Va Form 21-0960c-4 - Diabetic Sensory-Motor Peripheral Neuropathy Disability Benefits Questionnaire

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OMB Control No. 2900-0776
Respondent Burden: 30 minutes
DIABETIC SENSORY-MOTOR PERIPHERAL NEUROPATHY
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
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH DIABETIC PERIPHERAL NEUROPATHY?
(If "Yes," complete Item 1B)
YES
NO
1B. PROVIDE DIAGNOSES THAT PERTAIN TO DIABETIC PERIPHERAL NEUROPATHY:
DIAGNOSIS # 1 -
ICD CODE -
DATE OF DIAGNOSIS -
DIAGNOSIS # 2 -
ICD CODE -
DATE OF DIAGNOSIS -
DIAGNOSIS # 3 -
ICD CODE -
DATE OF DIAGNOSIS -
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO DIABETIC PERIPHERAL NEUROPATHY, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
2A. DOES THE VETERAN HAVE DIABETES MELLITUS TYPE I OR TYPE II?
YES
NO
(including cause, onset and course)
2B. DESCRIBE THE HISTORY
OF THE VETERAN'S DIABETIC PERIPHERAL NEUROPATHY
2C. DOMINANT HAND
RIGHT
LEFT
AMBIDEXTROUS
SECTION III - SYMPTOMS
3. DOES THE VETERAN HAVE ANY SYMPTOMS ATTRIBUTABLE TO DIABETIC PERIPHERAL NEUROPATHY?
(If "Yes," indicate symptoms' location and severity) (Check all that apply):
YES
NO
(may be excruciating at times)
CONSTANT PAIN
:
RIGHT UPPER EXTREMITY
None
Mild
Moderate
Severe
:
LEFT UPPER EXTREMITY
None
Mild
Moderate
Severe
:
RIGHT LOWER EXTREMITY
None
Mild
Moderate
Severe
:
LEFT LOWER EXTREMITY
None
Mild
Moderate
Severe
(usually dull)
INTERMITTENT PAIN
:
RIGHT UPPER EXTREMITY
None
Mild
Moderate
Severe
:
LEFT UPPER EXTREMITY
None
Mild
Moderate
Severe
:
None
Mild
Moderate
Severe
RIGHT LOWER EXTREMITY
:
LEFT LOWER EXTREMITY
None
Mild
Moderate
Severe
VA FORM
SUPERSEDES VA FORM 21-0960C-4, JAN 2011,
21-0960C-4
Page 1
OCT 2012
WHICH WILL NOT BE USED.

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