Va Form 21-0960c-5 - Central Nervous System And Neuromuscular Diseases Disability Benefits Questionnaire Page 8
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9SECTION VII - MENTAL HEALTH MANIFESTATIONS DUE TO CNS CONDITION OR ITS TREATMENT
7A. DOES THE VETERAN HAVE DEPRESSION, COGNITIVE IMPAIRMENT OR DEMENTIA, OR ANY OTHER MENTAL HEALTH CONDITIONS ATTRIBUTABLE TO A
CNS DISEASE AND/OR ITS TREATMENT?
YES
NO
7B. DOES THE VETERAN'S MENTAL HEALTH CONDITION(S), AS IDENTIFIED IN ITEM 7A, RESULT IN GROSS IMPAIRMENT IN THOUGHT PROCESSES OR
COMMUNICATION?
YES
NO
(Other than PTSD and Eating Disorders)
IF NO, ALSO COMPLETE VA FORM 21-0960P-2, MENTAL DISORDERS
DISABILITY BENEFITS QUESTIONNAIRE
(SCHEDULE WITH APPROPRIATE PROVIDER)
.
IF YES, BRIEFLY DESCRIBE THE VETERAN'S MENTAL HEALTH CONDITION:
SECTION VIII - DIFFERENTIATION OF SYMPTOMS OR NEUROLOGIC EFFECTS
8. ARE YOU ABLE TO DIFFERENTIATE WHAT PORTION OF THE SYMPTOMATOLOGY OR NEUROLOGIC EFFECTS DESCRIBED IN ITEM 7B IS CAUSED BY
EACH DIAGNOSIS?
YES
NO
IF YES, LIST WHICH SYMPTOMS OR NEUROLOGIC EFFECTS ARE ATTRIBUTABLE TO EACH DIAGNOSIS, WHERE POSSIBLE:
SECTION IX - ASSISTIVE DEVICES
9. DOES THE VETERAN USE ANY ASSISTIVE DEVICE(S) AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS
MAY BE POSSIBLE?
YES
NO
(Check all that apply and indicate frequency):
IF YES, IDENTIFY ASSISTIVE DEVICE(S) USED
Wheelchair
Frequency of use:
Occasional
Regular
Constant
Brace(s)
Frequency of use:
Occasional
Regular
Constant
Crutch(es)
Frequency of use:
Occasional
Regular
Constant
Cane(s)
Frequency of use:
Occasional
Regular
Constant
Walker
Frequency of use:
Occasional
Regular
Constant
Other:
Frequency of use:
Occasional
Regular
Constant
9B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:
SECTION X - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
10. DUE TO A CNS CONDITION, IS THERE FUNCTIONAL IMPAIRMENT OF AN EXTREMITY SUCH THAT NO EFFECTIVE FUNCTION REMAINS OTHER THAN THAT
(Functions of the upper extremity include grasping, manipulation, etc.,
WHICH WOULD BE EQUALLY WELL SERVED BY AN AMPUTATION WITH PROSTHESIS?
while functions for the lower extremity include balance and propulsion, etc.)
YES, FUNCTIONING IS SO DIMINISHED THAT AMPUTATION WITH PROSTHESIS WOULD EQUALLY SERVE THE VETERAN
NO
(Check all extremities for which this applies):
IF YES, INDICATE EXTREMITY(IES)
Right upper
Left upper
Right lower
Left lower
FOR EACH CHECKED EXTREMITY, DESCRIBE LOSS OF EFFECTIVE FUNCTION, IDENTIFY THE CONDITION CAUSING LOSS OF FUNCTION, AND PROVIDE
(brief summary):
SPECIFIC EXAMPLES
Page 8
VA FORM 21-0960C-5, OCT 2012
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