Va Form 21-0960f-2 - Skin Diseases Disability Benefits Questionnaire Page 3
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5SECTION III - TREATMENT (Continued)
NOTE - If a medication is used for more than one condition, provide names of all conditions, name of medication used for each condition, and
frequency of use for each condition in Section 10, "Remarks".
3B. HAS THE VETERAN HAD ANY TREATMENTS OR PROCEDURES OTHER THAN SYSTEMIC OR TOPICAL MEDICATIONS IN THE PAST 12 MONTHS
FOR EXFOLIATIVE DERMATITIS OR PAPULOSQUAMOUS DISORDERS?
(If "Yes," check all that apply)
YES
NO
PUVA (photo-chemotherapy with psoralen and ultraviolet A) treatment
(If checked, date of most recent treatment):
(Specify condition treated):
(Total duration of medication use in past 12 months):
<6 weeks
6 weeks or more, but not constant
Constant/near-constant
UVB (ultraviolet B phototherapy) treatment
(If checked, date of most recent treatment):
(Specify condition treated):
(Total duration of medication use in past 12 months):
<6 weeks
6 weeks or more, but not constant
Constant/near-constant
Electron beam therapy
(If checked, date of most recent treatment):
(Specify condition treated):
(Total duration of medication use in past 12 months):
<6 weeks
6 weeks or more, but not constant
Constant/near-constant
Intensive light therapy
(If checked, date of most recent treatment):
(Specify condition treated):
(Total duration of medication use in past 12 months):
<6 weeks
6 weeks or more, but not constant
Constant/near-constant
Other treatment (Specify treatment):
(If checked, date of most recent treatment):
(Specify condition treated):
(Total duration of medication use in past 12 months):
<6 weeks
6 weeks or more, but not constant
Constant/near-constant
SECTION IV - DEBILITATING AND NON-DEBILITATING EPISODES
4A. HAS THE VETERAN HAD ANY DEBILITATING EPISODES IN THE PAST 12 MONTHS DUE TO URTICARIA, PRIMARY CUTANEOUS VASCULITIS, ERYTHEMA
MULTIFORME, OR TOXIC EPIDERMAL NECROLYSIS?
YES
NO
If "Yes," specify condition causing debilitating episodes (for example, urticaria, vasculitis, erythema multiforme, or toxic epidermal necrolysis):
(brief summary)
Describe debilitating episodes
:
Number of debilitating episodes in past 12 months:
None
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2
3
4 or more
Characteristics of debilitating episodes:
Occurred despite ongoing immunosuppressive therapy
Required treatment with intermittent systemic immunosuppressive therapy
Responded to treatment with antihistamines or sympathomimetics
4B. HAS THE VETERAN HAD ANY NON-DEBILITATING EPISODES OF UTICARIA, PRIMARY CUTANEOUS VASCULITIS, ERYTHEMA MULTIFORME, OR TOXIC
EPIDERMAL NECROLYSIS IN THE PAST 12 MONTHS?
YES
NO
If "Yes," specify condition causing non-debilitating episodes:
Urticaria
Primary cutaneous vasculitis
Erythema multiforme
Toxic epidermal necrolysis
Describe episodes (brief summary):
Number of non-debilitating episodes in past 12 months:
None
1
2
3
4 or more
Characteristics of non-debilitating episodes:
Occurred despite ongoing immunosuppressive therapy
Required treatment with intermittent systemic immunosuppressive therapy
Responded to treatment with antihistamines or sympathomimetics
NOTE - If the veteran's debilitating and/or non-debilitating episodes are due to more than one condition, provide names of all conditions, indicating
severity and frequency of episodes for each condition in Section 10, "Remarks".
Page 3
VA FORM 21-0960F-2, OCT 2012
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