Va Form 21-0960e-1 - Diabetes Mellitus Disability Benefits Questionnaire

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OMB Control No. 2900-0776
Respondent Burden: 15 Minutes
Expiration Date: 11/30/2017
DIABETES MELLITUS 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. VA reserves the right to confirm the authenticity of ALL DBQ's completed by private
health care providers.
SECTION I - DIAGNOSIS
1A. SELECT THE VETERAN'S CONDITION:
DIABETES MELLITUS TYPE I
DIABETES MELLITUS TYPE II
IMPAIRED FASTING GLUCOSE
DOES NOT MEET CRITERIA FOR DIAGNOSIS OF DIABETES
(Specify, providing only diagnoses that pertain to Diabetes Mellitus or its complications)
OTHER
DIAGNOSIS # 1 -
ICD CODE -
DATE OF DIAGNOSIS -
DIAGNOSIS # 2 -
ICD CODE -
DATE OF DIAGNOSIS -
DIAGNOSIS # 3 -
ICD CODE -
DATE OF DIAGNOSIS -
1B. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO DIABETES MELLITUS LIST USING ABOVE FORMAT
SECTION II - MEDICAL HISTORY
(Check all that apply)
2A. TREATMENT
NONE
MANAGED BY RESTRICTED DIET
PRESCRIBED ORAL HYPOGLYCEMIC AGENT(S)
PRESCRIBED INSULIN 1 INJECTION PER DAY
PRESCRIBED INSULIN MORE THAN 1 INJECTION PER DAY
OTHER (Describe)
2B. DOES THE VETERAN REQUIRE REGULATION OF ACTIVITIES AS PART OF MEDICAL MANAGEMENT OF DIABETES MELLITUS?
(If "Yes," provide one or more examples of how the veteran must regulate his or her activities):
YES
NO
NOTE - For VA purposes, regulation of activities can be defined as avoidance of strenuous occupational and recreational activities with the intention of
avoiding hypoglycemic episodes.
2C. HOW FREQUENTLY DOES THE VETERAN VISIT HIS OR HER DIABETIC CARE PROVIDER FOR EPISODES OF KETOACIDOSIS OR HYPOGLYCEMIC REACTIONS?
LESS THAN 2 TIMES PER MONTH
2 TIMES PER MONTH
WEEKLY
2D. HOW MANY EPISODES OF KETOACIDOSIS REQUIRING HOSPITALIZATION OVER THE PAST 12 MONTHS?
0
1
2
3 OR MORE
2E. HOW MANY EPISODES OF HYPOGLYCEMIA REQUIRING HOSPITALIZATION OVER THE PAST 12 MONTHS?
0
1
2
3 OR MORE
2F. HAS THE VETERAN HAD PROGRESSIVE UNINTENTIONAL WEIGHT LOSS ATTRIBUTABLE TO DIABETES MELLITUS?
(If "Yes," provide percent of loss of individual's baseline weight):
%
YES
NO
NOTE - For VA purposes, "baseline weight" means the average weight for the two-year period preceding the onset of the disease.
2G. HAS THE VETERAN HAD PROGRESSIVE LOSS OF STRENGTH ATTRIBUTABLE TO DIABETES MELLITUS?
YES
NO
SUPERSEDES VA FORM 21-0960E-1, OCT 2012,
21-0960E-1
VA FORM
Page 1
WHICH WILL NOT BE USED.
DEC 2014

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