Va Form 21-0960f-2 - Skin Diseases Disability Benefits Questionnaire Page 4
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5SECTION V - PHYSICAL EXAM
5A. INDICATE THE VETERAN'S VISIBLE SKIN CONDITIONS; INDICATE THE APPROXIMATE TOTAL BODY AREA AND APPROXIMATE TOTAL EXPOSED BODY AREA
(face, neck and hands)
(check all that apply)
AFFECTED ON CURRENT EXAMINATION
Total body area
None
<5%
5% to <20%
20% to 40%
>40%
Dermatitis
EXPOSED area
None
<5%
5% to <20%
20% to 40%
>40%
Total body area
None
<5%
5% to <20%
20% to 40%
>40%
Eczema
EXPOSED area
None
<5%
5% to <20%
20% to 40%
>40%
Total body area
None
<5%
5% to <20%
20% to 40%
>40%
Bullous
disorders
EXPOSED area
None
<5%
5% to <20%
20% to 40%
>40%
Total body area
None
<5%
5% to <20%
20% to 40%
>40%
Psoriasis
EXPOSED area
None
<5%
5% to <20%
20% to 40%
>40%
Infections
Total body area
None
<5%
5% to <20%
20% to 40%
>40%
of the skin
EXPOSED area
None
<5%
5% to <20%
20% to 40%
>40%
Cutaneous manifestations
Total body area
None
<5%
5% to <20%
20% to 40%
>40%
of collagen-vascular
EXPOSED area
None
<5%
5% to <20%
20% to 40%
>40%
diseases
Total body area
None
<5%
5% to <20%
20% to 40%
>40%
Papulosquamous
disorder
EXPOSED area
None
<5%
5% to <20%
20% to 40%
>40%
The veteran does not have any of the above listed visible skin conditions
5B. FOR EACH SKIN CONDITION CHECKED IN ITEM 5A, GIVE SPECIFIC DIAGNOSIS AND DESCRIBE APPEARANCE AND LOCATION:
SECTION VI - SPECIFIC SKIN CONDITIONS
6. DOES THE VETERAN HAVE ANY OF THE FOLLOWING SKIN CONDITIONS: ACNE, CHLORACNE, VITILIGO, ALOPECIA OR HYPERHIDROSIS?
YES
NO
(If "Yes," indicate the skin condition and complete appropriate sections)
Acne or chloracne
(If checked, indicate severity and location (check all that apply)):
Superficial acne (comedones, papules, pustules, superficial cysts) of any extent
Deep acne (deep inflamed nodules and pus-filled cysts
Affects less than 40% of face and neck
Affects 40% or more of face and neck
Affects body areas other than face and neck
Vitiligo
(If checked, indicate areas affected by vitiligo):
Exposed areas affected
No exposed areas affected
Scarring alopecia
(If checked, indicate percent of scalp affected):
<20%
20% to 40%
>40%
Alopecia areata
(If checked, indicate amount of hair loss):
Hair loss limited to scalp and face
Loss of all body hair
Other, describe:
Hyperhidrosis
(If checked, indicate severity):
Able to handle paper or tools after treatment
Unresponsive to treatment; unable to handle paper or tools
Page 4
VA FORM 21-0960F-2, OCT 2012
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