OMB Control No. 2900-0778
Respondent Burden: 15 minutes
HEADACHES (INCLUDING MIGRAINE HEADACHES)
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 THIS 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 A HEADACHE CONDITION?
(If "Yes," complete Item 1B)
YES
NO
(check all that apply):
1B. SELECT THE VETERAN'S CONDITION
Migraine including migraine variants
ICD Code:
Date of Diagnosis:
Tension
ICD Code:
Date of Diagnosis:
Cluster
ICD Code:
Date of Diagnosis:
(specify type of headache):
Other
ICD Code:
Date of Diagnosis:
Other Diagnosis #1:
ICD Code:
Date of Diagnosis:
Other Diagnosis #2:
ICD Code:
Date of Diagnosis:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO A HEADACHE CONDITION, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
(brief summary):
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S HEADACHE CONDITIONS
2B. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING MEDICATION FOR THE DIAGNOSED CONDITION?
(list only those medications used for the diagnosed condition):
YES
NO
IF YES, DESCRIBE TREATMENT
SECTION III - SYMPTOMS
3A. DOES THE VETERAN EXPERIENCE HEADACHE PAIN?
YES
NO
(If "Yes," check all that apply to headache pain):
Constant head pain
Pulsating or throbbing head pain
Pain localized to one side of the head
Pain on both sides of the head
Pain worsens with physical activity
Other, describe:
21-0960C-8
VA FORM
SUPERSEDES VA FORM 21-0960C-8, FEB 2011,
Page 1
OCT 2012
WHICH WILL NOT BE USED.