Va Form 21-0960c-2 - Amyotrophic Lateral Sclerosis (Lou Gehrig'S Disease) Disability Benefits Questionnaire Page 5
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
1
2
3
4
5
6
7SECTION VII - HOUSEBOUND
(or if institutionalized, to the ward or clinical areas)?
7A. IS THE VETERAN SUBSTANTIALLY CONFINED TO HIS OR HER DWELLING AND THE IMMEDIATE PREMISES
(If "Yes," complete Item 7B)
YES
NO
(If "Yes," describe how often per day or week and under what circumstances the veteran is able to leave the home or immediate premises):
7B. DOES THE VETERAN HAVE MORE THAN ONE CONDITION CONTRIBUTING TO HIS OR HER BEING HOUSEBOUND?
(If "Yes," list conditions and describe how each condition contributes to causing the veteran to be housebound):
YES
NO
Describe how condition #1 contributes to causing the veteran to be housebound:
Condition # 1:
Describe how condition #2 contributes to causing the veteran to be housebound:
Condition # 2
Condition # 3:
Describe how condition #3 contributes to causing the veteran to be housebound:
7C. IF THE VETERAN HAS ADDITIONAL CONDITIONS CONTRIBUTING TO CAUSING THE VETERAN TO BE HOUSEBOUND, LIST USING FORMAT SHOWN IN
ITEM 7B?
SECTION VIII - AID AND ATTENDANCE
8A. IS THE VETERAN ABLE TO DRESS OR UNDRESS HIM OR HERSELF WITHOUT ASSISTANCE?
YES
NO
(If "No," is this limitation caused by the veteran's ALS?)
Yes
No
8B. DOES THE VETERAN HAVE SUFFICIENT UPPER EXTREMITY COORDINATION AND STRENGTH TO BE ABLE TO FEED HIM OR HERSELF WITHOUT ASSISTANCE?
YES
NO
(If "No," is this limitation caused by the veteran's ALS?)
Yes
No
8C. IS THE VETERAN ABLE TO ATTEND TO THE WANTS OF NATURE (toileting) WITHOUT ASSISTANCE?
YES
NO
(If "No," is this limitation caused by the veteran's ALS?)
Yes
No
8D. IS THE VETERAN ABLE TO BATHE HIM OR HERSELF WITHOUT ASSISTANCE?
YES
NO
(If "No," is this limitation caused by the veteran's ALS?)
Yes
No
8E. IS THE VETERAN ABLE TO KEEP HIM OR HERSELF ORDINARILY CLEAN AND PRESENTABLE WITHOUT ASSISTANCE?
YES
NO
(If "No," is this limitation caused by the veteran's ALS?)
Yes
No
8F. DOES THE VETERAN NEED FREQUENT ASSISTANCE FOR ADJUSTMENT OF ANY SPECIAL PROSTHETIC OR ORTHOPEDIC APPLIANCE(S)
(If "Yes," describe):
YES
NO
NOTE: For VA purposes, "bedridden" will be that condition which actually requires that the claimant remain in bed. The fact that claimant has voluntarily taken to bed
or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice.
8G. IS THE VETERAN BEDRIDDEN?
YES
NO
(If "Yes," is it due to the veteran's ALS?)
Yes
No
8H. DOES THE VETERAN REQUIRE CARE AND/OR ASSISTANCE ON A REGULAR BASIS DUE TO HIS OR HER PHYSICAL AND/OR MENTAL DISABILITIES IN ORDER
TO PROTECT HIM OR HERSELF FROM THE HAZARDS AND/OR DANGERS INCIDENT TO HIS OR HER DAILY ENVIRONMENT?
YES
NO
(If "Yes," is it due to the veteran's ALS?)
Yes
No
8I. LIST ANY CONDITION(S), IN ADDITION TO THE VETERAN'S ALS, THAT CAUSES ANY OF THE ABOVE LIMITATIONS:
Page 5
VA FORM 21-0960C-2, OCT 2012
ADVERTISEMENT
0 votes
Related Articles
Related forms
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
Legal
Va Form 21-0960h-1 - Hernias (including Abdominal, Inguinal And Femoral Hernias) Disability Benefits Questionnaire
Legal
Va Form 21-0960c-5 - Central Nervous System And Neuromuscular Diseases Disability Benefits Questionnaire
Legal
Related Categories
Parent category: Legal