Va Form 21-0960n-3 - Loss Of Sense Of Smell And/or Taste Disability Benefits Questionnaire

Download a blank fillable Va Form 21-0960n-3 - Loss Of Sense Of Smell And/or Taste Disability Benefits Questionnaire in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Va Form 21-0960n-3 - Loss Of Sense Of Smell And/or Taste Disability Benefits Questionnaire with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

OMB Control No. 2900-0781
Respondent Burden: 15 minutes
LOSS OF SENSE OF SMELL AND/OR TASTE
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 THIS 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
(This is the condition the
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH LOSS OF SENSE OF SMELL OR TASTE?
veteran is claiming or for which an exam has been requested.)
(If "Yes," complete Item 1B)
YES
NO
(check all that apply)
1B. SELECT THE VETERAN'S CONDITION
(inability to detect any odor)
ANOSMIA
ICD Code:
Date of diagnosis:
(reduced ability to detect any odors)
HYPOSMIA
ICD Code:
Date of diagnosis:
(complete lack of taste)
AGEUSIA
ICD Code:
Date of diagnosis:
(decrease in sense of taste)
HYPOGEUSIA
ICD Code:
Date of diagnosis:
(specify)
OTHER
Other diagnosis #1
ICD Code:
Date of diagnosis:
Other diagnosis #2
ICD Code:
Date of diagnosis:
1C. IF ADDITIONAL DIAGNOSES THAT PERTAIN TO COMPLETE LOSS OF SENSE OF SMELL OR TASTE, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL RECORD REVIEW
2. INDICATE MEDICAL RECORDS REVIEWED IN PREPARATION OF THIS REPORT:
C-FILE (VA ONLY)
OTHER, DESCRIBE:
SECTION III - MEDICAL HISTORY
(including onset and course)
(brief summary):
3. DESCRIBE THE HISTORY
OF THE VETERAN'S LOSS OF SENSE OF SMELL OR TASTE
SECTION IV - SYMPTOMS
4A. DOES THE VETERAN CURRENTLY HAVE LOSS OF SENSE OF SMELL?
(If "Yes," indicate severity)
YES
NO
PARTIAL
COMPLETE
(If "Yes," is there a known anatomical or pathological basis for this condition?)
(If "Yes," describe)
YES
NO
(unable to detect sweet, salty, sour, or bitter tastes)?
4B. DOES THE VETERAN CURRENTLY HAVE LOSS OF SENSE OF TASTE
(If "Yes," indicate severity)
YES
NO
PARTIAL
COMPLETE
(If "Yes," is there a known anatomical or pathological basis for this condition?)
(If "Yes," describe)
YES
NO
VA FORM
SUPERSEDES VA FORM 21-0960N-3, MAR 2011,
Page 1
21-0960N-3
OCT 2012
WHICH WILL NOT BE USED.

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 2