Va Form 21-0960c-6 - Narcolepsy Disability Benefits Questionnaire
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2OMB Approved No. 2900-0781
Respondent Burden: 15 minutes
NARCOLEPSY 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.
SECTION I - DIAGNOSIS
(This is the condition the veteran is claiming or for which an
1A. DOES THE VETERAN HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH NARCOLEPSY?
exam has been requested)
(If "Yes," complete Item 1B)
YES
NO
(check all that apply):
1B. DIAGNOSES
NARCOLEPSY
ICD code:
Date of diagnosis:
(specify):
OTHER
Other diagnosis #1:
ICD code:
Date of diagnosis:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO NARCOLEPSY, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL RECORD REVIEW
2. INDICATE MEDICAL RECORDS REVIEWED IN PREPARATION OF THIS REPORT:
C-FILE (VA ONLY)
OTHER, DESCRIBE:
SECTION III - MEDICAL HISTORY
(including onset and course)
(brief summary)
3A. DESCRIBE THE HISTORY
OF THE VETERAN'S NARCOLEPSY
:
3B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF NARCOLEPSY?
(If "Yes," list only those medications required for the veteran's narcolepsy):
YES
NO
SECTION IV- FINDINGS, SIGNS AND SYMPTOMS
4A. DOES THE VETERAN HAVE A CONFIRMED DIAGNOSIS OF NARCOLEPSY?
(If "Yes," complete Items 4A & 4B)
YES
NO
4B. DOES THE VETERAN REPORT ANY OF THE FOLLOWING FINDINGS, SIGNS OR SYMPTOMS?
YES
NO
(If "Yes," check all that apply):
Excessive daytime sleepiness
(strong urge to sleep followed by short nap)
Sleep attacks
(sudden loss of muscle tone while awake, resulting in brief inability to move)
Cataplexy
(inability to move on first awakening)
Sleep paralysis
Sleep onset/sleep offset hallucinations
Other
(For all checked conditions in item 4B, provide a description below):
(check all that apply):
4C. INDICATE FREQUENCY OF CATAPLECTIC (NARCOLEPTIC) EPISODES
Number of cataplectic (narcoleptic) episodes over past 6 months
0-1
2 or more
(If 2 or more over the past 6 months, indicate the "average frequency" of narcoleptic episodes):
0-4 per week
5-8 per week
9-10 per week
More than 10 per week
(If the Veteran has cataplectic (narcoleptic) episodes, provide a description below):
VA FORM
SUPERSEDES VA FORM 21-0960C-6, MAR 2011,
Page 1
21-0960C-6
OCT 2012
WHICH WILL NOT BE USED.
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