Fillable Printable Vba 21 0960F 2 Are
Fillable Printable Vba 21 0960F 2 Are
Vba 21 0960F 2 Are
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.
VA FORM
DEC 2014
21-0960F-2
SKIN DISEASES DISABILITY BENEFITS QUESTIONNAIRE
NAME OF PATIENT/VETERAN (First, Middle Initial, Last)
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
Other diagnosis #1:
Other diagnosis #2:
Acne
Keratinization skin disorders
OMB Approved No. 2900-0776
Respondent Burden: 15 Minutes
Expiration Date: 11/30/2017
SECTION I - DIAGNOSIS
(If, "Yes," complete Item 1B)
NOYES
Chloracne
Urticaria
Alopecia
Primary cutaneous vasculitis
Dermatitis or eczema
DIAGNOSIS:
Infectious skin conditions (including bacterial, fungal, viral, treponemal and parasitic skin conditions)
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO SKIN CONDITIONS (Indicate the category of skin condition, and then provide specific diagnosis in that category)
(Check all that apply)
Bullous disorders
DIAGNOSIS:
DIAGNOSIS:
DIAGNOSIS:
DIAGNOSIS:
DIAGNOSIS:
DIAGNOSIS:
DIAGNOSIS:
DIAGNOSIS:
DIAGNOSIS:
DIAGNOSIS:
DIAGNOSIS:
DIAGNOSIS:
DIAGNOSIS:
DIAGNOSIS:
DIAGNOSIS:
DIAGNOSIS:
1A. DOES THE VETERAN NOW HAVE OR HAS THE VETERAN HAD A SKIN CONDITION?
Hyperhidrosis
Tumors and neoplasms of the skin, including malignant melanoma
Erythema multiforme
Page 1
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. VA reserves the right to confirm the authenticity of ALL DBQ's completed by private health care providers.
Other skin condition
Other diagnosis #3:
Psoriasis
Exfoliative dermatitis (erythroderma)
Cutaneous manifestations of collagen-vascular diseases
Palpulosquamous skin disorders
Vitiligo
ICD Code:Date of Diagnosis:
Date of Diagnosis:ICD Code:
Date of Diagnosis:ICD Code:
Date of Diagnosis:ICD Code:
Date of Diagnosis:ICD Code:
Date of Diagnosis:ICD Code:
Date of Diagnosis:ICD Code:
Date of Diagnosis:ICD Code:
Date of Diagnosis:ICD Code:
Date of Diagnosis:ICD Code:
Date of Diagnosis:ICD Code:
Date of Diagnosis:ICD Code:
Date of Diagnosis:ICD Code:
Date of Diagnosis:ICD Code:
Date of Diagnosis:ICD Code:
Date of Diagnosis:ICD Code:
Date of Diagnosis:ICD Code:
Date of Diagnosis:ICD Code:
ICD Code:Date of Diagnosis:
ICD Code:Date of Diagnosis:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO THE SKIN CONDITIONS, LIST USING ABOVE FORMAT:
SUPERSEDES VA FORM 21-0960F-2, OCT 2012,
WHICH WILL NOT BE USED.
SECTION III - TREATMENT
SECTION II - MEDICAL HISTORY
(If "Yes," check all that apply):
3A. HAS THE VETERAN BEEN TREATED WITH ORAL OR TOPICAL MEDICATIONS IN THE PAST 12 MONTHS FOR ANY SKIN CONDITION?
(If checked, list medication(s):
(If checked, list medication(s):
(Specify condition medication used for):
YES
NO
6 weeks or more, but not constant
Antihistamines
Page 2
(If "Yes," complete Section VII, Tumors and Neoplasms, below)
(Specify condition medication used for):
<6 weeks
6 weeks or more, but not constant
Constant/near-constant
2D. DOES THE VETERAN HAVE ANY SYSTEMIC MANIFESTATIONS DUE TO ANY SKIN DISEASES (such as fever, weight loss or hypoproteinemia associated with
skin conditions such as erythroderma)?
Other topical medications
<6 weeksConstant/near-constant
(Total duration of medication use in past 12 months):
2B. DO ANY OF THE VETERAN'S SKIN CONDITIONS CAUSE SCARRING OR DISFIGUREMENT OF THE HEAD, FACE OR NECK?
(If "Yes," describe and complete additional questionnaires if appropriate)
2C. DOES THE VETERAN HAVE ANY BENIGN OR MALIGNANT SKIN NEOPLASMS (including malignant melanoma)?
YES
NO
(If "Yes," indicate skin condition and describe scarring and/or disfigurement and complete VA Form 21-0960F-1, Scars/Disfigurement
Disability Benefits Questionnaire if appropriate)
YES
NO
(Specify condition medication used for):
6 weeks or more, but not constant<6 weeksConstant/near-constant
(Total duration of medication use in past 12 months):
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S SKIN CONDITIONS (brief summary):
(If checked, list medication(s):
(Specify condition medication used for):
6 weeks or more, but not constant
Topical corticosteroids
<6 weeksConstant/near-constant
(Total duration of medication use in past 12 months):
(Total duration of medication use in past 12 months):
YES
NO
(If checked, list medication(s):
(Specify condition medication used for):
6 weeks or more, but not constant
Immunosuppressive retinoids
<6 weeksConstant/near-constant
(Total duration of medication use in past 12 months):
(If checked, list medication(s):
(If checked, list medication(s):
(Specify condition medication used for):
6 weeks or more, but not constant
(Specify condition medication used for):
6 weeks or more, but not constant
Sympathomimetics
<6 weeksConstant/near-constant
(Total duration of medication use in past 12 months):
Systemic corticosteroids or other immunosuppressive medications
<6 weeksConstant/near-constant
(Total duration of medication use in past 12 months):
(If checked, list medication(s):
Other oral medications
VA FORM 21-0960F-2, DEC 2014
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
SECTION IV - DEBILITATING AND NON-DEBILITATING EPISODES
NOTE - If a medication is used for more than one condition, provide names of all conditions, name of medication used for each condition, and
frequency of use for each condition in Section 10, "Remarks".
(If "Yes," check all that apply)
SECTION III - TREATMENT (Continued)
NOTE - If the veteran's debilitating and/or non-debilitating episodes are due to more than one condition, provide names of all conditions, indicating
severity and frequency of episodes for each condition in Section 10, "Remarks".
Page 3
4B. HAS THE VETERAN HAD ANY NON-DEBILITATING EPISODES OF UTICARIA, PRIMARY CUTANEOUS VASCULITIS, ERYTHEMA MULTIFORME, OR TOXIC
EPIDERMAL NECROLYSIS IN THE PAST 12 MONTHS?
If "Yes," specify condition causing non-debilitating episodes:
YES
NO
Describe episodes (brief summary):
YESNO
None4 or more
Characteristics of non-debilitating episodes:
Occurred despite ongoing immunosuppressive therapy
Responded to treatment with antihistamines or sympathomimetics
If "Yes," specify condition causing debilitating episodes (for example, urticaria, vasculitis, erythema multiforme, or toxic epidermal necrolysis):
4A. HAS THE VETERAN HAD ANY DEBILITATING EPISODES IN THE PAST 12 MONTHS DUE TO URTICARIA, PRIMARY CUTANEOUS VASCULITIS, ERYTHEMA
MULTIFORME, OR TOXIC EPIDERMAL NECROLYSIS?
Describe debilitating episodes
(brief summary):
YES
NO
Number of debilitating episodes in past 12 months:
Required treatment with intermittent systemic immunosuppressive therapy
Number of non-debilitating episodes in past 12 months:
3
3B. HAS THE VETERAN HAD ANY TREATMENTS OR PROCEDURES OTHER THAN SYSTEMIC OR TOPICAL MEDICATIONS IN THE PAST 12 MONTHS
FOR EXFOLIATIVE DERMATITIS OR PAPULOSQUAMOUS DISORDERS?
21
None4 or more
Characteristics of debilitating episodes:
Occurred despite ongoing immunosuppressive therapy
Responded to treatment with antihistamines or sympathomimetics
Required treatment with intermittent systemic immunosuppressive therapy
321
(If checked, date of most recent treatment):
(Specify condition treated):
6 weeks or more, but not constant
UVB (ultraviolet B phototherapy) treatment
<6 weeksConstant/near-constant
(Total duration of medication use in past 12 months):
(If checked, date of most recent treatment):
(Specify condition treated):
6 weeks or more, but not constant
Electron beam therapy
<6 weeksConstant/near-constant
(Total duration of medication use in past 12 months):
(If checked, date of most recent treatment):
(If checked, date of most recent treatment):
(Specify condition treated):
6 weeks or more, but not constant
(Specify condition treated):
6 weeks or more, but not constant
Intensive light therapy
<6 weeksConstant/near-constant
(Total duration of medication use in past 12 months):
PUVA (photo-chemotherapy with psoralen and ultraviolet A) treatment
<6 weeksConstant/near-constant
(Total duration of medication use in past 12 months):
(If checked, date of most recent treatment):
(Specify condition treated):
6 weeks or more, but not constant
Other treatment (Specify treatment):
<6 weeksConstant/near-constant
(Total duration of medication use in past 12 months):
UrticariaPrimary cutaneous vasculitis
Erythema multiformeToxic epidermal necrolysis
VA FORM 21-0960F-2, DEC 2014
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
5A. INDICATE THE VETERAN'S VISIBLE SKIN CONDITIONS; INDICATE THE APPROXIMATE TOTAL BODY AREA AND APPROXIMATE TOTAL EXPOSED BODY AREA
(face, neck and hands) AFFECTED ON CURRENT EXAMINATION (check all that apply)
6. DOES THE VETERAN HAVE ANY OF THE FOLLOWING SKIN CONDITIONS: ACNE, CHLORACNE, VITILIGO, ALOPECIA OR HYPERHIDROSIS?
SECTION VI - SPECIFIC SKIN CONDITIONS
(If checked, indicate severity):
Page 4
SECTION V - PHYSICAL EXAM
Papulosquamous
disorder
Dermatitis
Cutaneous manifestations
of collagen-vascular
diseases
Infections
of the skin
Psoriasis
The veteran does not have any of the above listed visible skin conditions
Eczema
Bullous
disorders
Hyperhidrosis
5B. FOR EACH SKIN CONDITION CHECKED IN ITEM 5A, GIVE SPECIFIC DIAGNOSIS AND DESCRIBE APPEARANCE AND LOCATION:
Unresponsive to treatment; unable to handle paper or tools
Able to handle paper or tools after treatment
Total body area
20% to 40%None5% to <20%>40%<5%
20% to 40%None5% to <20%>40%<5%
20% to 40%None5% to <20%>40%<5%
20% to 40%None5% to <20%>40%<5%
20% to 40%None5% to <20%>40%<5%
(If "Yes," indicate the skin condition and complete appropriate sections)
YESNO
(If checked, indicate percent of scalp affected):
Scarring alopecia
20% to 40%>40%<20%
20% to 40%
(If checked, indicate areas affected by vitiligo):
Vitiligo
Exposed areas affected
No exposed areas affected
None5% to <20%>40%<5%
(If checked, indicate severity and location (check all that apply)):
Acne or chloracne
Affects body areas other than face and neck
Superficial acne (comedones, papules, pustules, superficial cysts) of any extent
Deep acne (deep inflamed nodules and pus-filled cysts
Affects less than 40% of face and neck
Affects 40% or more of face and neck
(If checked, indicate amount of hair loss):
Alopecia areata
Other, describe:Loss of all body hair
Hair loss limited to scalp and face
EXPOSED area
Total body area
EXPOSED area
Total body area
EXPOSED area
Total body area
20% to 40%None5% to <20%>40%<5%
20% to 40%None5% to <20%>40%<5%
20% to 40%None5% to <20%>40%<5%
20% to 40%None5% to <20%>40%<5%
20% to 40%None5% to <20%>40%<5%
20% to 40%None5% to <20%>40%<5%
EXPOSED area
Total body area
EXPOSED area
Total body area
EXPOSED area
20% to 40%None5% to <20%>40%<5%
20% to 40%None5% to <20%>40%<5%
Total body area
EXPOSED area
VA FORM 21-0960F-2, DEC 2014
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
NOTE - VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.
SECTION IX - FUNCTIONAL IMPACT
SECTION XI - PHYSICIAN'S CERTIFICATION AND SIGNATURE
IMPORTANT - Physician please fax the completed form to:
SECTION VIII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of
Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the
United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and personnel
administration) as identified in the VA system of records, 58/VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA, published in the
Federal Register. Your obligation to respond is voluntary. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly associated with
your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for
refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is
considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to
verification through computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this information. We estimate
that you will need an average of 15 minutes to review the instructions, find the information, and complete the form. VA cannot conduct or sponsor a collection of information unless a valid
OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB
Internet Page at www.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
Page 5
9. DO ANY OF THE VETERAN'S SKIN CONDITIONS IMPACT HIS OR HER ABILITY TO WORK?
(If "Yes," describe impact of each of the veteran's skin conditions, providing one or more examples):
YESNO
8. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN SECTION I, DIAGNOSIS?
YES
NO
10. REMARKS
(If any)
11C. DATE SIGNED
11F. PHYSICIAN'S ADDRESS
11B. PHYSICIAN'S PRINTED NAME
(VA Regional Office FAX No.)
11A. PHYSICIAN'S SIGNATURE (Sign in ink)
NOTE - A list of VA Regional Office FAX Numbers can be found at www.benefits.va.gov/disabilityexams or obtained by calling 1-800-827-1000.
11D. PHYSICIAN'S PHONE AND FAX NUMBER
(If "Yes," describe):
SECTION X - REMARKS
SECTION VII - TUMORS AND NEOPLASMS
7A. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DIAGNOSIS?
YESNO
(If "Yes," complete Items 7B through 7E)
7B. IS THE NEOPLASM
BENIGNMALIGNANT
7C. HAS THE VETERAN COMPLETED TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT NEOPLASM
OR METASTASES?
YESNO; WATCHFUL WAITING
(If "Yes," indicate type of treatment the veteran is currently undergoing or has completed (check all that apply)
Treatment completed; currently in watchful waiting status
Surgery, if checked describe:
Radiation therapy, if checked date of most recent treatment:
Antineoplastic chemotherapy, if checked date of most recent treatment:
Other therapeutic procedure, if checked describe procedure:
Other therapeutic treatment, if checked describe treatment:
7D. DOES THE VETERAN CURRENTLY HAVE ANY RESIDUAL CONDITIONS OR COMPLICATIONS DUE TO THE NEOPLASM (including metastases) OR ITS TREATMENT,
OTHER THAN THOSE ALREADY DOCUMENTED IN THE REPORT ABOVE.
YESNO
(If "Yes," list residual conditions and complications - brief summary)
7E. IF THERE ARE ADDITIONAL BENIGN OR MALIGNANT NEOPLASMS OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DIAGNOSIS
DESCRIBE USING THE ABOVE FORMAT
VA FORM 21-0960F-2, DEC 2014
Date(s) of surgery:
Date of completion of treatment or anticipated date of completion:
Date of completion of treatment or anticipated date of completion:
Date of most recent procedure:
Date of completion of treatment or anticipated date of completion:
11E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
