Va Form 21-0960c-7 - Fibromyalgia Disability Benefits Questionnaire Page 2
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3SECTION IV - FINDINGS, SIGNS AND SYMPTOMS (Continued)
NOTE - If Mental Health conditions, such as depression due to fibromyalgia are identified, a VA Form 21-0960P-2, Mental Disorders (Other than PTSD) Disability
Benefits Questionnaire must ALSO be completed.
(check all that apply)
B. FREQUENCY OF FIBROMYALGIA SYMPTOMS
NO SYMPTOMS
EPISODIC WITH EXACERBATIONS
PRESENT MORE THAN ONE-THIRD OF THE TIME
CONSTANT OR NEARLY CONSTANT
(If checked, describe):
OFTEN PRECIPITATED BY ENVIRONMENTAL OR EMOTIONAL STRESS OR OVEREXERTION
(describe):
OTHER
(trigger points)
(check all that apply)
C. TENDER POINTS
FOR PAIN
None
All bilaterally
Low cervical region: at anterior aspect of the interspaces between
Right
Left
Both
(If checked, indicate side):
transverse processes of C5-C7
(If checked, indicate side):
Second rib: at second costochondral junction
Right
Left
Both
(If checked, indicate side):
Occiput: at suboccipital muscle insertion
Right
Left
Both
(If checked, indicate side):
Right
Left
Both
Trapezius muscle: midpoint of upper border
(If checked, indicate side):
Right
Left
Both
Supraspinatus Muscle: above medial border of the scapular spine
(If checked, indicate side):
Lateral epicondyle: 2 cm distal to lateral epicondyle
Right
Left
Both
(If checked, indicate side):
Gluteal: at upper outer quadrant of buttocks
Right
Left
Both
(If checked, indicate side):
Greater trochanter: posterior to greater trochanteric prominence
Right
Left
Both
(If checked, indicate side):
Right
Left
Both
Knee: medial joint line
:
(If checked, indicate side):
Right
Left
Both
Other, specify
SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
5. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN SECTION I, DIAGNOSIS?
(If "Yes," describe - brief summary):
YES
NO
SECTION VI - DIAGNOSTIC TESTING
NOTE - If diagnostic test results are in the medical record and reflect the veteran's current condition, repeat testing is not required.
6. ARE THERE ANY SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
(If "Yes," provide type of test or procedure, date and results (brief summary)):
YES
NO
Page 2
VA FORM 21-0960C-7, OCT 2012
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