Va Form 21-0960q-1 - Chronic Fatigue Syndrome Disability Benefits Questionnaire
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3OMB Control No. 2900-0781
Respondent Burden: 15 minutes
CHRONIC FATIGUE SYNDROME 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 THIS 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 CHRONIC FATIGUE SYNDROME?
(If "Yes," complete Item 1B)
YES
NO
(check all that apply)
1B. SELECT THE VETERAN'S CONDITION
CHRONIC FATIGUE SYNDROME
ICD Code:
Date of diagnosis:
(specify)
OTHER
Other diagnosis #1
ICD Code:
Date of diagnosis:
Other diagnosis #2
ICD Code:
Date of diagnosis:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO CHRONIC FATIGUE SYNDROME, LIST USING ABOVE FORMAT:
NOTE - For VA purposes, the diagnosis of chronic fatigue syndrome requires:
(A) New onset of debilitating fatigue severe enough to reduce daily activity to less than 50 percent of the usual level for at least 6 months; and
(B) The exclusion, by history, physical examination, and laboratory tests, of all other clinical conditions that may produce similar symptoms; and
(C) Six or more of the following:
1. Acute onset of the condition
7. Headaches (of a type, severity or pattern that is different from headaches in the pre-morbid state)
2. Low grade fever
8. Migratory joint pains
3. Non-exudative pharyngitis
9. Neuropsychological symptoms
4. Palpable or tender cervical or axillary lymph nodes
10. Sleep disturbance
5. Generalized muscle aches or weakness
6. Fatigue lasting 24 hours or longer after exercise
SECTION II - MEDICAL RECORD REVIEW
2. INDICATE MEDICAL RECORDS REVIEWED IN PREPARATION OF THIS REPORT:
C-FILE (VA ONLY)
OTHER, DESCRIBE:
SECTION III - MEDICAL HISTORY
(including onset and course)
(brief summary):
3A. DESCRIBE THE HISTORY
OF THE VETERAN'S CHRONIC FATIGUE SYNDROME
3B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF CHRONIC FATIGUE SYNDROME?
YES
NO
(If "Yes," are the veteran's symptoms controlled by continuous medication?)
YES
NO
(If "Yes," list only those medications required for the veteran's chronic fatigue syndrome):
3C. HAVE OTHER CLINICAL CONDITIONS THAT MAY PRODUCE SIMILAR SYMPTOMS BEEN EXCLUDED BY HISTORY, PHYSICAL EXAMINATION AND/OR
LABORATORY TESTS TO THE EXTENT POSSIBLE?
(If "No," describe):
YES
NO
3D. DID THE VETERAN HAVE AN ACUTE ONSET OF CHRONIC FATIGUE SYNDROME?
YES
NO
3E. HAS THE DEBILITATING FATIGUE REDUCED DAILY ACTIVITY LEVEL TO LESS THAN 50% OF PRE-ILLNESS LEVEL?
YES
NO
(If "Yes," specify length of time daily activity level has been reduced to less than 50% of pre-illness level):
Less than 6 months
6 months or longer
VA FORM
SUPERSEDES VA FORM 21-0960Q-1, MAR 2011,
Page 1
21-0960Q-1
OCT 2012
WHICH WILL NOT BE USED.
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