Va Form 21-0960e-3 - Thyroid And Parathyroid Conditions Disability Benefits Questionnaire Page 4
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6SECTION V - PHYSICAL EXAM
5A. EYES:
(If checked, describe):
NORMAL, NO EXOPTHALMOS
ABNORMAL
(If "Abnormal," complete VA Form 21-0960N-2, Eye Conditions Disability Benefits Questionnaire)
5B. NECK:
NORMAL, NO PALPABLE THYROID ENLARGEMENT OR NODULES
ABNORMAL, DIFFUSELY ENLARGED THYROID GLAND
(If checked, describe location, size and consistency):
ABNORMAL, ENLARGED THYROID NODULE
ABNORMAL, WITH DISFIGUREMENT OF THE HEAD OR NECK DUE TO ENLARGEMENT OF THE THYROID GLAND
(If checked, describe by completing Section VII, Scars or other Disfigurement of the Neck)
(Describe):
OTHER
5C. PULSE
(Provide heart rate:
)
REGULAR
IRREGULAR
5D. BLOOD PRESSURE
(Provide blood pressure:
)
SECTION VI - REFLEX EXAM
(Rate deep tendon reflexes (DTRs) according to the following scale):
6. REFLEXES
0 Absent
1+ Hypoactive
2+ Normal
3+ Hyperactive without clonus
4+ Hyperactive with clonus
ALL NORMAL
BICEPS:
KNEE:
Right
0
1+
2+
3+
4+
Right
0
1+
2+
3+
4+
Left
0
1+
2+
3+
4+
Left
0
1+
2+
3+
4+
TRICEPS:
ANKLE:
Right
0
1+
2+
3+
4+
Right
0
1+
2+
3+
4+
Left
0
1+
2+
3+
4+
Left
0
1+
2+
3+
4+
BRACHIORADIALIS:
Right
0
1+
2+
3+
4+
Left
0
1+
2+
3+
4+
SECTION VII - SCARS OR OTHER DISFIGUREMENT OF THE NECK
7A. DOES THE VETERAN HAVE ANY SCARS OR OTHER DISFIGUREMENT OF THE NECK RELATED TO TREATMENT FOR ANY THYROID OR PARATHYROID
CONDITION?
YES
NO
(If "Yes," complete the following):
0
1
2
3
4
5 or more
1.Total number of unstable or painful scars:
2. Is any scar 13 cm in length or longer?
YES
NO
3. Is any scar 0.6 cm in width or wider?
YES
NO
4. Is any scar elevated or depressed?
YES
NO
5. Is any scar adherent to underlying tissue?
YES
NO
7B. DOES THE VETERAN HAVE ANY AREAS OF SKIN OF THE NECK THAT ARE HYPO- OR HYPERPIGMENTED, THAT HAVE ABNORMAL TEXTURE, THAT HAVE
MISSING UNDERLYING SOFT TISSUE, OR THAT ARE INDURATED AND INFLEXIBLE RELATED TO THYROID OR PARATHYROID DISEASE OR THEIR TREATMENT?
YES
NO
(If "Yes," complete the following):
1. Approximate total area of skin with hypo- or hyperpigmentation:
cm2
2. Approximate total area of skin with abnormal texture:
cm2
3. Approximate total area of skin with missing underlying soft tissue:
cm2
4. Approximate total area of skin that is indurated and inflexible:
cm2
Page 4
VA FORM 21-0960E-3, OCT 2012
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