Va Form 21-0960n-1 - Ear Conditions (Including Vestibular And Infectious Conditions) Disability Benefits Questionnaire
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5OMB Control No. 2900-0778
Respondent Burden: 15 minutes
EAR CONDITIONS (INCLUDING VESTIBULAR AND INFECTIOUS
CONDITIONS) 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
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH AN EAR OR PERIPHERAL VESTIBULAR CONDITION?
(If "Yes," complete Item 1B)
YES
NO
1B. SELECT THE VETERAN'S CONDITION (check all that apply):
Meniere's syndrome or endolymphatic hydrops
ICD code:
Date of diagnosis:
Peripheral vestibular disorder
ICD code:
Date of diagnosis:
Benign Paroxysmal Positional Vertigo (BPPV)
ICD code:
Date of diagnosis:
Chronic otitis externa
ICD code:
Date of diagnosis:
Chronic suppurative otitis media
ICD code:
Date of diagnosis:
Chronic nonsuppurative otitis media (serous otitis media)
ICD code:
Date of diagnosis:
Mastoiditis
ICD code:
Date of diagnosis:
Cholesteatoma
ICD code:
Date of diagnosis:
(If the veteran has hearing loss or tinnitus attributable to any
ear condition, the VA regional office will schedule a hearing
loss or tinnitus exam, as appropriate)
Otosclerosis
ICD code:
Date of diagnosis:
(If the veteran has hearing loss or tinnitus attributable to any
ear condition, the VA regional office will schedule a hearing
loss or tinnitus exam, as appropriate)
Benign neoplasm of the ear (other than skin only)
ICD Code:
Date of Diagnosis:
Malignant neoplasm of the ear (other than skin only)
ICD Code:
Date of Diagnosis:
Other, specify:
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 EAR OR PERIPHERAL VESTIBULAR CONDITIONS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
(brief summary)
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S EAR OR PERIPHERAL VESTIBULAR CONDITIONS
:
2B. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING CONTINUOUS MEDICATION FOR THE DIAGNOSED CONDITION?
YES
NO
IF YES, LIST ONLY THOSE MEDICATIONS USED FOR THE DIAGNOSED CONDITION:
VA FORM
SUPERSEDES VA FORM 21-0960N-1, FEB 2011,
21-0960N-1
Page 1
OCT 2012
WHICH WILL NOT BE USED.
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