Va Form 21-0960i-3 - Infectious Diseases (Other Than Hiv-Related Illness, Chronic Fatigue Syndrome, Or Tuberculosis) Disability Benefits Questionnaire Page 2

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SECTION IV -STATUS, SYMPTOMS AND RESIDUALS

4A. COMPLETE THE FOLLOWING SECTION(S) FOR EACH OF THE VETERAN'S INFECTIOUS DISEASE CONDITION(S):

Disease #1:

A. Status of disease:

Active

Inactive

If "Inactive," date condition became inactive:

B. Does the veteran have symptoms attributable to disease #1?

Yes

If "Yes," describe:

C. Does the veteran have residuals attributable to disease #1?

Yes

If "Yes," describe:

NOTE: If the veteran has symptoms or residuals, ALSO complete the appropriate questionnaire for each symptomatic or residual condition

(such as Skin, Heart, Peripheral or Central Nervous System, Respiratory and appropriate Joint and Gastrointestinal Questionnaire)

Disease #2:

A. Status of disease:

Active

Inactive

If "Inactive," date condition became inactive:

B. Does the veteran have symptoms attributable to disease #2?

Yes

If "Yes," describe:

C. Does the veteran have residuals attributable to disease #2?

Yes

If "Yes," describe:

NOTE: If the veteran has symptoms or residuals, ALSO complete the appropriate questionnaire for each symptomatic or residual condition

(such as Skin, Heart, Peripheral or Central Nervous System, Respiratory and appropriate Joint and Gastrointestinal Questionnaire)

Disease #3:

A. Status of disease:

Active

Inactive

If "Inactive," date condition became inactive:

B. Does the veteran have symptoms attributable to disease #3?

Yes

If "Yes," describe:

C. Does the veteran have residuals attributable to disease #3?

Yes

If "Yes," describe:

NOTE: If the veteran has symptoms or residuals, ALSO complete the appropriate questionnaire for each symptomatic or residual condition

(such as Skin, Heart, Peripheral or Central Nervous System, Respiratory and appropriate Joint and Gastrointestinal Questionnaire)

4B. IF THE VETERAN HAS ANY ADDITIONAL INFECTIOUS DISEASE CONDITIONS, LIST AND DESCRIBE BY USING THE FORMAT SHOWN IN ITEM 4A.

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

(surgical or otherwise)

5A. DOES THE VETERAN HAVE ANY SCARS

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)?)

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

YES

5B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY

CONDITIONS LISTED IN SECTION I, DIAGNOSIS?

(If "Yes," describe (brief summary):

YES

Page 2

VA FORM 21-0960I-3, OCT 2012