Va Form 21-0960n-4 - Sinusitis/rhinitis And Other Conditions Of The Nose, Throat, Larynx And Pharynx Disability Benefits Questionnaire Page 3
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6(Continued)
SECTION IV - NOSE, THROAT, LARYNX OR PHARYNX CONDITIONS
(Continued)
PART B - RHINITIS
B5. DOES THE VETERAN HAVE ANY OF THE FOLLOWING GRANULOMATOUS CONDITIONS?
(If "Yes," check all that apply)
YES
NO
Granulomatous rhinitis
Rhinoscleroma
Wegener's granulomatosis
Lethal midline granuloma
(Describe):
Other granulomatous infection
PART C - LARYNX AND PHARYNX CONDITIONS
C1. DOES THE VETERAN HAVE CHRONIC LARYNGITIS?
YES
NO
(If "Yes," does the veteran have any of the following symptoms due to chronic laryngitis?)
(If "Yes," check all that apply)
YES
NO
(If checked, describe frequency):
Hoarseness
Inflammation of vocal cords or mucous membrane
Thickening or nodules of vocal chords
Submucous infiltration of vocal chords
Vocal chord polyps
(describe):
Other
C2. HAS THE VETERAN HAD A LARYNGECTOMY?
(If "Yes," specify)
YES
NO
Total laryngectomy
Partial laryngectomy
(If checked, does the veteran have any residuals of the partial laryngectomy?)
YES
NO
(If "Yes," describe):
(unilateral or bilateral)?
C3. DOES THE VETERAN HAVE LARYNGEAL STENOSIS, INCLUDING RESIDUALS OF LARYNGEAL TRAUMA
(If "Yes," assess for upper airway obstruction with pulmonary function testing to include Flow-Volume Loop, and provide results in Section V,
YES
NO
Diagnostic Testing)
C4. DOES THE VETERAN HAVE COMPLETE ORGANIC APHONIA?
(If "Yes," check all that apply)
YES
NO
Constant inability to speak above a whisper
Constant inability to communicate by speech
(describe):
Other
C5. DOES THE VETERAN HAVE INCOMPLETE ORGANIC APHONIA?
(If "Yes," check all that apply)
YES
NO
(If checked, describe frequency):
Hoarseness
Inflammation of vocal cords or mucous membrane
Thickening or nodules of vocal chords
Submucous infiltration of vocal chords
Vocal chord polyps
(describe):
Other
C6. HAS THE VETERAN HAD A PERMANENT TRACHEOSTOMY?
(If "Yes," describe reason for tracheostomy and potential for decannulation):
YES
NO
C7. HAS THE VETERAN HAD AN INJURY TO THE PHARYNX?
(If "Yes," check all findings, signs and symptoms that apply):
YES
NO
Stricture or obstruction of the pharynx or nasopharynx
Absence of the soft palate secondary to trauma
Absence of the soft palate secondary to chemical burn
Absence of the soft palate secondary to granulomatous disease
Paralysis of the soft palate with swallowing difficulty (nasal regurgitation) and speech impairment
(describe):
Other
C8. DOES THE VETERAN HAVE VOCAL CHORD PARALYSIS OR ANY OTHER PHARYNGEAL OR LARYNGEAL CONDITIONS?
(If "Yes," describe):
YES
NO
Page 3
VA FORM 21-0960N-4, OCT 2012
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