OMB Approved No. 2900-0781
Respondent Burden: 15 minutes
HIV - RELATED ILLNESSES 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.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER BEEN DIAGNOSED WITH AN HIV-RELATED ILLNESS?
(If "Yes," complete Item1B)
YES
NO
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO HIV-RELATED ILLNESSES OR COMPLICATIONS:
Diagnosis # 1 -
ICD code -
Date of diagnosis-
Diagnosis # 2 -
ICD code -
Date of diagnosis-
Diagnosis # 3 -
ICD code -
Date of diagnosis-
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO HIV-RELATED ILLNESS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL RECORD REVIEW
2. INDICATE MEDICAL RECORDS REVIEWED IN PREPARATION OF THIS REPORT.
(VA only)
C-FILE
(describe)
OTHER
SECTION III - MEDICAL HISTORY
(including onset and course)
(brief summary
3A. DESCRIBE THE HISTORY
OF THE VETERAN'S HIV-RELATED ILLNESS(ES)
):
3B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF HIV-RELATED ILLNESS(ES)?
(If "Yes," list only those medications required for the veteran's HIV-related illness(es)) (If the veteran has more than one HIV-related illness(es),
YES
NO
specify the condition for which each medication is required)
3C. DOES THE VETERAN HAVE ANY COMPLICATIONS DUE TO CURRENT OR PREVIOUS MEDICATIONS TAKEN FOR HIV-RELATED ILLNESS(ES)?
(If "Yes," list medication and describe complication(s) due to medication(s)):
YES
NO
VA FORM
SUPERSEDES VA FORM 21-0960I-2, MAR 2011,
21-0960I-2
Page 1
OCT 2012
WHICH WILL NOT BE USED.