Va Form 21-0960n-1 - Ear Conditions (Including Vestibular And Infectious Conditions) Disability Benefits Questionnaire Page 3

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SECTION V - SURGICAL TREATMENT
5A. HAS THE VETERAN HAD SURGICAL TREATMENT FOR ANY EAR CONDITION?
YES
NO
IF YES, INDICATE TYPE OF SURGERY:
Date:
Side affected:
Right
Left
Both
5B. DOES THE VETERAN HAVE ANY RESIDUALS AS A RESULT OF THE SURGERY?
YES
NO
IF YES, DESCRIBE:
SECTION VI - PHYSICAL EXAM
6A. EXTERNAL EAR:
Exam of external ear not indicated
Normal
Deformity of auricle, with loss of less than one-third of the substance
If checked, specify side:
Right
Left
Deformity of auricle, with loss of one-third or more of the substance
If checked, specify side:
Right
Left
Complete loss of auricle
If checked, specify side:
Right
Left
Other abnormality, describe:
6B. EAR CANAL:
Exam of ear canal not indicated
Normal
Abnormal, describe:
6C. TYMPANIC MEMBRANE:
Exam of tympanic membrane not indicated
Normal
Perforated tympanic membrane
If checked, specify side affected:
Right
Left
Evidence of a healed tympanic membrane perforation
If checked, specify side affected:
Right
Left
Other abnormality, describe:
6D. GAIT:
Exam of gait not indicated
Normal
Unsteady, describe:
Other abnormality, describe:
6E. ROMBERG TEST:
Exam using this test not indicated
Normal or negative
Abnormal or positive for unsteadiness
(Nylen-Barany test)
6F. DIX HALLPIKE TEST
FOR VERTIGO:
Exam using this test not indicated
Normal, no vertigo or nystagmus during test
Abnormal, vertigo or nystagmus during test, describe:
(finger-nose-finger):
6G. LIMB COORDINATION TEST
Exam using this test not indicated
Normal
Abnormal, describe:
Page 3
VA FORM 21-0960N-1, OCT 2012

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