OMB Approved No. 2900-0778
Respondent Burden: 30 minutes
CENTRAL NERVOUS SYSTEM AND NEUROMUSCULAR DISEASES
(EXCEPT TRAUMATIC BRAIN INJURY, AMYOTROPHIC LATERAL SCLEROSIS, PARKINSON'S
DISEASE, MULTIPLE SCLEROSIS, HEADACHES, TMJ CONDITIONS, EPILEPSY, NARCOLEPSY,
PERIPHERAL NEUROPATHY, SLEEP APNEA, CRANIAL NERVE DISORDERS, FIBROMYALGIA,
CHRONIC FATIGUE SYNDROME) 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 NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH A CENTRAL NERVOUS SYSTEM (CNS) CONDITION?
(If "Yes," complete Item 1B)
YES
NO
(check all that apply)
1B. SELECT THE VETERAN'S CONDITION:
CNS INFECTIONS:
ICD code:
Date of diagnosis:
Meningitis
Specify organism:
Brain abscess
Specify organism:
HIV
Neurosyphilis
Lyme disease
Encephalitis, epidemic, chronic, including poliomyelitis, anterior (anterior horn cells)
(specify)
Other
:
VASCULAR DISEASES:
ICD code:
Date of diagnosis:
Thrombosis, TIA or cerebral infarction
(specify type)
Hemorrhage
:
Cerebral arteriosclerosis
(specify)
Other
:
ICD code:
Date of diagnosis:
HYDROCEPHALUS:
Obstructive
Communicating
Normal pressure (NPH)
BRAIN TUMOR:
ICD code:
Date of diagnosis:
SPINAL CORD CONDITIONS:
ICD code:
Date of diagnosis:
Syringomyelia
Myelitis
Hematomyelia
Spinal Cord Injuries
Radiation injury
Electric or lightning injury
Decompression sickness (DCS)
(specify
Other
):
Spinal cord tumor
(specify)
Other
:
BRAIN STEM CONDITIONS:
ICD code:
Date of diagnosis:
Bulbar palsy
Pseudobulbar palsy
(specify)
Other
:
VA FORM
21-0960C-5
SUPERSEDES VA FORM 21-0960C-5, FEB 2011,
Page 1
OCT 2012
WHICH WILL NOT BE USED.