Va Form 21-0960e-1 - Diabetes Mellitus Disability Benefits Questionnaire Page 3

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SECTION V - DIAGNOSTIC TESTING

(If known) (Check all that apply)

5A. TEST RESULTS USED TO MAKE THE DIAGNOSIS OF DIABETES MELLITUS

NOTE: If laboratory test results are in the medical record, repeat testing is not required. A glucose tolerance test is not required for VA purposes; report

this test only if already completed.

(Dates:

)

FASTING PLASMA GLUCOSE TEST (FPG) OF >126 MG/DL ON 2 OR MORE OCCASIONS

(Dates:

)

A1C OF 6.5% OR GREATER ON 2 OR MORE OCCASIONS

(Date:

)

2-HR PLASMA GLUCOSE OF > 200 MG/DL ON GLUCOSE TOLERANCE TEST

(Dates:

)

RANDOM PLASMA GLUCOSE OF > 200 MG/DL WITH CLASSIC SYMPTOMS OF HYPERGLYCEMIA

(Describe):

OTHER

5B. CURRENT TEST RESULTS

(Date:

)

MOST RECENT A1C, IF AVAILABLE:

(Date:

)

MOST RECENT FASTING PLASMA GLUCOSE, IF AVAILABLE:

SECTION VI - FUNCTIONAL IMPACT

(and complications of Diabetes Mellitus if present)

(Impact on

6. DOES THE VETERAN'S DIABETES MELLITUS CONDITION

IMPACT HIS OR HER ABILITY TO WORK?

ability to work may also be addressed on the individual Questionnaire(s) for other diabetes-associated conditions and/or complications, if completed)

(If Yes," separately describe impact of each of the veteran's Diabetes Mellitus, diabetes-associated conditions, and complications, if present,

YES

providing one or more examples)

SECTION VII - REMARKS

(If any)

7. REMARKS

SECTION VIII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.

8A. PHYSICIAN'S SIGNATURE

8B. PHYSICIAN'S PRINTED NAME

8C. DATE SIGNED

8D. PHYSICIAN'S PHONE AND FAX NUMBERS

8E. PHYSICIAN'S MEDICAL LICENSE NUMBER

8F. PHYSICIAN'S ADDRESS

NOTE - VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.

IMPORTANT - Physician please fax the completed form to

(VA Regional Office FAX No.)

NOTE - A list of VA Regional Office FAX Numbers can be found at

or obtained by calling 1-800-827-1000.

PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of Federal

Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the United States,

litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel administration)

as identified in the VA system of records, 58/VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the Federal Register.

Your obligation to respond is voluntary. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving

us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or

her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and

necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through

computer matching programs with other agencies.

RESPONDENT BURDEN: We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this information. We estimate that

you will need an average of 15 minutes to review the instructions, find the information, and complete the form. VA cannot conduct or sponsor a collection of information unless a valid OMB

control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB Internet Page

at If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

VA FORM 21-0960E-1, OCT 2012

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