OMB Approved No. 2900-0781
Respondent Burden: 15 minutes
SEIZURE DISORDERS (EPILEPSY) 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
(epilepsy)? (This is the condition the veteran is claiming
1A. DOES THE VETERAN HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH A SEIZURE DISORDER
or for which an exam has been requested)
(If "Yes," complete Item 1B)
YES
NO
(check all that apply):
1B. SELECT THE APPROPRIATE DIAGNOSIS:
TONIC-CLONIC SEIZURES OR GRAND MAL
ICD Code:
Date of diagnosis:
(generalized convulsive seizures)
EPILEPSY
ABSENCE SEIZURES OR PETIT MAL OR ATONIC
ICD Code:
Date of diagnosis:
(generalized non-convulsive seizures)
SEIZURES
(simple partial seizures)
JACKSONIAN
ICD Code:
Date of diagnosis:
FOCAL MOTOR
ICD Code:
Date of diagnosis:
FOCAL SENSORY
ICD Code:
Date of diagnosis:
DIENCEPHALIC EPILEPSY
ICD Code:
Date of diagnosis:
(complex partial
PSYCHOMOTOR EPILEPSY
ICD Code:
Date of diagnosis:
seizures, temporal lobe seizures)
(specify)
OTHER
Other diagnosis #1
ICD Code:
Date of diagnosis:
Other diagnosis #2
ICD Code:
Date of diagnosis:
(epilepsy)
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO SEIZURE DISORDERS
, LIST USING ABOVE FORMAT:
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
(including onset and course)
(epilepsy) (brief summary)
3A. DESCRIBE THE HISTORY
OF THE VETERAN'S SEIZURE DISORDER
:
3B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF EPILEPSY OR SEIZURE ACTIVITY?
(If "Yes," list only those medications required for the veteran's epilepsy or seizure activity)
YES
NO
(such as surgery)
3C. HAS THE VETERAN HAD ANY OTHER TREATMENT
FOR EPILEPSY OR SEIZURE ACTIVITY?
(If "Yes," describe):
YES
NO
3D. HAS THE DIAGNOSIS OF A SEIZURE DISORDER BEEN CONFIRMED?
(If "Yes," describe):
YES
NO
3E. HAS THE VETERAN HAD A WITNESSED SEIZURE?
(If "Yes," describe, including relationship of witnesses to veteran):
YES
NO
VA FORM
SUPERSEDES VA FORM 21-0960C-11, MAR 2011,
Page 1
21-0960C-11
OCT 2012
WHICH WILL NOT BE USED.