Va Form 21-0960e-2 - Endocrine Diseases (Other Than Thyroid, Parathyroid Or Diabetes Mellitus) Disability Benefits Questionnaire
Download a blank fillable Va Form 21-0960e-2 - Endocrine Diseases (Other Than Thyroid, Parathyroid Or Diabetes Mellitus) Disability Benefits Questionnaire in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Va Form 21-0960e-2 - Endocrine Diseases (Other Than Thyroid, Parathyroid Or Diabetes Mellitus) Disability Benefits Questionnaire with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4OMB Control No. 2900-0781
Respondent Burden: 15 minutes
ENDOCRINE DISEASES (Other than Thyroid, Parathyroid or Diabetes
Mellitus) 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.
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
NAME OF PATIENT/VETERAN
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 OR HAS HE/SHE EVER HAD AN ENDOCRINE CONDITION? (This is the condition the veteran is claiming or for which an exam has been
requested)
YES
NO (If "Yes," complete Item 1B)
1B. SELECT THE VETERAN'S CONDITION (Check all that apply)
Date of diagnosis - ______________
CUSHING'S SYNDROME
ICD code - _____________
ACROMEGALY
Date of diagnosis - ______________
ICD code - _____________
DIABETES INSIPIDUS
ICD code - _____________
Date of diagnosis - ______________
ICD code - _____________
Date of diagnosis - ______________
ADDISON'S DISEASE
POLYGLANDULAR (Pluriglandular) SYNDROME
ICD code - _____________
Date of diagnosis - ______________
Date of diagnosis - ______________
ICD code - _____________
HYPOPITUITARISM
Date of diagnosis - ______________
ICD code - _____________
HYPERPITUITARISM
Date of diagnosis - ______________
ICD code - _____________
HYPERALDOSTERONISM
Date of diagnosis - ______________
ICD code - _____________
PHEOCHROMOCYTOMA
Date of diagnosis - ______________
HYPOGONADISM
ICD code - _____________
Date of diagnosis - ______________
OSTEOPOROSIS
ICD code - _____________
OTHER (specify):
OTHER DIAGNOSIS #1:
ICD code - _____________
Date of diagnosis - ______________
Date of diagnosis - ______________
ICD code - _____________
OTHER DIAGNOSIS #2:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO ENDOCRINE CONDITION(S), LIST USING ABOVE FORMAT:
NOTE: If there are any cardiovascular, psychiatric, eye, skin or skeletal complications attributable to an endocrine condition, ALSO complete appropriate questionnaires if
indicated.
SECTION II - MEDICAL RECORD REVIEW
2. INDICATE MEDICAL RECORDS REVIEWED IN PREPARATION OF THIS REPORT
C-FILE (VA ONLY)
OTHER, describe:___________________________
SECTION III - MEDICAL HISTORY
3A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S ENDOCRINE CONDITION (brief summary):
3B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF AN ENDOCRINE CONDITION?
YES
NO
(If "Yes," specify the condition and list only those medications required for the veteran's endocrine condition):________________________________________________
_______________________________________________________________________________________________________________________________________
3C. HAS THE VETERAN HAD SURGERY FOR AN ENDOCRINE CONDITION?
YES
NO
(If "Yes," specify the condition and type of surgery):__________________________________________________
(Date of surgery):_____________
3D. HAS THE VETERAN HAD ANY OTHER TYPE OF TREATMENT FOR AN ENDOCRINE CONDITION?
YES
NO
(If "Yes," specify the condition and type of treatment):__________________________________________________
(Date of treatment):_____________
VA FORM
21-0960E-2
Page 1
MAR 2011
ADVERTISEMENT
0 votes
Related Articles
Related forms
Va Form 21-0960i-3 - Infectious Diseases (other Than Hiv-related Illness, Chronic Fatigue Syndrome, Or Tuberculosis) Disability Benefits Questionnaire
Legal
Va Form 21-0960g-3 - Intestinal Conditions (other Than Surgical Or Infectious) (including Irritable Bowel Syndrome, Crohn's Disease, Ulcerative Colitis, And Diverticulitis) Disability Benefits Questionnaire
Legal
Va Form 21-0960m-6 - Foot Miscellaneous (other Than Flatfoot/pes Planus) Disability Benefits Questionnaire
Legal
Va Form 21-0960a-2 - Artery And Vein Conditions (vascular Diseases Including Varicose Veins) Disability Benefits Questionnaire
Legal
Related Categories
Parent category: Legal