Va Form 21-0960i-5 - Nutritional Deficiencies Disability Benefits Questionnaire
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2OMB Approved No. 2900-0781
Respondent Burden: 15 minutes
NUTRITIONAL DEFICIENCIES 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
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH A NUTRITIONAL DEFICIENCY?
(If "Yes," complete Item 1B)
YES
NO
(check all that apply)
1B. SELECT THE VETERAN'S CONDITION
AVITAMINOSIS
ICD Code:
Date of diagnosis:
(Vitamin B1 or thiamine deficiency)
BERIBERI
ICD Code:
Date of diagnosis:
(Vitamin B3 or niacin deficiency)
PELLAGRA
ICD Code:
Date of diagnosis:
(specify)
OTHER
Other diagnosis #1
ICD Code:
Date of diagnosis:
Other diagnosis #2
ICD Code:
Date of diagnosis:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO NUTRITIONAL DEFICIENCIES, LIST USING ABOVE FORMAT:
NOTE - For all identified complications or residual conditions, ALSO complete additional questionnaires as appropriate (i.e., VA Form 21-0960F-2, Skin Disease
Disability Benefits Questionnaire, VA Form 21-0960A-4, Heart Disease Disability Benefits Questionnaire and VA Form 21-0960C-10, Peripheral Nerves Disability
Benefits Questionnaire)
SECTION II - MEDICAL HISTORY
(including onset and course)
(brief summary)
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S NUTRITIONAL DEFICIENCY CONDITION(S)
:
2B. DOES THE VETERAN'S NUTRITIONAL DEFICIENCY CONDITION REQUIRE CONTINUOUS MEDICATIONS FOR CONTROL?
(If "Yes," list medications used for nutritional deficiency conditions):
YES
NO
SECTION III - FINDINGS, SIGNS AND SYMPTOMS
3A. DOES THE VETERAN HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO PELLAGRA OR AVITAMINOSIS?
(If "Yes," check all that apply):
YES
NO
Confirmed diagnosis
Nonspecific symptoms such as decreased appetite, weight loss, abdominal discomfort, weakness, inability to concentrate and irritability
Stomatitis
Achlorhydria
Diarrhea
Symmetrical dermatitis
Mental symptoms
Impaired bodily vigor
Marked mental changes, moist dermatitis, inability to retain nourishment, exhaustion and cachexia
Other
3B. FOR ALL CHECKED CONDITIONS IN ITEM 3A, DESCRIBE:
3C. DOES THE VETERAN HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO BERIBERI?
(If "Yes," check all that apply):
YES
NO
Peripheral neuropathy with absent knee or ankle jerks and loss of sensation
Symptoms such as weakness, fatigue, anorexia, dizziness, heaviness and stiffness of legs, headache, or sleep disturbance
Cardiomegaly
Peripheral neuropathy with foot drop or atrophy of thigh or calf muscles
Congestive heart failure, anasarca, or Wernicke-Korsakoff syndrome
Other
3D. FOR ALL CHECKED CONDITIONS IN ITEM 3C, DESCRIBE:
21-0960I-5
VA FORM
SUPERSEDES VA FORM 21-0960I-5, MAR 2011,
Page 1
OCT 2012
WHICH WILL NOT BE USED.
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