Va Form 21-0960d-1 - Oral And Dental Conditions Including Mouth, Lips And Tongue (Other Than Temporomandibular Joint Conditions) Disability Benefits Questionnaire

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OMB Approved No. 2900-0781

Respondent Burden: 15 minutes

ORAL AND DENTAL CONDITIONS INCLUDING MOUTH, LIPS AND TONGUE

(OTHER THAN TEMPOROMANDIBULAR JOINT CONDITIONS)

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

(This is the condition the veteran is

1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH AN ORAL OR DENTAL CONDITION?

claiming or for which an exam has been requested)

(If "Yes," complete Item 1B)

YES

(check all that apply)

1B. SELECT THE VETERAN'S CONDITION

LOSS OF ANY PORTION OF MANDIBLE

ICD Code:

Date of diagnosis:

(for reasons other than periodontal disease or edentulous atrophy)

LOSS OF ANY PORTION OF MAXILLA

ICD Code:

Date of diagnosis:

(for reasons other than periodontal disease or edentulous atrophy)

MALUNION OR NONUNION OF MANDIBLE

ICD Code:

Date of diagnosis:

MALUNION OR NONUNION OF MAXILLA

ICD Code:

Date of diagnosis:

(for reasons other than periodontal disease, or other

LOSS OF TEETH

ICD Code:

Date of diagnosis:

routine dental maladies: this is intended for loss of teeth

due to service-related trauma)

(TMJD) (If checked,

TEMPOROMANDIBULAR JOINT DISORDER

ICD Code:

Date of diagnosis:

complete the VA Form 21-0960M-15, Temporomandibular Joint

Conditions Disability Benefits Questionnaire in lieu of this questionnaire

if that is the veteran's only condition. If the veteran has a TMJD condition

AND additional oral or dental conditions, complete this questionnaire and

ALSO complete VA Form 21-0960M-15)

LIMITATION OF MOTION OF THE TEMPOROMANDIBULAR JOINT

ICD Code:

Date of diagnosis:

(If checked, complete this

DUE TO CAUSES OTHER THAN TMJD

questionnaire and ALSO complete VAF Form 21-0960M-15,

Temporomandibular Joint Conditions Disability Benefits Questionnaire)

ANATOMICAL LOSS OR INJURY OF THE MOUTH, LIPS OR TONGUE

ICD Code:

Date of diagnosis:

OSTEOMYELITIS, OSTEORADIONECROSIS OR BISPHOSPHONATE-

ICD Code:

Date of diagnosis:

RELATED OSTEONECROSIS OF THE JAW

(If checked, specify):

ORAL NEOPLASM

ICD Code:

Date of diagnosis:

(If this is the ONLY diagnosis checked, proceed

PERIODONTAL DISEASE

ICD Code:

Date of diagnosis:

to the signature section at the end of this form (for VA purposes this

disease is not considered disabling)

(specify):

OTHER

Other diagnosis #1

ICD Code:

Date of diagnosis:

Other diagnosis #2

ICD Code:

Date of diagnosis:

1C. IF ADDITIONAL DIAGNOSES THAT PERTAIN TO ORAL OR DENTAL CONDITIONS, LIST USING ABOVE FORMAT:

NOTE: This questionnaire is appropriate for bone loss due to trauma or disease such as osteomyelitis and not to the loss of the alveolar process as a result of periodontal

disease, edentuious atrophy since such loss is not considered disabling. This is intended for loss of teeth due to service-related trauma.

SECTION II - MEDICAL RECORD REVIEW

2. INDICATE MEDICAL RECORDS REVIEWED IN PREPARATION OF THIS REPORT:

C-FILE (VA ONLY)

OTHER, DESCRIBE:

SECTION III - MEDICAL HISTORY

(including onset and course)

3. MEDICAL/DENTAL HISTORY

OF THE VETERAN'S ORAL AND/OR DENTAL CONDITION:

VA FORM

SUPERSEDES VA FORM 21-0960D-1, MAR 2011,

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