Va Form 21-0960c-10 - Peripheral Nerves Conditions (Not Including Diabetic Sensory- Motor Peripheral Neuropathy) Disability Benefits Questionnaire

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OMB Control No. 2900-0779
Respondent Burden: 45 minutes
Peripheral Nerves Conditions (Not Including Diabetic Sensory- Motor Peripheral
Neuropathy) 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 HAVE A PERIPHERAL NERVE CONDITION OR PERIPHERAL NEUROPATHY?
(If "Yes," complete Item 1B)
Yes
No
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO A PERIPHERAL NERVE CONDITION AND/OR PERIPHERAL NEUROPATHY:
Diagnosis # 1:
ICD Code:
Date of diagnosis:
Diagnosis # 2:
ICD Code:
Date of diagnosis:
Diagnosis # 3:
ICD Code:
Date of diagnosis:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO A PERIPHERAL NERVE CONDITION AND/OR PERIPHERAL NEUROPATHY, LIST USING ABOVE
FORMAT:
DEFINITIONS: For VA purposes, neuralgia indicates a condition characterized by a dull and intermittent pain of typical distribution so as to identify
the nerve, while neuritis is characterized by loss of reflexes, muscle atrophy, sensory disturbances and constant pain, at times excruciating.
SECTION II - MEDICAL HISTORY
(including onset and course)
(brief summary)
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S PERIPHERAL NERVE CONDITION
:
2B. DOMINANT HAND
Right
Left
Ambidextrous
SECTION III - SYMPTOMS
3A. Does the veteran have any symptoms attributable to any peripheral nerve conditions?
Yes
No
(check all that apply):
If yes, indicate symptoms' location and severity
(may be excruciating at times)
Constant pain
Right upper extremity:
None
Mild
Moderate
Severe
None
Mild
Moderate
Severe
Left upper extremity:
None
Mild
Moderate
Severe
Right lower extremity:
None
Mild
Moderate
Severe
Left lower extremity:
(usually dull)
Intermittent pain
Right upper extremity:
None
Mild
Moderate
Severe
None
Mild
Moderate
Severe
Left upper extremity:
None
Mild
Moderate
Severe
Right lower extremity:
None
Mild
Moderate
Severe
Left lower extremity:
Paresthesias and/or dysesthesias
Right upper extremity:
None
Mild
Moderate
Severe
None
Mild
Moderate
Severe
Left upper extremity:
None
Mild
Moderate
Severe
Right lower extremity:
None
Mild
Moderate
Severe
Left lower extremity:
Page 1
SUPERSEDES VA FORM 21-0960C-10, DEC 2010,
VA FORM
21-0960C-10
WHICH WILL NOT BE USED.
OCT 2012

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