Va Form 21-0960n-1 - Ear Conditions (Including Vestibular And Infectious Conditions) Disability Benefits Questionnaire Page 2
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5SECTION III - VESTIBULAR CONDITIONS
3. DOES THE VETERAN HAVE ANY OF THE FOLLOWING FINDINGS, SIGNS, OR SYMPTOMS ATTRIBUTABLE TO MENIERE'S SYNDROME (ENDOLYMPHATIC
HYDROPS), A PERIPHERAL VESTIBULAR CONDITION OR ANOTHER DIAGNOSED CONDITION FROM SECTION 1, DIAGNOSIS?
YES
NO
IF YES, CHECK ALL THAT APPLY:
Hearing impairment with vertigo
If checked, indicate frequency:
Less than once a month
1 to 4 times per month
More than once weekly
Indicate duration of episodes:
< 1 hour
1 to 24 hours
> 24 hours
Hearing impairment with attacks of vertigo and cerebellar gait
If checked, indicate frequency:
Less than once a month
1 to 4 times per month
More than once weekly
Indicate duration of episodes:
< 1 hour
1 to 24 hours
> 24 hours
Tinnitus, unilateral or bilateral
If checked, indicate frequency:
Less than once a month
1 to 4 times per month
More than once weekly
Indicate duration of episodes:
< 1 hour
1 to 24 hours
> 24 hours
Vertigo
If checked, indicate frequency:
Less than once a month
1 to 4 times per month
More than once weekly
Indicate duration of episodes:
< 1 hour
1 to 24 hours
> 24 hours
Staggering
If checked, indicate frequency:
Less than once a month
1 to 4 times per month
More than once weekly
Indicate duration of episodes:
< 1 hour
1 to 24 hours
> 24 hours
Hearing impairment and/or tinnitus
If checked, the VA regional office will schedule a hearing loss or tinnitus exam as appropriate.
Other, describe:
SECTION IV - INFECTIOUS, INFLAMMATORY AND OTHER EAR CONDITIONS
4A. DOES THE VETERAN HAVE ANY OF THE FOLLOWING FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO CHRONIC EAR INFECTION, INFLAMMATION,
CHOLESTEATOMA OR ANY OF THE DIAGNOSES LISTED IN SECTION 1, DIAGNOSIS?
YES
NO
IF YES, CHECK ALL THAT APPLY:
(external ear canal)
Swelling
If checked, describe:
(external ear canal)
Dry and scaly
(external ear canal)
Serous discharge
(external ear canal)
Itching
Effusion
Active suppuration
Aural polyps
Hearing impairment and/or tinnitus
If checked, the VA regional office will schedule a hearing loss or tinnitus exam as appropriate.
Facial nerve paralysis
If checked, ALSO complete Cranial Nerves Questionnaire.
Bone loss of skull
If checked, indicate severity:
(4.619 cm2)
Area lost smaller than an American quarter
Area lost larger than an American quarter but smaller than a 50-cent piece
(7.355 cm2)
Area lost larger than an American 50-cent piece
Requiring frequent and prolonged treatment
If checked, describe type and durations of treatment:
Other, describe:
(other than skin only, such as keloid)
4B. DOES THE VETERAN HAVE A BENIGN NEOPLASM OF THE EAR
THAT CAUSES ANY IMPAIRMENT OF FUNCTION?
YES
NO
IF YES, DESCRIBE IMPAIRMENT OF FUNCTION CAUSED BY THIS CONDITION:
Page 2
VA FORM 21-0960N-1, OCT 2012
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