OMB Approved No. 2900-0781
Respondent Burden: 30 minutes
CRANIAL NERVES DISEASES 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 THIS 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 OR SHE EVER BEEN DIAGNOSED WITH A CRANIAL NERVE CONDITION? (This is the condition
the veteran is claiming or for which an exam has been requested)
(If "Yes," complete Item 1B)
YES
NO
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO CRANIAL NERVE CONDITIONS
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 CRANIAL NERVES, 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 etiology, onset and course)
(brief summary)
3A. DESCRIBE THE HISTORY
OF THE VETERAN'S CRANIAL NERVE CONDITION
:
(check all that apply)
3B. INDICATE THE CRANIAL NERVES AFFECTED BY THE VETERAN'S CONDITION
(olfactory) (If checked, complete VA Form 21-0960N-3, Loss of Sense of Smell and Taste Disability Benefits Questionnaire)
CRANIAL NERVE I
(If checked, complete VA Form 21-0960N-2, Eye Conditions Disability Benefits Questionnaire)
CRANIAL NERVES II - IV, VI
(trigeminal)
CRANIAL NERVE V
(facial)
CRANIAL NERVE VII
(If the veteran has hearing loss or tinnitus attributable to any cranial nerve condition, the VA regional office
CRANIAL NERVE VIII
will schedule a hearing loss or tinnitus exam, as appropriate)
(glossopharyngeal)
CRANIAL NERVE IX
(vagus)
CRANIAL NERVE X
(spinal accessory)
CRANIAL NERVE XI
(hypoglossal)
CRANIAL NERVE XII
VA FORM
Page 1
SUPERSEDES VA FORM 21-0960C-3, MAR 2011,
21-0960C-3
OCT 2012
WHICH WILL NOT BE USED.