Va Form 21-0960n-2 - Eye Conditions Disability Benefits Questionnaire Page 8

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SECTION IV - EYE CONDITIONS

13. TUMORS AND NEOPLASMS

Does the veteran have a benign or malignant neoplasm or metastases related to any of the diagnosis listed in Section 1, Diagnosis?

Yes

(If "Yes," complete Items 13A thru 13E):

a. Is the neoplasm:

Benign

Malignant

b. 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:

c. Does the veteran currently have any residual conditions or complications due to the neoplasm (including metastases) or its treatment, other than those already

documented in the report in Item 13B?

Yes

(Brief summary):

If "Yes," list residual conditions and complication

d. If there are additional benign or malignant neoplasms or metastases related to any of the diagnosis in Section I, Diagnosis, describe using the format in Item 13B:

e. Do any benign or malignant neoplasms or metastases identified in this section cause scarring or disfigurement?

Yes

(If "Yes," complete Section V, Scarring and Disfigurement)

14. OTHER EYE CONDITIONS, PERTINENT PHYSICAL FINDINGS, COMPLICATION, CONDITIONS, SIGNS AND/OR SYMPTOMS

a. Does the veteran have any other eye conditions, pertinent physical findings, complications, signs, and/or related to the condition at hand?

Yes

If "Yes," describe:

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VA FORM 21-0960N-2, OCT 2012