Va Form 21-0960c-3 - Cranial Nerves Diseases Disability Benefits Questionnaire Page 4
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5SECTION VI - SENSORY EXAM
6. PROVIDE RESULTS FOR SENSATION TESTING TO LIGHT TOUCH FOR FACIAL SENSATION:
ALL NORMAL
Cranial nerve V:
Upper face and forehead
RIGHT:
Normal
Decreased
Absent
LEFT:
Normal
Decreased
Absent
Mid face
RIGHT:
Normal
Decreased
Absent
LEFT:
Normal
Decreased
Absent
Lower face
RIGHT:
Normal
Decreased
Absent
LEFT:
Normal
Decreased
Absent
SECTION VII - CRANIAL NERVE SUMMARY EVALUATION
("degree of paralysis")
7A. INDICATE THE CRANIAL NERVE(S) AFFECTED. FOR EACH NERVE, INDICATE SEVERITY
, BASING THE RESPONSES ON SYMPTOMS
AND FINDINGS FROM THE ABOVE EXAM. THIS SECTION PROVIDES AN ESTIMATION OF THE SEVERITY OF THE VETERAN'S CRANIAL NERVE CONDITION,
WHICH IS USEFUL FOR VA PURPOSES.
NOTE: For VA purposes, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the description of complete paralysis
that is given below with each nerve, whether due to a varied level of the nerve lesion or to partial regeneration.
(trigeminal)
Cranial nerve V
RIGHT:
Not affected
Incomplete, moderate
Incomplete, severe
Complete
LEFT:
Not affected
Incomplete, moderate
Incomplete, severe
Complete
(facial)
Cranial nerve VII
RIGHT:
Not affected
Incomplete, moderate
Incomplete, severe
Complete
Incomplete, moderate
Incomplete, severe
Complete
LEFT:
Not affected
(glossopharyngeal)
Cranial nerve IX
RIGHT:
Not affected
Incomplete, moderate
Incomplete, severe
Complete
LEFT:
Not affected
Incomplete, moderate
Incomplete, severe
Complete
Cranial nerve X (vagus)
Incomplete, moderate
Incomplete, severe
Complete
RIGHT:
Not affected
LEFT:
Not affected
Incomplete, moderate
Incomplete, severe
Complete
(spinal accessory)
Cranial nerve XI
RIGHT:
Not affected
Incomplete, moderate
Incomplete, severe
Complete
LEFT:
Not affected
Incomplete, moderate
Incomplete, severe
Complete
Cranial nerve XII (hypoglossal)
RIGHT:
Not affected
Incomplete, moderate
Incomplete, severe
Complete
LEFT:
Not affected
Incomplete, moderate
Incomplete, severe
Complete
SECTION VII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
(surgical or otherwise)
8A. DOES THE VETERAN HAVE ANY SCARS
RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
SECTION I, DIAGNOSIS?
YES
NO
(If "Yes," are any of the scars painful and/or unstable, or is the total area of all related scars greater than 39 square cm (6 square inches)?
YES
NO
(If "Yes," also complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)
8B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN SECTION 1, DIAGNOSIS?
(If "Yes," describe (brief summary):
YES
NO
VA FORM 21-0960C-3, OCT 2012
Page 4
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