Va Form 21-0960n-4 - Sinusitis/rhinitis And Other Conditions Of The Nose, Throat, Larynx And Pharynx Disability Benefits Questionnaire Page 5

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SECTION V - DIAGNOSTIC TESTING
NOTE - If testing has been performed and reflects the veteran's current condition, repeat testing is not required. Specific diagnostic testing is not required for many
conditions, but if performed, record in this section.
5A. HAVE IMAGING STUDIES OF THE SINUSES OR OTHER AREAS BEEN PERFORMED?
YES
NO
(If "Yes," check all that apply)
(MRI)
Magnetic resonance imaging
Date:
Results:
(CT)
Computed tomography
Date:
Results:
X-rays:
Date:
Results:
Other:
Date:
Results:
5B. HAS ENDOSCOPY BEEN PERFORMED?
YES
NO
(If "Yes," check all that apply):
Nasal endoscopy
Date:
Results:
Laryngeal endoscopy
Date:
Results:
Bronchoscopy
Date:
Results:
Other endoscopy
Date:
Results:
5C. HAS THE VETERAN HAD A BIOPSY OF THE LARYNX OR PHARYNX?
YES
NO
(If "Yes," complete the following):
Site of biopsy:
Date:
Results:
Benign
Pre-malignant
Malignant
Describe results:
5D. HAS THE VETERAN HAD PULMONARY FUNCTION TESTING TO ASSESS FOR UPPER AIRWAY OBSTRUCTION DUE TO LARYNGEAL STENOSIS?
YES
NO
(If "Yes," indicate results)
FEV-1 of 71 to 80% predicted
FEV-1 of 56 to 70% predicted
FEV-1 of 40 to 55% predicted
FEV-1 less than 40% predicted
(Is the Flow-Volume Loop compatible with upper airway obstruction?)
YES
NO
5E. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES
NO
(If "Yes," provide type of test or procedure, date and results (brief summary)):
Page 5
VA FORM 21-0960N-4, OCT 2012

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