Va Form 21-0960q-1 - Chronic Fatigue Syndrome Disability Benefits Questionnaire Page 2
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3SECTION IV - FINDINGS, SIGNS AND SYMPTOMS
4A. DOES THE VETERAN NOW HAVE OR HAS THE VETERAN HAD ANY FINDINGS, SIGNS AND SYMPTOMS ATTRIBUTABLE TO CHRONIC FATIGUE SYNDROME?
YES
NO
(If "Yes," check all that apply):
Debilitating fatigue
Low grade fever
Nonexudative pharyngitis
Palpable or tender cervical or axillary lymph nodes
Generalized muscle aches or weakness
Fatigue lasting 24 hours or longer after exercise
(of a type, severity or pattern that is different from headaches in the pre-morbid state)
Headaches
Migratory joint pain
Neuropsychologic symptoms
Sleep disturbance
Other
(Note: Describe all checked conditions in Item 4B)
4B. PROVIDE A DESCRIPTION OF THE CONDITION(S):
4C. DOES THE VETERAN NOW HAVE OR HAS THE VETERAN HAD ANY COGNITIVE IMPAIRMENT ATTRIBUTABLE TO CHRONIC FATIGUE SYNDROME?
YES
NO
(If "Yes," check all that apply):
Poor attention
Inability to concentrate
Forgetfulness
Confusion
Other cognitive impairments
(Note: Describe all checked conditions in Item 4D)
4D. PROVIDE A DESCRIPTION OF THE CONDITION(S):
4E. SPECIFY FREQUENCY OF SYMPTOMS:
Symptoms wax and wane
Symptoms are nearly constant
Other
(Note: Describe frequency in Item 4F)
4F. PROVIDE A DESCRIPTION OF THE FREQUENCY:
4G. DO THE VETERAN'S SYMPTOMS DUE TO CHRONIC FATIGUE SYNDROME RESTRICT ROUTINE DAILY ACTIVITIES AS COMPARED TO THE PRE-ILLNESS LEVEL?
YES
NO
(If "Yes," specify % of restriction (check all that apply)):
(more than 75% of the pre-illness level of activities are not restricted)
Symptoms restrict routine daily activities by less than 25 % of the pre-illness level
Symptoms restrict routine daily activities to 50% to 75% of the pre-illness level
Symptoms restrict routine daily activities to less than 50% of the pre-illness level
Symptoms are so severe as to restrict routine daily activities almost completely
(If checked, describe frequency with which this occurs):
Symptoms are so severe as to occasionally preclude self-care
(describe):
Other
NOTE: For VA purposes, chronic fatigue syndrome is considered incapacitating only while it requires bed rest and treatment by a physician.
4H. DO THE VETERAN'S SYMPTOMS DUE TO CHRONIC FATIGUE SYNDROME RESULT IN PERIODS OF INCAPACITATION?
YES
NO
(If "Yes," indicate total duration of periods of incapacitation over the past 12 months):
Less than 1 week
At least 1 but less than 2 weeks
At least 2 but less than 4 weeks
At least 4 but less than 6 weeks
At least 6 weeks total duration per year
(describe):
Other
Page 2
VA FORM 21-060Q-1, OCT 2012
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