Va Form 21-0960n-2 - Eye Conditions Disability Benefits Questionnaire

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OMB Approved No. 2900-XXXX

Respondent Burden: 45 minutes

EYE 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

ON REVERSE 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. This report is not for treatment purposes; it is to provide a summary of medical

information for disability claims resolution.

NOTE: This examination must be conducted by a licensed ophthalmologist or by a licensed optometrist. The examiner must identify the disease, injury or other

pathologic process responsible for any decrease in visual acuity or other visual impairment found. Examinations of visual fields or muscle function should be conducted

ONLY when there is a medical indication of disease or injury that may be associated with visual field defect or impaired muscle function. Unless medically

contraindicated, the funds must be examined with the veteran's pupils dilated.

SECTION I - DIAGNOSIS

NOTE: The diagnosis section should be filled out AFTER the clinician has completed the examination.

(other than congenital or developmental errors of

1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH AN EYE CONDITION

refraction)

(If "Yes," provide only diagnosis that pertain to eye conditions:)

YES

DIAGNOSIS # 1 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 2 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 3 -

ICD CODE -

DATE OF DIAGNOSIS -

1B. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO EYE CONDITIONS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY

(including onset and course)

(Brief summary):

2. DESCRIBE THE HISTORY

OF THE VETERAN'S CURRENT EYE CONDITION(S)

SECTION III - PHYSICAL EXAMINATION

1. VISUAL ACUITY

Visual acuity should be reported according to the lines on the Snellen chart or its equivalent. If assessment of the veteran's visual acuity falls between two lines on the

Snellen chart, round up to the higher (worse) level (poorer vision) for answers a-d below. (For example, 20/60 would be reported as 20/70; 20/80 would be reported as

20/100. etc.)

Examination of visual acuity must include central uncorrected and corrected visual acuity for distance and near vision. Evaluate visual acuity on the basis of corrected

distance vision with central fixation. Visual acuity should not be determined with eccentric fixation or viewing.

a. Uncorrected distance:

RIGHT:

5/200

20/400

15/200

20/200

20/100

20/70

20/50

20/40 or better

LEFT: