Va Form 21-0960i-1 - Persian Gulf And Afghanistan Infectious Diseases Disability Benefits Questionnaire Page 2

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SECTION III - MEDICAL HISTORY FOR DISEASE #2

3B. STATUS OF DISEASE #2:

ACTIVE

INACTIVE/TREATED AND RESOLVED

3C. IF INACTIVE, DATE DISEASE BECAME INACTIVE/RESOLVED:

3D. IF INACTIVE/RESOLVED, ARE THERE RESIDUALS DUE TO THE DISEASE?

(If "Yes," describe residuals):

YES

(Also complete appropriate Questionnaire for each specific residual condition, if indicated.)

SECTION IV - MEDICAL HISTORY FOR DISEASE #3

4A. NAME OF DISEASE #3:

(including onset and course)

DESCRIBE HISTORY

OF THE VETERAN'S DISEASE #3:

4B. STATUS OF DISEASE #3:

ACTIVE

INACTIVE/TREATED AND RESOLVED

4C. IF INACTIVE, DATE DISEASE BECAME INACTIVE/RESOLVED:

4D. IF INACTIVE/RESOLVED, ARE THERE RESIDUALS DUE TO THE DISEASE?

(If "Yes," describe residuals):

YES

(Also complete appropriate Questionnaire for each specific residual condition, if indicated.)

SECTION V - ADDITIONAL GULF WAR INFECTIOUS DISEASES

5. IF THE VETERAN HAS HAD ANY ADDITIONAL GULF WAR INFECTIOUS DISEASES, DESCRIBE USING ABOVE FORMAT:

SECTION VI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, SIGNS AND/OR SYMPTOMS

6A. DOES THE VETERAN HAVE ANY SCARS (SURGICAL OR OTHERWISE) 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

6B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS?

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

YES

SECTION VII - DIAGNOSTIC TESTING

NOTE: If the veteran has had diagnostic testing for suspected or confirmed Gulf War infectious diseases and the results are in the medical record and reflect the

veteran's current status, repeat testing is not indicated.

7. ARE THERE ANY SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?

(If "Yes," provide type of test or procedure, date and results (brief summary)):

YES

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VA FORM 21-0960I-1, OCT 2012