Va Form 21-0960c-1 - Parkinson'S Disease Disability Benefits Questionnaire
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2OMB Approved No. 2900-0749
Respondent Burden: 15 minutes
PARKINSON'S DISEASE 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 ON
REVERSE 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 use the information you provide on
this questionnaire to process the Veteran's claim.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH
1B. ICD CODES(S)
1C. DATE OF DIAGNOSIS
PARKINSON'S DISEASE?
YES
NO
2. DOMINANT HAND
RIGHT
LEFT
AMBIDEXTROUS
SECTION II - MOTOR MANIFESTATIONS
3. MOTOR MANIFESTATIONS DUE TO PARKINSON'S OR ITS TREATMENT (Check all that apply)
MOTOR MANIFESTATIONS
NONE
MILD
MODERATE
SEVERE
A. STOOPED POSTURE
B. BALANCE IMPAIRMENT
(Difficulty initiating
C. BRADYKINESIA OR SLOWED MOTION
movement, "freezing," short shuffling steps)
(Such as blinking, leading to
D. LOSS OF AUTOMATIC MOVEMENTS
fixed gaze, typical Parkinson's facies)
(Monotone, slurring words, soft or rapid speech)
E. SPEECH CHANGES
(Characteristic hand shaking, "pill-rolling")
F. TREMOR
YES
NO
EXTREMITIES AFFECTED:
RIGHT UPPER
NOT AFFECTED
MILD
MODERATE
SEVERE
LEFT UPPER
NOT AFFECTED
MILD
MODERATE
SEVERE
RIGHT LOWER
MODERATE
SEVERE
NOT AFFECTED
MILD
LEFT LOWER
MODERATE
SEVERE
NOT AFFECTED
MILD
G. MUSCLE RIGIDITY AND STIFFNESS
YES
NO
EXTREMITIES AFFECTED:
RIGHT UPPER
NOT AFFECTED
MILD
MODERATE
SEVERE
LEFT UPPER
NOT AFFECTED
MILD
MODERATE
SEVERE
RIGHT LOWER
MODERATE
SEVERE
NOT AFFECTED
MILD
LEFT LOWER
NOT AFFECTED
MILD
MODERATE
SEVERE
SECTION lII - MENTAL MANIFESTATIONS
4. MENTAL MANIFESTATIONS DUE TO PARKINSON'S OR ITS TREATMENT (Check all that apply)
MENTAL MANIFESTATIONS
NONE
MILD
MODERATE
SEVERE
A. DEPRESSION
B. COGNITIVE IMPAIRMENT OR DEMENTIA
21-0960C-1
VA FORM
SUPERSEDES VA FORM 21-0960C-1, MAY 2010,
Page 1
OCT 2012
WHICH WILL NOT BE USED.
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