Va Form 21-0960c-9 - Multiple Sclerosis (Ms) Disability Benefits Questionnaire Page 2
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SECTION III - CONDITIONS, SIGNS AND SYMPTOMS DUE TO MS
3D. DOES THE VETERAN HAVE SLEEP DISTURBANCES ATTRIBUTABLE TO MS?
YES
NO
(If "Yes," check all that apply):
Insomnia
Hypersomnolence and/or daytime “sleep attacks "
Persistent daytime hypersomnolence
(CPAP)
Sleep apnea requiring the use of breathing assistance device such as continuous airway pressure
machine
Sleep apnea causing chronic respiratory failure with carbon dioxide retention or cor pulmonale
Sleep apnea requiring tracheostomy
3E. DOES THE VETERAN HAVE ANY BOWEL FUNCTIONAL IMPAIRMENT ATTRIBUTABLE TO MS?
YES
NO
(If "Yes," check all that apply):
Slight impairment of sphincter control, without leakage
Constant slight leakage
Occasional moderate leakage
Occasional involuntary bowel movements, necessitating wearing of a pad
Extensive leakage and fairly frequent involuntary bowel movements
Total loss of bowel sphincter control
Chronic constipation
(describe):
Other bowel impairment
3F. DOES THE VETERAN HAVE VOIDING DYSFUNCTION CAUSING URINE LEAKAGE ATTRIBUTABLE TO MS?
YES
NO
(If "Yes," check all that apply):
Does not require/does not use absorbent material
Requires absorbent material that is changed less than 2 times per day
Requires absorbent material that is changed 2 to 4 times per day
Requires absorbent material that is changed more than 4 times per day
3G. DOES THE VETERAN HAVE VOIDING DYSFUNCTION CAUSING URINARY FREQUENCY ATTRIBUTABLE TO MS?
YES
NO
(If "Yes," check all that apply):
Daytime voiding interval between 2 and 3 hours
Daytime voiding interval between 1 and 2 hours
Daytime voiding interval less than 1 hour
Nighttime awakening to void 2 times
Nighttime awakening to void 3 to 4 times
Nighttime awakening to void 5 or more times
3H. DOES THE VETERAN HAVE VOIDING DYSFUNCTION CAUSING OBSTRUCTED VOIDING ATTRIBUTABLE TO MS?
YES
NO
(If "Yes," check all signs and symptoms that apply):
Hesitancy
(If checked, is hesitancy marked?)
YES
NO
Slow or weak stream
(If checked, is stream markedly slow or weak?)
YES
NO
Decreased force of stream
(If checked, is force of stream markedly decreased?)
YES
NO
Stricture disease requiring dilatation 1 to 2 times per year
Stricture disease requiring periodic dilatation every 2 to 3 months
Recurrent urinary tract infections secondary to obstruction
Uroflowmetry peak flow rate less than 10 cc/sec
Post void residuals greater than 150 cc
Urinary retention requiring intermittent or continuous catheterization
Page 2
VA FORM 21-0960C-9, OCT 2012
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