Va Form 21-0960c-9 - Multiple Sclerosis (Ms) Disability Benefits Questionnaire Page 6

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SECTION VI - MENTAL HEALTH MANIFESTATIONS DUE TO MULTIPLE SCLEROSIS OR ITS TREATMENT

6A. DOES THE VETERAN HAVE SIGNS OR SYMPTOMS OF DEPRESSION, COGNITIVE IMPAIRMENT OR DEMENTIA, OR ANY OTHER MENTAL HEALTH CONDITIONS

ATTRIBUTABLE TO MS AND/OR ITS TREATMENT?

(If "Yes," briefly describe):

YES

(If "Yes," also complete VA Form 21-0960P-2, Mental Disorders (other than PTSD and Eating Disorders) Disability Benefits Questionnaire and schedule with

appropriate provider)

6B. DOES THE VETERAN'S MENTAL DISORDER(S), AS IDENTIFIED IN ITEM 6A, RESULT IN GROSS IMPAIRMENT IN THOUGHT PROCESSES OR COMMUNICATION?

YES

(If "No," also complete VA Form 21-0960P-2, Mental Disorders (other than PTSD and Eating Disorders) Disability Benefits Questionnaire and schedule with

appropriate provider).

(If "Yes," briefly describe the signs and symptoms of the veteran's mental disorder):

SECTION VII - HOUSEBOUND

(or if institutionalized, to the ward or clinical areas)?

7A. IS THE VETERAN SUBSTANTIALLY CONFINED TO HIS OR HER DWELLING AND THE IMMEDIATE PREMISES

YES

(If "Yes," describe how often per day or week and under what circumstances the veteran is able to leave the home or immediate premises):

7B. IF YES, DOES THE VETERAN HAVE MORE THAN ONE CONDITION CONTRIBUTING TO HIS OR HER BEING HOUSEBOUND?

(If "Yes," list conditions and describe how each condition contributes to causing the veteran to be housebound)

YES

PROVIDE CONDITIONS AND DESCRIBE HOW EACH CONDITION CONTRIBUTES TO THE VETERAN BEING HOUSEBOUND

CONDITION # 1 -