Va Form 21-0960f-2 - Skin Diseases Disability Benefits Questionnaire Page 2
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5SECTION II - MEDICAL HISTORY
(including onset and course)
(brief summary)
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S SKIN CONDITIONS
:
2B. DO ANY OF THE VETERAN'S SKIN CONDITIONS CAUSE SCARRING OR DISFIGUREMENT OF THE HEAD, FACE OR NECK?
(If "Yes," indicate skin condition and describe scarring and/or disfigurement and complete VA Form 21-0960F-1, Scars/Disfigurement
YES
NO
Disability Benefits Questionnaire if appropriate)
(including malignant melanoma)
2C. DOES THE VETERAN HAVE ANY BENIGN OR MALIGNANT SKIN NEOPLASMS
?
(If "Yes," complete Section VII, Tumors and Neoplasms, below)
YES
NO
(such as fever, weight loss or hypoproteinemia associated with
2D. DOES THE VETERAN HAVE ANY SYSTEMIC MANIFESTATIONS DUE TO ANY SKIN DISEASES
skin conditions such as erythroderma)
?
(If "Yes," describe and complete additional questionnaires if appropriate)
YES
NO
SECTION III - TREATMENT
3A. HAS THE VETERAN BEEN TREATED WITH ORAL OR TOPICAL MEDICATIONS IN THE PAST 12 MONTHS FOR ANY SKIN CONDITION?
YES
NO
(If "Yes," check all that apply):
Systemic corticosteroids or other immunosuppressive medications
(If checked, list medication(s):
(Specify condition medication used for):
(Total duration of medication use in past 12 months):
<6 weeks
6 weeks or more, but not constant
Constant/near-constant
Antihistamines
(If checked, list medication(s):
(Specify condition medication used for):
(Total duration of medication use in past 12 months):
<6 weeks
6 weeks or more, but not constant
Constant/near-constant
Immunosuppressive retinoids
(If checked, list medication(s):
(Specify condition medication used for):
(Total duration of medication use in past 12 months):
<6 weeks
6 weeks or more, but not constant
Constant/near-constant
Sympathomimetics
(If checked, list medication(s):
(Specify condition medication used for):
(Total duration of medication use in past 12 months):
<6 weeks
6 weeks or more, but not constant
Constant/near-constant
Other oral medications
(If checked, list medication(s):
(Specify condition medication used for):
(Total duration of medication use in past 12 months):
<6 weeks
6 weeks or more, but not constant
Constant/near-constant
Topical corticosteroids
(If checked, list medication(s):
(Specify condition medication used for):
(Total duration of medication use in past 12 months):
<6 weeks
6 weeks or more, but not constant
Constant/near-constant
Other topical medications
(If checked, list medication(s):
(Specify condition medication used for):
(Total duration of medication use in past 12 months):
<6 weeks
6 weeks or more, but not constant
Constant/near-constant
Page 2
VA FORM 21-0960F-2, OCT 2012
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