Va Form 21-0960p-1 - Eating Disorders Disability Benefits Questionnaire
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2OMB Approved No. 2900-0779
Respondent Burden: 15 minutes
EATING DISORDERS 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
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.
IMPORTANT- If the veteran experiences a mental health emergency during the interview, please terminate the interview and obtain help, using local resources as
appropriate. You may also contact the VA Suicide Prevention Hotline at 1-800-273-TALK. Stay on the Hotline until help can link the veteran to emergency care.
NOTE - In order to conduct an INITIAL examination for eating disorders, the examiner must meet one of the following criteria: a board-certified or board-eligible
psychiatrist; a licensed doctorate-level psychologist; a doctorate-level mental health provider under the close supervision of a board-certified or board-eligible
psychiatrist or licensed doctorate-level psychologist; a psychiatry resident under close supervision of a board-certified or board-eligible psychiatrist or licensed
doctorate-level psychologist; or a clinical or counseling psychologist completing a one-year internship or residency (for purposes of a doctorate-level degree) under
close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist.
In order to conduct a REVIEW examination for eating disorders, the examiner must meet one of the criteria from above, OR be a licensed clinical social worker
(LCSW), a nurse practitioner, a clinical nurse specialist, or a physician assistant, under close supervision of a board-certified or board-eligible psychiatrist or doctorate-
level psychologist.
SECTION I - DIAGNOSIS
1. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH AN EATING DISORDER(S)?
YES
NO
(If "Yes," check all diagnoses that apply):
BULIMIA
DATE OF DIAGNOSIS:
ICD CODE:
NAME OF DIAGNOSING FACILITY OR CLINICIAN:
ANOREXIA
DATE OF DIAGNOSIS:
ICD CODE:
NAME OF DIAGNOSING FACILITY OR CLINICIAN:
EATING DISORDER NOT OTHERWISE SPECIFIED
DATE OF DIAGNOSIS:
ICD CODE:
NAME OF DIAGNOSING FACILITY OR CLINICIAN:
SECTION II - MEDICAL HISTORY
(including onset and course)
(brief summary):
2. DESCRIBE THE HISTORY
OF THE VETERAN'S EATING DISORDER
SECTION III - FINDINGS
NOTE - For VA purposes, an incapacitating episode is defined as a period during which bed rest and treatment by a physician are required.
BINGE EATING FOLLOWED BY SELF-INDUCED VOMITING OR OTHER MEASURES TO PREVENT WEIGHT GAIN, OR RESISTANCE TO WEIGHT GAIN EVEN
WHEN BELOW EXPECTED MINIMUM WEIGHT, WITH DIAGNOSIS OF AN EATING DISORDER BUT WITHOUT INCAPACITATING EPISODES
BINGE EATING FOLLOWED BY SELF-INDUCED VOMITING OR OTHER MEASURES TO PREVENT WEIGHT GAIN, OR RESISTANCE TO WEIGHT GAIN EVEN
WHEN BELOW EXPECTED MINIMUM WEIGHT, WITH DIAGNOSIS OF AN EATING DISORDER AND INCAPACITATING EPISODES OF UP TO TWO WEEKS
TOTAL DURATION PER YEAR
SELF-INDUCED WEIGHT LOSS TO LESS THAN 85 PERCENT OF EXPECTED MINIMUM WEIGHT WITH INCAPACITATING EPISODES OF MORE THAN TWO
BUT LESS THAN SIX WEEKS TOTAL DURATION PER YEAR
SELF-INDUCED WEIGHT LOSS TO LESS THAN 85 PERCENT OF EXPECTED MINIMUM WEIGHT WITH INCAPACITATING EPISODES OF SIX OR MORE WEEKS
TOTAL DURATION PER YEAR
SELF-INDUCED WEIGHT LOSS TO LESS THAN 80 PERCENT OF EXPECTED MINIMUM WEIGHT WITH INCAPACITATING EPISODES OF AT LEAST SIX WEEKS
TOTAL DURATION PER YEAR, AND REQUIRING HOSPITALIZATION MORE THAN TWICE A YEAR FOR PARENTERAL NUTRITION OR TUBE FEEDING
VA FORM
SUPERSEDES VA FORM 21-0960P-1, DEC 2010,
21-0960P-1
Page 1
OCT 2012
WHICH WILL NOT BE USED.
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