Va Form 21-0960n-1 - Ear Conditions (Including Vestibular And Infectious Conditions) Disability Benefits Questionnaire Page 4

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SECTION VII - TUMORS AND NEOPLASMS
7A. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES LISTED IN SECTION 1, DIAGNOSIS?
YES
NO
IF YES, COMPLETE THE FOLLOWING:
7B. IS THE NEOPLASM
BENIGN
MALIGNANT
7C. HAS THE VETERAN COMPLETED TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT NEOPLASM
OR METASTASES?
YES
NO; WATCHFUL WAITING
(check all that apply):
IF YES, INDICATE TYPE OF TREATMENT THE VETERAN IS CURRENTLY UNDERGOING OR HAS COMPLETED
Treatment completed; currently in watchful waiting status
Surgery
If checked, describe:
Date(s) of surgery:
Radiation therapy
Date of most recent treatment:
Date of completion of treatment or anticipated date of completion:
Antineoplastic chemotherapy
Date of most recent treatment:
Date of completion of treatment or anticipated date of completion:
Other therapeutic procedure
If checked, describe procedure:
Date of most recent procedure:
Other therapeutic treatment
If checked, describe treatment:
Date of completion of treatment or anticipated date of completion:
(including metastases)
7D. DOES THE VETERAN CURRENTLY HAVE ANY RESIDUAL CONDITIONS OR COMPLICATIONS DUE TO THE NEOPLASM
OR ITS
TREATMENT, OTHER THAN THOSE ALREADY DOCUMENTED IN THE REPORT ABOVE?
YES
NO
(brief summary):
IF YES, LIST RESIDUAL CONDITIONS AND COMPLICATIONS
7E. IF THERE ARE ADDITIONAL BENIGN OR MALIGNANT NEOPLASMS OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION 1, DIAGNOSIS,
DESCRIBE USING THE ABOVE FORMAT:
SECTION VIII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
(surgical or otherwise)
8A. DOES THE VETERAN HAVE ANY SCARS
RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
SECTION 1, DIAGNOSIS?
YES
NO
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)
?
YES
NO
IF YES, ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT DISABILITY BENEFITS QUESTIONNAIRE.
8B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN SECTION 1, DIAGNOSIS?
YES
NO
(brief summary):
IF YES, DESCRIBE
Page 4
VA FORM 21-0960N-1, OCT 2012

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