Va Form 21-0960a-2 - Artery And Vein Conditions (Vascular Diseases Including Varicose Veins) Disability Benefits Questionnaire Page 4

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SECTION VIII - ARTERIOVENOUS (AV) FISTULA, ANGIONEUROTIC EDEMA OR ERYTHROMELALGIA (Continued)

NOTE: Characteristic attack of erythromelalgia consists of burning pain in the hands, feet or both, usually bilateral and symmetrical, with increased skin

temperature and redness, occurring at warm ambient temperatures.

8F. DOES THE VETERAN HAVE ERYTHROMELALGIA?

(If "Yes," indicate severity and frequency of characteristic attacks):

YES

Does not restrict most routine daily activities

Restricts most routine daily activities

Occurs less than 3 times a week

Occurs at least 3 times a week

Occurs daily

Occurs more than once a day

Lasts an average of more than 2 hours each

Responds to treatment

Responds poorly to treatment

SECTION IX - MISCELLANEOUS ISSUES

9A. HAS THE VETERAN HAD AN AMPUTATION OF AN EXTREMITY DUE TO A VASCULAR CONDITION?

(If "Yes," ALSO complete VA Form 21-0960M-1, Amputations Disability Benefits Questionnaire)

YES

9B. DOES THE VETERAN USE ANY ASSISTIVE DEVICE(S) AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER

METHODS MAY BE POSSIBLE?

(If "Yes," identify assistive device(s) used.) (Check all that apply and indicate frequency):

YES

Wheelchair

Frequency of use:

Occasional

Regular

Constant

Brace(s)

Frequency of use:

Occasional

Regular

Constant

Crutch(es)

Frequency of use:

Occasional

Regular

Constant

Cane(s)

Frequency of use:

Occasional

Regular

Constant

Walker

Frequency of use:

Occasional

Regular

Constant

Other

Frequency of use:

Occasional

Regular

Constant

9C. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:

9D. DUE TO A VASCULAR CONDITION, IS THERE FUNCTIONAL IMPAIRMENT OF AN EXTREMITY SUCH THAT NO EFFECTIVE FUNCTION REMAINS OTHER THAN

(Functions of the upper extremity include grasping, manipulation, etc.,

THAT WHICH WOULD BE EQUALLY WELL SERVED BY AN AMPUTATION WITH PROSTHESIS?

while functions for the lower extremity include balance and propulsion, etc.)

YES, functioning is so diminished that amputation with prosthesis would equally serve the veteran.

(If "Yes," indicate extremity(ies.) (Check all extremities for which this applies):

Right upper

Right lower

Left upper

Left lower

9E. DESCRIBE LOSS OF EFFECTIVE FUNCTION FOR EACH EXTREMITY CHECKED, IDENTIFY THE CONDITION CAUSING LOSS OF FUNCTION AND PROVIDE

(Brief summary)

SPECIFIC EXAMPLES

SECTION X - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS

10A. DOES THE VETERAN HAVE ANY SCARS (SURGICAL OR OTHERWISE) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED

IN SECTION I, DIAGNOSIS?

YES

(If "Yes," are any of the scars painful and/or unstable, or is the total area of all related scars greater than or equal to 39 square cm (6 square inches)?)

YES

(If "Yes," ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)

VA FORM 21-0960A-2, OCT 2012

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