Fillable Va Form 21-0960c-7 - Fibromyalgia Disability Benefits Questionnaire printable pdf download

Va Form 21-0960c-7 - Fibromyalgia Disability Benefits Questionnaire

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OMB Approved No. 2900-0781

Respondent Burden: 15 minutes

FIBROMYALGIA 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 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

NOTE - Fibromyalgia may also be called fibrositis or primary fibromyalgia syndrome.

(This is the condition the veteran is claiming or for which an

1A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER BEEN DIAGNOSED WITH FIBROMYALGIA?

exam has been requested)

(If "Yes," complete Item 1B)

YES

(check all that apply)

1B. SELECT THE VETERAN'S CONDITION

FIBROMYALGIA

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 FIBROMYALGIA, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL RECORD REVIEW

2. INDICATE MEDICAL RECORDS REVIEWED IN PREPARATION OF THIS REPORT:

(VA ONLY)

C-FILE

(Describe):

OTHER

SECTION III - MEDICAL HISTORY

(including onset and course)

3A. DESCRIBE THE HISTORY

OF THE VETERAN'S FIBROMYALGIA CONDITION:

3B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF FIBROMYALGIA SYMPTOMS?

(If "Yes," list only those medications required for the veteran's fibromyalgia condition):

YES

3C. IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR THIS CONDITION?

(If "Yes," describe):

YES

3D. ARE THE VETERAN'S FIBROMYALGIA SYMPTOMS REFRACTORY TO THERAPY?

(If "Yes," describe):

YES

SECTION IV - FINDINGS, SIGNS AND SYMPTOMS

4. DOES THE VETERAN CURRENTLY HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO FIBROMYALGIA?

(If "Yes," complete items 4A thru 4C)

YES

NOTE: For VA purposes widespread musculoskeletal pain means that pain occurs in both sides of the body, both

WIDESPREAD MUSCULOSKELETAL PAIN (

above and below the waist and affecting both the axial skeleton (i.e., cervical spine, anterior chest, thoracic spine or low back) and the extremities)

STIFFNESS

(If checked, describe)

MUSCLE WEAKNESS

FATIGUE

SLEEP DISTURBANCES

PARESTHESIAS

HEADACHE

DEPRESSION

ANXIETY

IRRITABLE BOWEL SYMPTOMS

RAYNAUD'S-LIKE SYMPTOMS

(describe):