Va Form 21-0960c-5 - Central Nervous System And Neuromuscular Diseases Disability Benefits Questionnaire Page 7
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9SECTION V - TUMORS AND NEOPLASMS
5A. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES LISTED
IN SECTION I, DIAGNOSIS?
YES
NO
IF YES, COMPLETE THE FOLLOWING:
5B. IS THE NEOPLASM?
BENIGN
MALIGNANT
5C. HAS THE VETERAN COMPLETED TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT NEOPLASM OR
METASTASES?
YES
NO; WATCHFUL WAITING
IF YES, INDICATE TYPE OF TREATMENT THE VETERAN IS CURRENTLY UNDERGOING OR HAS COMPLETED (CHECK ALL THAT APPLY):
Treatment completed; currently in watchful waiting status
Surgery - If checked, describe:
Date(s) of surgery:
Radiation therapy - Date of most recent treatment
Date of completion of treatment or anticipated date of completion:
Antineoplastic chemotherapy - Date of most recent treatment:
Date of completion of treatment or anticipated date of completion:
Other therapeutic procedure - If checked, describe procedure:
Date of most recent procedure:
Other therapeutic treatment - If checked, describe treatment:
Date of completion of treatment or anticipated date of completion:
5D. DOES THE VETERAN CURRENTLY HAVE ANY RESIDUAL CONDITIONS OR COMPLICATIONS DUE TO THE NEOPLASM (including metastases) OR ITS
TREATMENT, OTHER THAN THOSE ALREADY DOCUMENTED IN THE REPORT ABOVE?
YES
NO
(brief summary)
IF YES, LIST RESIDUAL CONDITIONS AND COMPLICATIONS
:
5E. IF THERE ARE ADDITIONAL BENIGN OR MALIGNANT NEOPLASMS OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DIAGNOSIS,
DESCRIBE USING THE ABOVE FORMAT:
SECTION VI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
6A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) 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 OR EQUAL TO 39 SQUARE CM
(6 SQUARE INCHES)?
YES
NO
IF YES, ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT DISABILITY BENEFITS QUESTIONNAIRE.
6B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN SECTION I, DIAGNOSIS?
YES
NO
(brief summary):
IF YES, DESCRIBE
Page 7
VA FORM 21-0960C-5, OCT 2012
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