OMB Approved No. 2900-0778
Respondent Burden: 15 minutes
OSTEOMYELITIS 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 NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH OSTEOMYELITIS?
(If "No," complete Item 1B)
YES
NO
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO OSTEOMYELITIS
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 OSTEOMYELITIS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
(brief summary):
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S OSTEOMYELITIS
2B. INDICATE LOCATION OF INITIAL INFECTION (Check all that apply):
PELVIS
CERVICAL VERTEBRAE
THORACOLUMBAR VERTEBRAE
LONG BONES OF UPPER EXTREMITY
Side affected:
Right
Left
LONG BONES OF LOWER EXTREMITY
Side affected:
Right
Left
Left digit(s) affected:
Right digit(s) affected:
FINGER(S):
Left digit(s) affected:
TOE(S):
Right digit(s) affected:
OTHER, Specify:
EXTENSION INTO JOINTS
If checked, indicate joints affected:
Right:
Shoulder
Elbow
Wrist
Hip
Knee
Ankle
Multiple hand joints
Multiple foot joints
Left:
Shoulder
Elbow
Wrist
Hip
Knee
Ankle
Multiple hand joints
Multiple foot joints
OTHER, Specify:
2C. HAS THE VETERAN HAD MEDICAL TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING MEDICAL TREATMENT FOR OSTEOMYELITIS?
YES
NO
(If "Yes," describe treatment)
:
Date treatment started:
Date treatment completed or anticipated date of completion:
VA FORM
21-0960M-11
Page 1
SUPERSEDES VA FORM 21-0960M-11, FEB 2011,
OCT 2012
WHICH WILL NOT BE USED.