Va Form 21-0960c-2 - Amyotrophic Lateral Sclerosis (Lou Gehrig'S Disease) Disability Benefits Questionnaire

Download a blank fillable Va Form 21-0960c-2 - Amyotrophic Lateral Sclerosis (Lou Gehrig'S Disease) Disability Benefits Questionnaire in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Va Form 21-0960c-2 - Amyotrophic Lateral Sclerosis (Lou Gehrig'S Disease) Disability Benefits Questionnaire with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

OMB Control No. 2900-0779
Respondent Burden: 30 minutes
AMYOTROPHIC LATERAL SCLEROSIS (LOU GEHRIG'S DISEASE)
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 AMYOTROPHIC LATERAL SCLEROSIS (ALS)?
(If "Yes," complete Item 1B)
YES
NO
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO AMYOTROPHIC LATERAL SCLEROSIS (ALS):
Diagnosis # 1 -
ICD code -
Date of diagnosis -
Diagnosis # 2 -
ICD code -
Date of diagnosis -
Diagnosis # 3 -
ICD code -
Date of diagnosis -
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO AMYOTROPHIC LATERAL SCLEROSIS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S ALS (brief summary):
2B. DOMINANT HAND
RIGHT
LEFT
AMBIDEXTROUS
SECTION III - CONDITIONS, SIGNS AND SYMPTOMS DUE TO ALS
3A. DOES THE VETERAN HAVE ANY MUSCLE WEAKNESS IN THE UPPER AND/OR LOWER EXTREMITIES ATTRIBUTABLE TO ALS?
YES
NO
(If "Yes," report under strength testing in Section IV, Neurologic Exam)
3B. DOES THE VETERAN HAVE ANY PHARYNX AND/OR LARYNX AND/OR SWALLOWING CONDITIONS ATTRIBUTABLE TO ALS?
YES
NO
(If "Yes," check all that apply)
CONSTANT INABILITY TO COMMUNICATE BY SPEECH
SPEECH NOT INTELLIGIBLE OR INDIVIDUAL IS APHONIC
(nasal regurgitation)
PARALYSIS OF SOFT PALATE WITH SWALLOWING DIFFICULTY
AND SPEECH IMPAIRMENT
HOARSENESS
MILD SWALLOWING DIFFICULTIES
MODERATE SWALLOWING DIFFICULTIES
SEVERE SWALLOWING DIFFICULTIES, PERMITTING PASSAGE OF LIQUIDS ONLY
REQUIRES FEEDING TUBE DUE TO SWALLOWING DIFFICULTIES
(describe):
OTHER
3C. DOES THE VETERAN HAVE ANY RESPIRATORY CONDITIONS ATTRIBUTABLE TO ALS?
YES
NO
(If "Yes," provide PFT results in Section XIII, Diagnostic Testing)
21-0960C-2
VA FORM
SUPERSEDES VA FORM 21-0960C-2, DEC 2010,
Page 1
OCT 2012
WHICH WILL NOT BE USED.

ADVERTISEMENT

00 votes

Related Articles

5 Things You Need To Know About The Gi Bill Benefits
Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids

Related forms

Va Form 21-0960m-6 - Foot Miscellaneous (other Than Flatfoot/pes Planus) Disability Benefits Questionnaire Va Form 21-0960m-6 - Foot Miscellaneous (other Than Flatfoot/pes Planus) Disability Benefits Questionnaire Legal
Va Form 21-0960n-1 - Ear Conditions (including Vestibular And Infectious Conditions) Disability Benefits Questionnaire Va Form 21-0960n-1 - Ear Conditions (including Vestibular And Infectious Conditions) Disability Benefits Questionnaire Legal
Va Form 21-0960h-1 - Hernias (including Abdominal, Inguinal And Femoral Hernias) Disability Benefits Questionnaire Va Form 21-0960h-1 - Hernias (including Abdominal, Inguinal And Femoral Hernias) Disability Benefits Questionnaire Legal
Va Form 21-0960b-1 - Hairy Cell And Other B-cell Leukemias Disability Benefits Questionnaire Va Form 21-0960b-1 - Hairy Cell And Other B-cell Leukemias Disability Benefits Questionnaire Legal
Va Form 21-0960c-1 - Parkinson's Disease Disability Benefits Questionnaire Va Form 21-0960c-1 - Parkinson's Disease Disability Benefits Questionnaire Legal
Va Form 21-0960c-9 - Multiple Sclerosis (ms) Disability Benefits Questionnaire Va Form 21-0960c-9 - Multiple Sclerosis (ms) Disability Benefits Questionnaire Legal
Va Form 21-0960c-5 - Central Nervous System And Neuromuscular Diseases Disability Benefits Questionnaire Va Form 21-0960c-5 - Central Nervous System And Neuromuscular Diseases Disability Benefits Questionnaire Legal
Va Form 21-0960c-3 - Cranial Nerves Diseases Disability Benefits Questionnaire Va Form 21-0960c-3 - Cranial Nerves Diseases Disability Benefits Questionnaire Legal
Va Form 21-0960a-2 - Artery And Vein Conditions (vascular Diseases Including Varicose Veins) Disability Benefits Questionnaire Va Form 21-0960a-2 - Artery And Vein Conditions (vascular Diseases Including Varicose Veins) Disability Benefits Questionnaire Legal
Va Form 21-0960f-2 - Skin Diseases Disability Benefits Questionnaire Va Form 21-0960f-2 - Skin Diseases Disability Benefits Questionnaire Legal

Related Categories

Parent category: Legal
Download
Go
Page of 7