONENTS OF BOTH
ICD Code:
Date of diagnosis:
(specify):
OTHER SLEEP DISORDER
ICD Code:
Date of diagnosis:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO A DIAGNOSIS OF SLEEP APNEA, LIST USING ABOVE FORMAT:
NOTE - The diagnosis of sleep apnea must be confirmed by a sleep study, provide the sleep study results in Section V, Diagnostic Testing. If other respiratory condition is
diagnosed, complete VA Form 21-0960L-1, Respiratory Conditions Disability Benefits Questionnaire and/or VA Form 21-0960C-6, Narcolepsy Disability Benefits
Questionnaire in lieu of this one.
SECTION II - MEDICAL HISTORY
(including onset and course)
(brief summary)
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S SLEEP DISORDER CONDITION
:
2B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF A SLEEP DISORDER CONDITION?
(If "Yes," list only those medications required for the veteran's sleep disorder condition):
YES
NO
(CPAP)
2C. DOES THE VETERAN REQUIRE THE USE OF A BREATHING ASSISTANCE DEVICE SUCH AS A CONTINUOUS POSITIVE AIRWAY PRESSURE
MACHINE?
YES
NO
SECTION III - FINDINGS, SIGNS AND SYMPTOMS
3. DOES THE VETERAN CURRENTLY HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO SLEEP APNEA?
YES
NO
(If, "Yes," check all that apply)
Persistent daytime hypersomnolence
Evidence of chronic respiratory failure with carbon dioxide retention
Cor pulmonale
Requires tracheostomy
Other, describe:
SECTION IV - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
(surgical or otherwise)
4A. DOES THE VETERAN HAVE ANY SCARS
RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
SECTION I, DIAGNOSIS?
YES
NO
(If "Yes," are any of the scars painful and/or unstable, or is the total area of all related scars greater than 39 cm (6 square inches?)
YES
NO
(If "Yes," ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)
4B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN SECTION I, DIAGNOSIS?
(If, "Yes," describe - brief summary):
YES
NO
VA FORM
21-0960L-2
Page 1
FEB 2011
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