Va Form 21-0960e-1 - Diabetes Mellitus Disability Benefits Questionnaire Page 2

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SECTION III - COMPLICATIONS OF DIABETES MELLITUS

3A. DOES THE VETERAN HAVE ANY OF THE FOLLOWING RECOGNIZED COMPLICATIONS OF DIABETES MELLITUS?

YES

(If "Yes," indicate the conditions below) (Check all that apply)

DIABETIC PERIPHERAL NEUROPATHY

DIABETIC NEUROPATHY OR RENAL DYSFUNCTION CAUSED BY DIABETES MELLITUS

DIABETIC RETINOPATHY

NOTE - For all checked boxes, also complete appropriate Questionnaire(s). VA Form 21-0960N-2, Eye Disability Benefits Questionnaire must be completed by an

ophthalmologist or optometrist.

(at least a 50% probability)

3B. DOES THE VETERAN HAVE ANY OF THE FOLLOWING CONDITIONS THAT ARE AT LEAST AS LIKELY AS NOT

DUE TO DIABETES

MELLITUS?

YES

(If "Yes," indicate the conditions below) (Check all that apply)

(If checked also complete the VA Form 21-0960J-2, Male Reproductive Organs Disability Benefits Questionnaire)

ERECTILE DYSFUNCTION

(If checked also complete appropriate cardiac Questionnaires (VA Forms 21-0960A-1 thru 21-0960A-4)

CARDIAC CONDITION(S)

(If checked also complete VA Form 21-0960A-3, Hypertension Disability Benefits Questionnaire)

HYPERTENSION (in the presence of diabetic renal disease)

(If checked also complete VA Form 21-0960A-2, Arteries and Veins Disability Benefits Questionnaire)

PERIPHERAL VASCULAR DISEASE

(If checked also complete VA Form 21-0960C-3, Cranial Nerve Conditions Disability Benefits Questionnaire and/or 21-0960C-5, Central Nervous System

STROKE

and Neuromuscular Diseases Disability Benefits Questionnaire)

(If checked also complete VA Form 21-0960F-2, Skin Conditions Disability Benefits Questionnaire)

SKIN CONDITIONS

(If checked also complete VA Form 21-0960N-2, Eye Conditions Disability Benefits Questionnaire

EYE CONDITIONS OTHER THAN DIABETIC RETINOPATHY

which must be completed by an ophthalmologist or optometrist)

(Describe)

OTHER COMPLICATION(S)

(at least 50% probability)

(meaning that any worsening of

3C. HAS THE VETERAN'S DIABETES MELLITUS AT LEAST AS LIKELY AS NOT

PERMANENTLY AGGRAVATED

the condition is not due to natural progress)

ANY OF THE FOLLOWING CONDITIONS?

YES

(If "Yes," indicate the conditions below) (Check all that apply)

(If checked also complete appropriate cardiac Questionnaires (VA Forms 21-0960A-1 thru 21-0960A-4)

CARDIAC CONDITIONS(S)

(If checked also complete VA Form 21-0960A-3, Hypertension Disability Benefits Questionnaire)

HYPERTENSION

(If checked also complete VA Form 21-0960J-1, Kidney Conditions (Nephrology) Disability Benefits Questionnaire)

RENAL DISEASE

(If checked also complete VA Form 21-0960A-2, Artery and Vein Conditions (Vascular Diseases Including Varicose Veins)

PERIPHERAL VASCULAR DISEASE

Disability Benefits Questionnaire)

(If checked also complete VA Form 21-0960N-2, Eye Conditions Disability Benefits Questionnaire,

EYE CONDITION(S) OTHER THAN DIABETIC RETINOPATHY

which must be completed by an ophthalmologist or optometrist)

(Describe)

OTHER PERMANENTLY AGGRAVATED CONDITION(S)

SECTION IV - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS

4A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN

SECTION I, DIAGNOSIS?

YES

(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)?

If "Yes," also complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)

YES

4B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY

CONDITIONS LISTED IN SECTION I, DIAGNOSIS?

(If "Yes," describe (brief summary)):

YES

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VA FORM 21-0960E-1, OCT 2012