Va Form 21-0960e-3 - Thyroid And Parathyroid Conditions Disability Benefits Questionnaire Page 3
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SECTION IV - FINDINGS, SIGNS AND SYMPTOMS
4E. DOES THE VETERAN CURRENTLY HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO A HYPERPARATHYROID CONDITION?
YES
NO
(If "Yes," check all that apply):
(If checked, describe):
Weakness
(If checked, describe, providing dates and treatment):
Kidney stones
(If checked, has the veteran had a bone density test, such as a DEXA scan?)
Generalized decalcification of bones
(If "Yes," provide date of test
results:
)
YES
NO
Nausea
Vomiting
Constipation
Anorexia
Peptic Ulcer
Weight loss
(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 4F)
4F. DESCRIBE THE CHECKED CONDITION(S):
4G. DOES THE VETERAN CURRENTLY HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO A HYPOPARATHYROID CONDITION?
YES
NO
(If "Yes," check all that apply):
(of arms, legs or circumoral area)
Paresthesias
(If checked, ALSO complete VA Form 21-0960N-2, Eye Conditions Disability Benefits Questionnaire)
Cataract
(such as papilledema)
Evidence of increased intracranial pressure
Marked neuromuscular excitability
Convulsions
(tetany)
Muscular spasms
Laryngeal stridor
Other
(For all checked conditions complete 4H)
4H. DESCRIBE THE CHECKED CONDITION(S):
4I. DOES THE VETERAN CURRENTLY HAVE SYMPTOMS DUE TO PRESSURE ON ADJACENT ORGANS SUCH AS THE TRACHEA, LARYNX, OR ESOPHAGUS
ATTRIBUTABLE TO A THYROID CONDITION?
YES
NO
(If "Yes," indicate which adjacent organs are affected):
(If checked, report pulmonary function testing results in Section X, Diagnostic Testing)
Larynx and/or trachea
(If checked, indicate severity of pressure-related symptoms/swallowing difficulty - check all that apply)
Esophagus
Mild
Moderate
Severe, permitting the passage of liquids only
Causing marked impairment of health
(For all checked conditions complete 4J)
4J. DESCRIBE THE CHECKED CONDITION(S):
Page 3
VA FORM 21-0960E-3, OCT 2012
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