Va Form 21-0960f-2 - Skin Diseases Disability Benefits Questionnaire
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5OMB Approved No. 2900-0776
Respondent Burden: 15 minutes
SKIN 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 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 THE VETERAN HAD A SKIN CONDITION?
(If, "Yes," complete Item 1B)
YES
NO
(Indicate the category of skin condition, and then provide specific diagnosis in that category)
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO SKIN CONDITIONS
(Check all that apply)
Dermatitis or eczema
DIAGNOSIS:
ICD Code:
Date of Diagnosis:
Infectious skin conditions (including bacterial, fungal, viral, treponemal and parasitic skin conditions)
DIAGNOSIS:
ICD Code:
Date of Diagnosis:
Bullous disorders
DIAGNOSIS:
ICD Code:
Date of Diagnosis:
Psoriasis
ICD Code:
Date of Diagnosis:
DIAGNOSIS:
Exfoliative dermatitis (erythroderma)
ICD Code:
Date of Diagnosis:
DIAGNOSIS:
Cutaneous manifestations of collagen-vascular diseases
ICD Code:
Date of Diagnosis:
DIAGNOSIS:
Palpulosquamous skin disorders
ICD Code:
Date of Diagnosis:
DIAGNOSIS:
Vitiligo
DIAGNOSIS:
ICD Code:
Date of Diagnosis:
Keratinization skin disorders
DIAGNOSIS:
ICD Code:
Date of Diagnosis:
Urticaria
ICD Code:
Date of Diagnosis:
DIAGNOSIS:
Primary cutaneous vasculitis
DIAGNOSIS:
ICD Code:
Date of Diagnosis:
Erythema multiforme
DIAGNOSIS:
ICD Code:
Date of Diagnosis:
Acne
ICD Code:
Date of Diagnosis:
DIAGNOSIS:
Chloracne
DIAGNOSIS:
ICD Code:
Date of Diagnosis:
Alopecia
ICD Code:
Date of Diagnosis:
DIAGNOSIS:
Hyperhidrosis
ICD Code:
Date of Diagnosis:
DIAGNOSIS:
Tumors and neoplasms of the skin, including malignant melanoma
ICD Code:
Date of Diagnosis:
DIAGNOSIS:
Other skin condition
Other diagnosis #1:
ICD Code:
Date of Diagnosis:
Other diagnosis #2:
ICD Code:
Date of Diagnosis:
Other diagnosis #3:
ICD Code:
Date of Diagnosis:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO THE SKIN CONDITIONS, LIST USING ABOVE FORMAT:
21-0960F-2
VA FORM
Page 1
SUPERSEDES VA FORM 21-0960F-2, JAN 2011,
OCT 2012
WHICH WILL NOT BE USED.
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