Va Form 21-0960i-3 - Infectious Diseases (Other Than Hiv-Related Illness, Chronic Fatigue Syndrome, Or Tuberculosis) Disability Benefits Questionnaire

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OMB Approved No. 2900-0781

Respondent Burden: 15 minutes

INFECTIOUS DISEASES (OTHER THAN HIV-RELATED ILLNESS, CHRONIC FATIGUE

SYNDROME, OR TUBERCULOSIS) 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 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.

NOTE - If the veteran has HIV-related illness, complete VA Form 21-0960I-2, if chronic fatigue syndrome complete VA Form 21-0960Q-1, or if tuberculosis complete

VA Form 21-0960I-6 in lieu of this questionnaire.

SECTION I - DIAGNOSIS

(This is the condition the veteran is claiming

1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH AN INFECTIOUS DISEASE?

or for which an exam has been requested)

(If "Yes," complete Item 1B)

YES

(Check all that apply):

1B. SELECT THE VETERAN'S CONDITION

MALARIA

ICD code:

Date of diagnosis:

ASIATIC CHOLERA

ICD code:

Date of diagnosis:

VISCERAL LEISHMANIASIS

ICD code:

Date of diagnosis:

(Hansen's disease)

LEPROSY

ICD code:

Date of diagnosis:

LYMPHATIC FILARIASIS

ICD code:

Date of diagnosis:

ICD code:

Date of diagnosis:

BARTONELLOSIS

PLAGUE

ICD code:

Date of diagnosis:

RELAPSING FEVER

ICD code:

Date of diagnosis:

RHEUMATIC FEVER

ICD code:

Date of diagnosis:

ENDOCARDITIS

ICD code:

Date of diagnosis:

SYPHILIS

ICD code:

Date of diagnosis:

BRUCELLOSIS

ICD code:

Date of diagnosis:

TYPHUS SCRUB

ICD code:

Date of diagnosis:

MELIOIDOSIS

ICD code:

Date of diagnosis:

LYME DISEASE

ICD code:

Date of diagnosis:

PARASITIC DISEASE, NOS

ICD code:

Date of diagnosis:

(specify):

OTHER

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 INFECTIOUS DISEASES, LIST USING ABOVE FORMAT:

NOTE - The diagnosis of malaria depends on the identification of the malarial parasites in blood smears. If the veteran served in an endemic area and presents signs and

symptoms compatible with malaria, the diagnosis may be based on clinical grounds alone. Relapses must be confirmed by the presence of malarial parasites in blood

smears.

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):

3. DESCRIBE THE HISTORY

OF THE VETERAN'S INFECTIOUS DISEASE CONDITION(S)

VA FORM

SUPERSEDES VA FORM 21-0960I-3, MAR 2011,