Va Form 21-0960d-1 - Oral And Dental Conditions Including Mouth, Lips And Tongue (Other Than Temporomandibular Joint Conditions) Disability Benefits Questionnaire Page 3
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SECTION IV - DENTAL AND ORAL CONDITIONS
PART C - TEETH, INCLUDING ANATOMICAL LOSS OR BONY INJURY LEADING TO LOSS OF ANY TEETH
(OTHER THAN THAT DUE TO THE LOSS OF THE ALVEOLAR PROCESS AS A RESULT OF PERIODONTAL DISEASE)
1. IS THE LOSS OF TEETH DUE TO LOSS OF SUBSTANCE OF BODY OF MAXILLA OR MANDIBLE WITHOUT LOSS OF CONTINUITY?
YES
NO
2. IS THE LOSS OF TEETH DUE TO TRAUMA OR DISEASE (SUCH AS OSTEOMYELITIS?)
(If "Yes," describe):
YES
NO
3. CAN THE MASTICATORY SURFACES BE RESTORED BY SUITABLE PROSTHESIS?
(If "Yes," describe):
YES
NO
(Check all that apply):
4. INDICATE THE EXTENT OF LOSS OF TEETH
Upper Teeth
No missing teeth
All right posterior missing
Other, describe:
All posterior teeth missing bilaterally
All right anterior missing
All anterior teeth missing bilaterally
All left posterior missing
All upper teeth missing
All left anterior missing
Lower Teeth
No missing teeth
All right posterior missing
Other, describe:
All posterior teeth missing bilaterally
All right anterior missing
All anterior teeth missing bilaterally
All left posterior missing
All lower teeth missing
All left anterior missing
5. LIST MISSING TEETH BY NUMBER:
PART D - MOUTH, LIPS, TONGUE AND DISFIGURING SCARS TO THE MOUTH OR LIPS (ANATOMICAL LOSS OR INJURY)
1. DOES THE VETERAN HAVE ANY DISFIGURING SCARS TO THE MOUTH OR LIPS?
(If "Yes," ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)
YES
NO
2. DOES THE VETERAN HAVE A MOUTH INJURY THAT RESULTS IN IMPAIRMENT OF MASTICATION?
(If "Yes," describe):
YES
NO
3. DOES THE VETERAN HAVE PARTIAL OR COMPLETE LOSS OF THE TONGUE?
(If "Yes," indicate severity)
YES
NO
Loss of less than 1/2 of tongue
Loss of 1/2 or more of tongue
4. DOES THE VETERAN HAVE A SPEECH IMPAIRMENT CAUSED BY PARTIAL OR COMPLETE LOSS OF THE TONGUE, OR BY ANY OTHER TONGUE CONDITION?
(If "Yes," indicate severity)
YES
NO
(If checked, describe):
Marked speech impairment
(If checked, describe):
Inability to communicate by speech
PART E - OSTEOMYELITIS/OSTEORADIONECROSIS/BISPHOSPHONATE-RELATED OSTEONECROSIS OF THE JAW
1. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH OSTEOMYELITIS OR OSTEORADIONECROSIS OF THE MANDIBLE?
(If "Yes," ALSO complete VA Form 21-0960M-11, Osteomyelitis Disability Benefits Questionnaire)
YES
NO
2. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH BISPHOSPHONATE-RELATED OSTEONECROSIS OF THE JAW?
(If "Yes," describe):
YES
NO
PART F - TUMORS AND NEOPLASMS
1. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES CHECKED IN SECTION I,
DIAGNOSIS?
(If "Yes," complete the following section)
YES
NO
2. IS THE NEOPLASM?
BENIGN
MALIGNANT
Page 3
VA FORM 21-0960D-1, OCT 2012
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