Va Form 21-0960c-5 - Central Nervous System And Neuromuscular Diseases Disability Benefits Questionnaire Page 2

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SECTION I - DIAGNOSIS (Continued)
(Continued) (check all that apply)
1B. SELECT THE VETERAN'S CONDITION:
MOVEMENT DISORDERS:
ICD code:
Date of diagnosis:
Athetosis, acquired
Myoclonus I
(convulsive state, myoclonic type)
Paramyoclonus multiplex
(Gilles de la Tourette Syndrome)
Tic convulsive
(specify type)
Dystonia
:
Essential tremor
Tardive dyskinesia or other neuroleptic induced syndromes
(specify)
Other
:
NEUROMUSCULAR DISORDERS:
ICD code:
Date of diagnosis:
Myasthenia gravis
Myasthenic syndrome
Botulism
(specify):
Hereditary muscular disorders
Familial periodic paralysis
Myoglobinuria
(specify
Dermatomyositis or polyomiositis
):
(specify)
Other
:
INTOXICATIONS:
ICD code:
Date of diagnosis:
(specify):
Heavy metal intoxication
(specify)
Solvents
:
(specify)
Insecticides, pesticides, others
:
Nerve gas agents
(specify)
Herbicides/defoliants
:
(specify)
Other
:
OTHER CENTRAL NERVOUS CONDITION
Other diagnosis # 1
ICD code:
Date of diagnosis:
Other diagnosis # 2
ICD code:
Date of diagnosis:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO CENTRAL NERVOUS SYSTEM CONDITIONS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
(Brief summary) (Continued on Page 3)
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S CENTRAL NERVOUS SYSTEM CONDITION(S)
VA FORM 21-0960C-5, OCT 2012
Page 2

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