Va Form 21-0960e-3 - Thyroid And Parathyroid Conditions Disability Benefits Questionnaire Page 2
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SECTION III - MEDICAL HISTORY
3F. DOES THE VETERAN HAVE ANY RESIDUAL ENDOCRINE DYSFUNCTION FOLLOWING TREATMENT FOR THYROID OR PARATHYROID CONDITION?
YES
NO
(If "Yes," check all that apply):
Hypothyroid endocrine dysfunction
Hypoparathyroid endocrine dysfunction
(Describe):
Other
SECTION IV - FINDINGS, SIGNS AND SYMPTOMS
4A. DOES THE VETERAN CURRENTLY HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO A HYPERTHYROID CONDITION?
YES
NO
(If "Yes," check all that apply):
(more than 100 beats per minute)
Tachycardia
(If "Yes," indicate frequency of tachycardia):
Constant
Intermittent
Palpitations
Atrial fibrillation or other arrhythmia attributable to a thyroid condition
(If checked, indicate frequency):
(paroxysmal)
Constant
Intermittent
(If "intermittent," indicate number of episodes in the past 12 months):
0
1-3
More than 4
(Indicate how these episodes were documented (check all that apply)):
(Specify):
EKG
Holter
Other
Increased pulse pressure or blood pressure
Tremor
Emotional instability
Fatigability
Thyroid enlargement
(exophthalmos) (If checked, ALSO complete VA Form 21-0960N-2, Eye Conditions Disability Benefits Questionnaire)
Eye involvement
Muscular weakness
Increased sweating
Flushing
Heat Intolerance
Frequent bowel movements
Irregular or absent menstrual periods in women
Weight loss attributable to a hyperthyroid condition
(If checked, provide baseline weight:
and current weight:
)
(For VA purposes, baseline weight is the average weight for a 2-year period preceding onset of disease)
Other
(For all checked conditions complete 4B)
4B. DESCRIBE THE CHECKED CONDITION(S):
4C. DOES THE VETERAN HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO A HYPOTHYROID CONDITION?
YES
NO
(If "Yes," check all that apply):
(If checked, describe):
Fatigability
Constipation
Mental sluggishness
(dementia, slowing of thought, depression)
Mental disturbance
Muscular weakness
Weight gain
(If checked, provide baseline weight:
and current weight:
)
(For VA purposes, baseline weight is the average weight for a 2-year period preceding onset of disease)
Sleepiness
Cold Intolerance
(less than 60 beats per minute)
Bradycardia
Other
(For all checked conditions complete 4D)
4D. DESCRIBE THE CHECKED CONDITION(S):
Page 2
VA FORM 21-0960E-3, OCT 2012
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