Va Form 21-0960n-4 - Sinusitis/rhinitis And Other Conditions Of The Nose, Throat, Larynx And Pharynx Disability Benefits Questionnaire

Download a blank fillable Va Form 21-0960n-4 - Sinusitis/rhinitis And Other Conditions Of The Nose, Throat, Larynx And Pharynx Disability Benefits Questionnaire in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Va Form 21-0960n-4 - Sinusitis/rhinitis And Other Conditions Of The Nose, Throat, Larynx And Pharynx Disability Benefits Questionnaire with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

OMB Approved No. 2900-0781
Respondent Burden: 30 minutes
SINUSITIS/RHINITIS AND OTHER CONDITIONS OF THE NOSE, THROAT,
LARYNX AND PHARYNX 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
(This is
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH A SINUS, NOSE, THROAT, LARYNX OR PHARYNX CONDITION?
the condition the veteran is claiming or for which an exam has been requested.)
(If "Yes," complete Item 1B)
YES
NO
(check all that apply)
1B. SELECT THE VETERAN'S CONDITION
CHRONIC SINUSITIS
ICD Code:
Date of diagnosis:
ALLERGIC RHINITIS
ICD Code:
Date of diagnosis:
NON-ALLERGIC RHINITIS
ICD Code:
Date of diagnosis:
BACTERIAL RHINITIS
ICD Code:
Date of diagnosis:
GRANULOMATOUS RHINITIS
ICD Code:
Date of diagnosis:
CHRONIC LARYNGITIS
ICD Code:
Date of diagnosis:
LARYNGECTOMY
ICD Code:
Date of diagnosis:
LARYNGEAL STENOSIS
ICD Code:
Date of diagnosis:
APHONIA
ICD Code:
Date of diagnosis:
(Traumatic)
DEVIATED NASAL SEPTUM
ICD Code:
Date of diagnosis:
(Describe):
PHARYNGEAL INJURY
ICD Code:
Date of diagnosis:
ICD Code:
Date of diagnosis:
BENIGN OR MALIGNANT NEOPLASM OF
SINUS, NOSE, THROAT, LARYNX OR
PHARYNX
ICD Code:
Date of diagnosis:
ANATOMICAL LOSS OF PART OF NOSE
(Complete VA Form 21-0960F-1, Scars/
Disfigurement Disability Benefits
Questionnaire in lieu of this questionnaire)
(specify)
OTHER
Other diagnosis #1
ICD Code:
Date of diagnosis:
Other diagnosis #2
ICD Code:
Date of diagnosis:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO THE SINUSES, NOSE, THROAT, LARYNX, OR PHARYNX CONDITION(S), LIST USING ABOVE FORMAT:
SECTION II - MEDICAL RECORD REVIEW
2. INDICATE MEDICAL RECORDS REVIEWED IN PREPARATION OF THIS REPORT:
C-FILE (VA ONLY)
OTHER, DESCRIBE:
SECTION III - MEDICAL HISTORY
(including onset and course)
3. DESCRIBE THE HISTORY
OF THE VETERAN'S SINUS, NOSE, THROAT, LARYNX, OR PHARYNX CONDITION:
VA FORM
SUPERSEDES VA FORM 21-0960N-4, MAR 2011,
Page 1
21-0960N-4
OCT 2012
WHICH WILL NOT BE USED.

ADVERTISEMENT

00 votes

Related Articles

5 Things You Need To Know About The Gi Bill Benefits
Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids

Related forms

Va Form 21-0960n-1 - Ear Conditions (including Vestibular And Infectious Conditions) Disability Benefits Questionnaire Va Form 21-0960n-1 - Ear Conditions (including Vestibular And Infectious Conditions) Disability Benefits Questionnaire Legal
Va Form 21-0960n-2 - Eye Conditions Disability Benefits Questionnaire Va Form 21-0960n-2 - Eye Conditions Disability Benefits Questionnaire Legal
Va Form 21-0960n-3 - Loss Of Sense Of Smell And/or Taste Disability Benefits Questionnaire Va Form 21-0960n-3 - Loss Of Sense Of Smell And/or Taste Disability Benefits Questionnaire Legal
Va Form 21-0960g-3 - Intestinal Conditions (other Than Surgical Or Infectious) (including Irritable Bowel Syndrome, Crohn's Disease, Ulcerative Colitis, And Diverticulitis) Disability Benefits Questionnaire Va Form 21-0960g-3 - Intestinal Conditions (other Than Surgical Or Infectious) (including Irritable Bowel Syndrome, Crohn's Disease, Ulcerative Colitis, And Diverticulitis) Disability Benefits Questionnaire Legal
Va Form 21-0960a-4 - Heart Conditions (including Ischemic And Non-ischemic Heart Disease, Arrhythmias, Valvular Disease And Cardiac Surgery) Disability Benefits Questionnaire Va Form 21-0960a-4 - Heart Conditions (including Ischemic And Non-ischemic Heart Disease, Arrhythmias, Valvular Disease And Cardiac Surgery) Disability Benefits Questionnaire Legal
Va Form 21-0960g-5 - Hepatitis, Cirrhosis And Other Liver Conditions Disability Benefits Questionnaire Va Form 21-0960g-5 - Hepatitis, Cirrhosis And Other Liver Conditions Disability Benefits Questionnaire Legal
Va Form 21-0960m-4 - Elbow And Forearm Conditions Disability Benefits Questionnaire Va Form 21-0960m-4 - Elbow And Forearm Conditions Disability Benefits Questionnaire Legal
Va Form 21-0960j-4 - Urinary Tract (including Bladder And Urethra) Conditions (excluding Male Reproductive System) Disability Benefits Questionnaire Va Form 21-0960j-4 - Urinary Tract (including Bladder And Urethra) Conditions (excluding Male Reproductive System) Disability Benefits Questionnaire Legal
Va Form 21-0960k-1 - Breast Conditions And Disorders Disability Benefits Questionnaire Va Form 21-0960k-1 - Breast Conditions And Disorders Disability Benefits Questionnaire Legal
Va Form 21-0960b-1 - Hairy Cell And Other B-cell Leukemias Disability Benefits Questionnaire Va Form 21-0960b-1 - Hairy Cell And Other B-cell Leukemias Disability Benefits Questionnaire Legal

Related Categories

Parent category: Legal
Download
Go
Page of 6