Va Form 21-0960m-3 - Non-Degenerative Arthritis (Including Inflammatory, Autoimmune, Crystalline And Infectious Arthritis) And Dysbaric Osteonecrosis Disability Benefits Questionnaire
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5OMB Approved No. 2900-0778
Respondent Burden: 15 minutes
NON-DEGENERATIVE ARTHRITIS (INCLUDING INFLAMMATORY, AUTOIMMUNE,
CRYSTALLINE AND INFECTIOUS ARTHRITIS) AND DYSBARIC OSTEONECROSIS
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.
NOTE: Complete this Questionnaire if the veteran has an inflammatory, autoimmune, crystalline or infectious arthritis, or dysbaric osteonecrosis (Caisson disease of
bone).
If the veteran has degenerative arthritis (osteoarthritis) or traumatic arthritis, do not complete this Questionnaire, INSTEAD complete the joint Questionnaire for the
affected area (e.g., if the diagnosis is osteoarthritis of the knee, complete VA Form 21-0960M-9, Knee and Lower Leg Disability Benefits Questionnaire).
If the veteran has arthritis due to systemic lupus erythematosus (SLE), INSTEAD complete the VA Form 21-0960I-4, Systemic Lupus Erythematosus (SLE) and Other
Autoimmune Diseases Disability Benefits Questionnaire.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH INFLAMMATORY, AUTOIMMUNE, CRYSTALLINE OR INFECTIOUS
(Caisson disease)
ARTHRITIS OR DYSBARIC OSTEONECROSIS
?
(If "Yes," complete Item 1B)
YES
NO
1B. INDICATE THE DIAGNOSIS:
GOUT
ICD CODE(S):
DATE OF DIAGNOSIS:
(atrophic)
RHEUMATOID ARTHRITIS
ICD CODE(S):
DATE OF DIAGNOSIS:
GONORRHEAL ARTHRITIS
ICD CODE(S):
DATE OF DIAGNOSIS:
PNEUMOCOCCIC ARTHRITIS
ICD CODE(S):
DATE OF DIAGNOSIS:
TYPHOID ARTHRITIS
ICD CODE(S):
DATE OF DIAGNOSIS:
SYPHILITIC ARTHRITIS
ICD CODE(S):
DATE OF DIAGNOSIS:
STREPTOCOCCIC ARTHRITIS
ICD CODE(S):
DATE OF DIAGNOSIS:
(Caisson Disease of Bone)
DYSBARIC OSTEONECROSIS
ICD CODE(S):
DATE OF DIAGNOSIS:
OTHER
IF CHECKED, PROVIDE ONLY DIAGNOSES THAT PERTAIN TO INFLAMMATORY, AUTOIMMUNE, CRYSTALLINE OR INFECTIOUS ARTHRITIS:
OTHER DIAGNOSIS #1:
ICD CODE:
DATE OF DIAGNOSIS:
OTHER DIAGNOSIS #2:
ICD CODE:
DATE OF DIAGNOSIS:
OTHER DIAGNOSIS #3:
ICD CODE:
DATE OF DIAGNOSIS:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO INFLAMMATORY, AUTOIMMUNE, CRYSTALLINE OR INFECTIOUS ARTHRITIS, LIST USING ABOVE
FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
2A. DESCRIBE HISTORY
OF THE VETERAN'S INFLAMMATORY, AUTOIMMUNE, CRYSTALLINE OR INFECTIOUS ARTHRITIS OR
(brief summary):
DYSBARIC OSTEONECROSIS
2B. DOES THE VETERAN REQUIRE CONTINUOUS USE OF MEDICATION FOR THIS ARTHRITIS CONDITION?
YES
NO
IF YES, LIST ONLY THOSE MEDICATIONS USED FOR THIS ARTHRITIS:
2C. HAS THE VETERAN LOST WEIGHT DUE TO THIS ARTHRITIS CONDITION?
YES
NO
(average weight for 2-year period preceding onset of disease):
IF YES, PROVIDE BASELINE WEIGHT
, AND CURRENT WEIGHT
IF YES, DOES THE VETERAN'S WEIGHT LOSS ATTRIBUTABLE TO THIS ARTHRITIS CONDITION CAUSE IMPAIRMENT OF HEALTH?
YES
NO
IF YES, DESCRIBE THE IMPAIRMENT:
21-0960M-3
VA FORM
SUPERSEDES VA FORM 21-0960M-3, FEB 2011,
Page 1
OCT 2012
WHICH WILL NOT BE USED.
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