Va Form 21-0960a-2 - Artery And Vein Conditions (Vascular Diseases Including Varicose Veins) Disability Benefits Questionnaire Page 3

Download a blank fillable Va Form 21-0960a-2 - Artery And Vein Conditions (Vascular Diseases Including Varicose Veins) Disability Benefits Questionnaire in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Va Form 21-0960a-2 - Artery And Vein Conditions (Vascular Diseases Including Varicose Veins) Disability Benefits Questionnaire with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

SECTION VII - RAYNAUD'S SYNDROME (Continued)
NOTE: Characteristic attacks consist of sequential color changes of the digits of one or more extremities lasting minutes to hours, sometimes with pain
and paresthesias, and precipitated by exposure to cold or by emotional upsets.
7B. DOES THE VETERAN HAVE CHARACTERISTIC ATTACKS?
(If "Yes," indicate frequency of characteristic attacks):
YES
NO
Less than once a week
1 to 3 times a week
4 to 6 times a week
At least daily
7C. DOES THE VETERAN HAVE TWO OR MORE DIGITAL ULCERS?
YES
NO
7D. DOES THE VETERAN HAVE AUTOAMPUTATION OF ONE OR MORE DIGITS?
YES
NO
SECTION VIII - ARTERIOVENOUS (AV) FISTULA, ANGIONEUROTIC EDEMA OR ERYTHROMELALGIA
8A. DOES THE VETERAN HAVE ARTERIOVENOUS (AV) FISTULA, ANGIONEUROTIC EDEMA OR ERYTHROMELALGIA?
(If "Yes," complete Items 8B through 8D)
YES
NO
8B. DOES THE VETERAN HAVE A TRAUMATIC ARTERIOVENOUS (AV) FISTULA?
(If "Yes," indicate site of traumatic fistula):
YES
NO
Right upper extremity
Right lower extremity
Left upper extremity
Left lower extremity
(Specify)
Other location,
:
8C. INDICATE FINDINGS:
Edema
Stasis dermatitis
Ulceration
Cellulitis
Enlarged heart
Wide pulse pressure
Tachycardia
High output heart failure
8D. IS THERE MORE THAN ONE TRAUMATIC AV FISTULA?
(If "Yes," provide location and findings for each):
YES
NO
8E. DOES THE VETERAN HAVE ANGIONEUROTIC EDEMA?
(If "Yes," indicate severity and frequency of characteristic attacks):
YES
NO
Without laryngeal involvement
With laryngeal involvement
Lasts 1 to 7 days
Lasts longer than 7 days
Occurs once a year or less
Occurs 1 to 2 times a year
Occurs 2 to 4 times a year
Occurs 5 to 8 times a year
Occurs more than 8 times a year
VA FORM 21-0960A-2, OCT 2012
Page 3

ADVERTISEMENT

00 votes

Related Articles

5 Things You Need To Know About The Gi Bill Benefits
Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids

Related forms

Va Form 21-0960b-2 - Hematologic And Lymphatic Conditions, Including Leukemia Disability Benefits Questionnaire Va Form 21-0960b-2 - Hematologic And Lymphatic Conditions, Including Leukemia Disability Benefits Questionnaire Legal
Va Form 21-0960h-2 - Rectum And Anus Conditions (including Hemorrhoids) Disability Benefits Questionnaire Va Form 21-0960h-2 - Rectum And Anus Conditions (including Hemorrhoids) Disability Benefits Questionnaire Legal
Va Form 21-0960g-2 - Gallbladder And Pancreas Conditions Disability Benefits Questionnaire Va Form 21-0960g-2 - Gallbladder And Pancreas Conditions Disability Benefits Questionnaire Legal
Va Form 21-0960d-1 - Oral And Dental Conditions Including Mouth, Lips And Tongue (other Than Temporomandibular Joint Conditions) Disability Benefits Questionnaire Va Form 21-0960d-1 - Oral And Dental Conditions Including Mouth, Lips And Tongue (other Than Temporomandibular Joint Conditions) Disability Benefits Questionnaire Legal
Va Form 21-0960g-7 - Stomach And Duodenal Conditions (not Including Gerd Or Esophageal Disorders) Disability Benefits Questionnaire Va Form 21-0960g-7 - Stomach And Duodenal Conditions (not Including Gerd Or Esophageal Disorders) Disability Benefits Questionnaire Legal
Va Form 21-0960j-2 - Male Reproductive Organ Conditions Disability Benefits Questionnaire Va Form 21-0960j-2 - Male Reproductive Organ Conditions Disability Benefits Questionnaire Legal
Va Form 21-0960e-3 - Thyroid And Parathyroid Conditions Disability Benefits Questionnaire Va Form 21-0960e-3 - Thyroid And Parathyroid Conditions Disability Benefits Questionnaire Legal
Va Form 21-0960m-4 - Elbow And Forearm Conditions Disability Benefits Questionnaire Va Form 21-0960m-4 - Elbow And Forearm Conditions Disability Benefits Questionnaire Legal
Va Form 21-0960m-8 - Hip And Thigh Conditions Disability Benefits Questionnaire Va Form 21-0960m-8 - Hip And Thigh Conditions Disability Benefits Questionnaire Legal
Va Form 21-0960m-7 - Hand And Finger Conditions Disability Benefits Questionnaire Va Form 21-0960m-7 - Hand And Finger Conditions Disability Benefits Questionnaire Legal

Related Categories

Parent category: Legal
Download
Go
Page of 5