Va Form 21-0960f-1 - Scars/disfigurement Disability Benefits Questionnaire

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OMB Approved No. 2900-0776

Respondent Burden: 15 minutes

SCARS/DISFIGUREMENT 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 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 HAVE ONE OR MORE SCARS ANYWHERE ON THE BODY, OR DISFIGUREMENT OF THE HEAD, FACE, OR NECK?

(If "Yes," complete Item 1B)

YES

1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO SCARS ANYWHERE ON THE BODY, OR DISFIGUREMENT OF THE HEAD, FACE, OR NECK:

DIAGNOSIS # 1:

ICD CODE:

DATE OF DIAGNOSIS:

DIAGNOSIS # 2:

ICD CODE:

DATE OF DIAGNOSIS:

DIAGNOSIS # 3:

ICD CODE:

DATE OF DIAGNOSIS:

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO SCARS ANYWHERE ON THE BODY, OR DISFIGUREMENT OF THE HEAD, FACE, OR NECK DUE

TO SCARS OR OTHER CAUSES, LIST USING ABOVE FORMAT:

INSTRUCTIONS: Provide all linear measurements in centimeters and area measurements in centimeters squared.

For non-linear scars, measure the length and width at their widest points.

After measuring the scars, use the summary sections to provide the combined approximate total area for all scars in each region.

If scars are too numerous to count (for example, multiple scattered shrapnel wound scars, acne scarring or pseudofolliculitis barbae), indicate “TNTC” and provide

approximate combined total area.

NOTE: For VA purposes, superficial non-linear scars are those not associated with underlying soft tissue damage, while deep non-linear scars are associated with

underlying soft tissue damage.

SECTION II - SCARS OF THE TRUNK AND EXTREMITIES

2. DOES THE VETERAN HAVE ANY SCARS ON THE TRUNK OR EXTREMITIES (REGIONS OTHER THAN THE HEAD, FACE OR NECK)?

(If "Yes," complete this section)

(If "No," skip to Section III)

YES

2-1 - MEDICAL HISTORY

(including cause/origin and course)

(brief summary):

A. DESCRIBE THE HISTORY

OF THE VETERAN'S SCAR(S) OF THE TRUNK OR EXTREMITIES

B. ARE ANY OF THE SCARS OF THE TRUNK OR EXTREMITIES PAINFUL?