Va Form 21-0960n-2 - Eye Conditions Disability Benefits Questionnaire Page 5
Download a blank fillable Va Form 21-0960n-2 - Eye Conditions Disability Benefits Questionnaire in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Va Form 21-0960n-2 - Eye Conditions Disability Benefits Questionnaire with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10(Continued)
SECTION IV - EYE CONDITIONS
2. ANATOMICAL LOSS OF EYELIDS, BROWS, LASHES
(Check all that apply)
a. Indicate the condition and side affected
Partial or complete loss of eyelid
Right
Left
Both
Complete loss of eyebrows
Right
Left
Both
Complete loss of eyelashes
Right
Left
Both
b. Is the veteran's decrease in visual acuity or other visual impairment, if present, attributable to eyelid loss?
Yes
No
There is no decrease in visual acuity or other visual impairment
If "No," explain:
c. If present, does eyelid loss cause scarring or disfigurement?
Yes
No
(If "Yes," complete Section V, Scarring and Disfigurement)
3. LACRIMAL GLAND AND LIP CONDITIONS
(Check all that apply):
a. Indicate the veteran's condition(s) and side affected
Ectropion
Side affected:
Right
Left
Both
Entropion
Side affected:
Right
Left
Both
Lagophthalmos
Side affected:
Right
Left
Both
(epiphora, dacryocystitis, etc.)
Disorders of the lacrimal apparatus
If checked, specify condition:
Side affected:
Right
Left
Both
b. If present, does lacrimal or lid condition cause scarring or disfigurement?
Yes
No
(If "Yes," complete Section V, Scarring and Disfigurement)
4. PTOSIS
a. If ptosis is present, indicate side affected:
Right
Left
Both
b. Is the veteran's decrease in visual acuity or other visual impairment, if present, attributable to ptosis?
Yes
No
There is no decrease in visual acuity or other visual impairment
If "No," explain:
c. Does the Ptosis loss cause disfigurement?
Yes
No
(If "Yes," complete Section V, Scarring and Disfigurement)
5. CONJUNCTIVITIS AND OTHER CONJUCTIVAL CONDITIONS
(check all that apply):
a. Indicate type of conjunctivitis, activity, and side affected
Trachomatous
Nontrachomatous
Active
Eye affected:
Right
Left
Both
Active
Eye affected:
Right
Left
Both
Inactive
Eye affected:
Right
Left
Both
Inactive
Eye affected:
Right
Left
Both
(Check all that apply):
b. Indicate the veteran's other conjunctival conditions, if any
Pinguecula
Eye affected:
Right
Left
Both
Symblepharon
Eye affected:
Right
Left
Both
Other, describe:
Eye affected:
Right
Left
Both
c. Is the veteran's decrease in visual acuity or other visual impairment, if present, attributable to any of the eye conditions checked above in this section?
Yes
No
There is no decrease in visual acuity or other visual impairment
If "No," explain:
d. Does any eye condition in this section cause scarring or disfigurement?
Yes
No
(If "Yes," complete Section V, Scarring and Disfigurement)
6. CORNEAL CONDITIONS
a. Has the veteran had a corneal transplant?
Yes
No
Right
Left
Both
If "Yes," indicate side of transplant:
(Check all that apply):
Indicate residuals
Pain
Eye affected:
Right
Left
Both
Photophobia
Eye affected:
Right
Left
Both
Glare sensitivity
Eye affected:
Right
Left
Both
Other, (Describe):
Eye affected:
Right
Left
Both
b. Does the veteran have keratoconus?
Yes
No
If "Yes," indicate eye affected
Right
Left
Both
Page 5
VA FORM 21-0960N-2, OCT 2012
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal