Va Form 21-0960c-4 - Diabetic Sensory-Motor Peripheral Neuropathy Disability Benefits Questionnaire Page 5

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SECTION VII - DIAGNOSTIC TESTING

NOTE: For purposes of this examination, electromyography (EMG) studies are rarely required to diagnose diabetic peripheral neuropathy. The diagnosis of diabetic

peripheral neuropathy can be made in the appropriate clinical setting by a history of characteristic pain and/or sensory changes in a stocking/glove distribution and

objective clinical findings, which may include symmetrical lost/decreased reflexes, decreased strength, lost/decreased sensation for cold, vibration and/or position sense,

and/or lost/decreased sensation to monofilament testing.

7A. HAVE EMG STUDIES BEEN PERFORMED?

YES

(Extremities tested):

RIGHT UPPER EXTREMITY

Results:

Normal

Abnormal

Date:

LEFT UPPER EXTREMITY

Results:

Normal

Abnormal

Date:

RIGHT LOWER EXTREMITY

Results:

Normal

Abnormal

Date:

LEFT LOWER EXTREMITY

Results:

Normal

Abnormal

Date:

(If abnormal, describe):

7B. IF THERE ARE OTHER SIGNIFICANT FINDINGS OR DIAGNOSTIC TEST RESULTS, PROVIDE DATES AND DESCRIBE

SECTION VIII - FUNCTIONAL IMPACT

8. DOES THE VETERAN'S DIABETIC PERIPHERAL NEUROPATHY IMPACT HIS OR HER ABILITY TO WORK?

If "Yes," describe impact of the veteran's diabetic peripheral neuropathy, providing one or more examples:

YES

SECTION IX - REMARKS

9. REMARKS, if any

SECTION X - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.

10A. PHYSICIAN'S SIGNATURE

10B. PHYSICIAN'S PRINTED NAME

10C. DATE SIGNED

10D. PHYSICIAN'S PHONE AND FAX NUMBER

10E. PHYSICIAN'S MEDICAL LICENSE NUMBER

10F. PHYSICIAN'S ADDRESS

NOTE - VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.

IMPORTANT - Physician please fax the completed form to

(VA Regional Office FAX No.)

NOTE - A list of VA Regional Office FAX Numbers can be found at

or obtained by calling 1-800-827-1000.

PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of

Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the

United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel

administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the

Federal Register. Your obligation to respond is voluntary. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your

claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for

refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is

considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to

verification through computer matching programs with other agencies.

RESPONDENT BURDEN: We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this information. We estimate that

you will need an average of 30 minutes to review the instructions, find the information, and complete a form. VA cannot conduct or sponsor a collection of information unless a valid OMB

control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet

Page at If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

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VA FORM 21-0960C-4, OCT 2012