Va Form 21-0960i-2 - Hiv - Related Illnesses Disability Benefits Questionnaire Page 3
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5SECTION V - COMPLICATIONS
5A. DOES THE VETERAN HAVE ANY COMPLICATIONS ATTRIBUTABLE TO AN HIV-RELATED ILLNESS?
(If "Yes," check all that apply)
YES
NO
(If checked, ALSO complete VA Form 21-0960C-10, Peripheral Nerves Disability Benefits Questionnaire)
HIV-associated neuropathy, radiculopathy or myelopathy
(If checked, ALSO complete VA Form 21-0960N-2, Eye Conditions Disability Benefits Questionnaire)
HIV-associated retinopathy
(If checked, ALSO complete VA Form 21-0960A-4, Heart Disease (including arrhythmias and surgery) Disability Benefits Questionnaire)
HIV-associated cardiopathy
(If checked, ALSO complete VA Form 21-0960L-1, Respiratory Conditions Disability Benefits Questionnaire)
HIV-associated pulmonary hypertension
(If checked, ALSO complete VA Form 21-0960G-3, Intestinal Conditions (other than surgical or infectious) Disability Benefits
HIV-associated enteropathy
Questionnaire or VA Form 21-0960G-4, Intestinal Conditions (surgical or infectious) Disability Benefits Questionnaire)
(If checked, ALSO complete VA Form 21-0960J-1, Kidney Conditions Disability Benefits Questionnaire)
HIV-associated nephropathy
HIV-associated impaired lipid and glucose metabolism
HIV-associated wasting
Lipodystrophy
Myopathy
Other, describe:
(except those for which an additional DBQ is completed) DESCRIBE (providing date of onset, and a brief
5B. FOR EACH CHECKED CONDITION IN ITEM 5A,
summary of symptoms, treatment and course).
SECTION VI - INFECTIOUS AND ONCOLOGIC COMPLICATIONS
6A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER HAD ANY HIV-RELATED OPPORTUNISTIC INFECTIOUS OR ONCOLOGIC CONDITIONS?
YES
NO
(If "Yes," check all that apply)
Oral candidiasis
Viral meningoencephalitis
Tuberculosis
Cytomegalovirus
Hepatitis
Herpes simplex virus
Pneumocystosis
Varicella zoster virus
Toxoplasmosis
Progressive multifocal leukoencephalopathy
Cryptococcosis
Neurosyphilis
Cerebral toxoplasmosis
Primary central nervous system lymphoma
Cryptococcal meningoencephalitis
Other, describe:
(except those for which an additional DBQ is completed), DESCRIBE (providing date of onset, and brief summary
6B. FOR EACH CHECKED CONDITION IN ITEM 6A,
of symptoms, treatment and course):
6C. DOES THE VETERAN HAVE RECURRENT OPPORTUNISTIC INFECTION(S)?
(If "Yes," provide type of infection(s), date(s) of first onset, date(s) of recurrences, treatment and course (brief summary)):
NO
YES
(NOTE : ALSO complete the appropriate questionnaire for each recurrent opportunistic infection)
Page 3
VA FORM 21-0960I-2, OCT 2012
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