Va Form 21-0960i-2 - Hiv - Related Illnesses Disability Benefits Questionnaire Page 4

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SECTION VII - MENTAL HEALTH MANIFESTATIONS DUE TO HIV-RELATED ILLNESS OR ITS TREATMENT

7A. DOES THE VETERAN HAVE DEPRESSION, HIV-ASSOCIATED NEUROCOGNITIVE DISORDER, DEMENTIA, OR ANY OTHER MENTAL HEALTH CONDITIONS

ATTRIBUTABLE TO HIV-RELATED ILLNESS OR ITS TREATMENT?

YES

(such that an

7B. DOES THE VETERAN'S MENTAL HEALTH CONDITION(S), RESULT IN GROSS IMPAIRMENT IN THOUGHT PROCESSES OR COMMUNICATION

interview with the veteran would not yield useful information)?

(If "No," ALSO complete VA Form 21-0960P-2, Mental Health Disorders (other than PTSD) Disability Benefits Questionnaire)

YES

(If "Yes," briefly describe the veteran's mental health condition):

SECTION VIII - SUMMARY

8. BASED ON SYMPTOMS AND FINDINGS FROM THIS EXAM, COMPLETE THE FOLLOWING, ITEMS 8A THRU 8E TO PROVIDE A SUMMARY OF THE SEVERITY

(NOTE: This summary provides useful information for VA purposes)

OF THE VETERAN'S HIV-RELATED CONDITION

(Check all that apply from each level):

A. LEVEL I

Asymptomatic, with or without lymphadenopathy or decreased T4 cell count

B. LEVEL II

Symptomatic, with current T4 cell of 200 or more and less than 500, and on approved medication(s)

(For VA purposes, approved medications include medications prescribed as part of a research protocol at an accredited medical institution)

Evidence of depression with employment limitations

Evidence of memory loss with employment limitations

C. LEVEL III

Recurrent constitutional symptoms, intermittent diarrhea, and on approved medications

Current T4 cell count less than 200

Hairy cell leukoplakia

Oral candidiasis

D. LEVEL IV

Refractory constitutional symptoms

Diarrhea and pathological weight loss

Development of AIDS-related opportunistic infection or neoplasm

E. LEVEL V

AIDS with recurrent opportunistic infections

Secondary diseases afflicting multiple body systems

HIV-related illness with debility and progressive weight loss, without remission or few or brief remissions

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

(surgical or otherwise)

9A. DOES THE VETERAN HAVE ANY SCARS

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)?

Yes

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

9B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, SCARS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO

ANY CONDITIONS LISTED IN SECTION I, DIAGNOSIS?

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

YES

VA FORM 21-0960I-2, OCT 2012

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