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Vba 21 0960N 1 Are

VA FORM
SEP 2016
21-0960N-1
EAR CONDITIONS (INCLUDING VESTIBULAR AND INFECTIOUS
CONDITIONS) DISABILITY BENEFITS QUESTIONNAIRE
2B. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING CONTINUOUS MEDICATION FOR THE DIAGNOSED CONDITION?
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH AN EAR OR PERIPHERAL VESTIBULAR CONDITION?
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 DBQs completed by private health care providers.
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO EAR OR PERIPHERAL VESTIBULAR CONDITIONS, LIST USING ABOVE FORMAT:
OMB Control No. 2900-0778
Respondent Burden: 15 Minutes
Expiration Date: 09/30/2019
SECTION I - DIAGNOSIS
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S EAR OR PERIPHERAL VESTIBULAR CONDITIONS (brief summary):
SECTION II - MEDICAL HISTORY
NOYES
YESNO
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.
1B. SELECT THE VETERAN'S CONDITION (check all that apply):
Meniere's syndrome or endolymphatic hydrops
Peripheral vestibular disorder
Benign Paroxysmal Positional Vertigo (BPPV)
Chronic otitis externa
Chronic suppurative otitis media
Chronic nonsuppurative otitis media (serous otitis media)
Mastoiditis
Cholesteatoma
Otosclerosis
(If the veteran has hearing loss or tinnitus attributable to any
ear condition, the VA regional office will schedule a hearing
loss or tinnitus exam, as appropriate)
Benign neoplasm of the ear (other than skin only)
Malignant neoplasm of the ear (other than skin only)
Other, specify:
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:
Other, diagnosis #1:
Date of Diagnosis:ICD Code:
Other, diagnosis #2: Date of Diagnosis:ICD Code:
IF YES, LIST ONLY THOSE MEDICATIONS USED FOR THE DIAGNOSED CONDITION:
Page 1
ICD Code:
Date of Diagnosis:ICD Code:
Date of diagnosis:
(If "Yes," complete Item 1B)
(If the veteran has hearing loss or tinnitus attributable to any
ear condition, the VA regional office will schedule a hearing
loss or tinnitus exam, as appropriate)
SUPERSEDES VA FORM 21-0960N-1, OCT 2014,
WHICH WILL NOT BE USED.
NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed below. If there is no diagnosis, if the diagnosis is different from a previous
diagnosis for this condition, or if there is a diagnosis of a complication due to the claimed condition, explain your findings and reasons in the Remarks section. Date of diagnosis can be the date
of the evaluation if the clinician is making the initial diagnosis, or an approximate date is determined through record review or reported history.
NAME OF PATIENT/VETERAN (First, Middle Initial, Last)
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
SECTION III - VESTIBULAR CONDITIONS
3. DOES THE VETERAN HAVE ANY OF THE FOLLOWING FINDINGS, SIGNS, OR SYMPTOMS ATTRIBUTABLE TO MENIERE'S SYNDROME (ENDOLYMPHATIC
HYDROPS), A PERIPHERAL VESTIBULAR CONDITION OR ANOTHER DIAGNOSED CONDITION FROM SECTION 1, DIAGNOSIS?
YESNO
IF YES, CHECK ALL THAT APPLY:
Hearing impairment with vertigo
If checked, indicate frequency:
Less than once a month1 to 4 times per monthMore than once weekly
Indicate duration of episodes:< 1 hour
1 to 24 hours> 24 hours
Hearing impairment with attacks of vertigo and cerebellar gait
If checked, indicate frequency:
Less than once a month1 to 4 times per monthMore than once weekly
Indicate duration of episodes:< 1 hour
1 to 24 hours> 24 hours
Tinnitus, unilateral or bilateral
If checked, indicate frequency:
Less than once a month1 to 4 times per monthMore than once weekly
Indicate duration of episodes:< 1 hour
1 to 24 hours> 24 hours
Vertigo
If checked, indicate frequency:
Less than once a month1 to 4 times per monthMore than once weekly
Indicate duration of episodes:< 1 hour
1 to 24 hours> 24 hours
Staggering
If checked, indicate frequency:
Less than once a month1 to 4 times per monthMore than once weekly
Indicate duration of episodes:< 1 hour
1 to 24 hours> 24 hours
Hearing impairment and/or tinnitus
If checked, the VA regional office will schedule a hearing loss or tinnitus exam as appropriate.
Other, describe:
SECTION IV - INFECTIOUS, INFLAMMATORY AND OTHER EAR CONDITIONS
NOYES
4A. DOES THE VETERAN HAVE ANY OF THE FOLLOWING FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO CHRONIC EAR INFECTION, INFLAMMATION,
CHOLESTEATOMA OR ANY OF THE DIAGNOSES LISTED IN SECTION 1, DIAGNOSIS?
IF YES, CHECK ALL THAT APPLY:
Swelling
(external ear canal)
If checked, describe:
Dry and scaly (external ear canal)
Serous discharge (external ear canal)
Itching (external ear canal)
Effusion
Active suppuration
Aural polyps
Hearing impairment and/or tinnitus
If checked, the VA regional office will schedule a hearing loss or tinnitus exam as appropriate.
Facial nerve paralysis
If checked, ALSO complete Cranial Nerves Questionnaire.
Bone loss of skull
If checked, indicate severity:
Area lost smaller than an American quarter
(4.619 cm2)
Area lost larger than an American quarter but smaller than a 50-cent piece
Area lost larger than an American 50-cent piece (7.355 cm2)
Requiring frequent and prolonged treatment
If checked, describe type and durations of treatment:
Other, describe:
4B. DOES THE VETERAN HAVE A BENIGN NEOPLASM OF THE EAR (other than skin only, such as keloid) THAT CAUSES ANY IMPAIRMENT OF FUNCTION?
NOYES
IF YES, DESCRIBE IMPAIRMENT OF FUNCTION CAUSED BY THIS CONDITION:
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VA FORM 21-0960N-1, SEP 2016
PATIENT/VETERAN'S SOCIAL SECURITY NO.
Page 3
SECTION V - SURGICAL TREATMENT
NOYES
5A. HAS THE VETERAN HAD SURGICAL TREATMENT FOR ANY EAR CONDITION?
IF YES, INDICATE TYPE OF SURGERY:
Date:Side affected:
RightLeftBoth
5B. DOES THE VETERAN HAVE ANY RESIDUALS AS A RESULT OF THE SURGERY?
NO
YESIF YES, DESCRIBE:
SECTION VI - PHYSICAL EXAM
6A. EXTERNAL EAR:
Exam of external ear not indicated
Normal
Deformity of auricle, with loss of less than one-third of the substance
If checked, specify side:LeftRight
Deformity of auricle, with loss of one-third or more of the substance
If checked, specify side:LeftRight
Complete loss of auricle
If checked, specify side:LeftRight
Other abnormality, describe:
6B. EAR CANAL:
Exam of ear canal not indicated
Normal
Abnormal, describe:
6C. TYMPANIC MEMBRANE:
Exam of tympanic membrane not indicated
Normal
Perforated tympanic membrane
Left
RightIf checked, specify side affected:
Evidence of a healed tympanic membrane perforation
Left
RightIf checked, specify side affected:
Other abnormality, describe:
6D. GAIT:
Exam of gait not indicated
Normal
Unsteady, describe:
Other abnormality, describe:
6E. ROMBERG TEST:
Exam using this test not indicated
Normal or negative
Abnormal or positive for unsteadiness
6F. DIX HALLPIKE TEST (Nylen-Barany test) FOR VERTIGO:
Exam using this test not indicated
Normal, no vertigo or nystagmus during test
Abnormal, vertigo or nystagmus during test, describe:
6G. LIMB COORDINATION TEST (finger-nose-finger):
Abnormal, describe:
Normal
Exam using this test not indicated
VA FORM 21-0960N-1, SEP 2016
PATIENT/VETERAN'S SOCIAL SECURITY NO.
IF YES, ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT DISABILITY BENEFITS QUESTIONNAIRE.
IF NO, PROVIDE LOCATION AND MEASURMENTS OF SCAR IN CENTIMETERS.
LOCATION:
MEASUREMENTS: Length cm X width cm.
Page 4
SECTION VIII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
SECTION VII - TUMORS AND NEOPLASMS
7A. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES LISTED IN SECTION 1, DIAGNOSIS?
7B. IS THE NEOPLASM
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?
7E. IF THERE ARE ADDITIONAL BENIGN OR MALIGNANT NEOPLASMS OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION 1, DIAGNOSIS,
DESCRIBE USING THE ABOVE FORMAT:
7C. HAS THE VETERAN COMPLETED TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT NEOPLASM
OR METASTASES?
NO
YES
Treatment completed; currently in watchful waiting status
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 most recent treatment:
Antineoplastic chemotherapy
Other therapeutic procedure
Radiation therapy
If checked, describe:
Date of most recent treatment:
Date(s) of surgery:
IF YES, INDICATE TYPE OF TREATMENT THE VETERAN IS CURRENTLY UNDERGOING OR HAS COMPLETED
(check all that apply):
NO; WATCHFUL WAITING
YESNO
BENIGNMALIGNANT
YES
IF YES, COMPLETE THE FOLLOWING:
IF YES, LIST RESIDUAL CONDITIONS AND COMPLICATIONS (brief summary):
8A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN THE
DIAGNOSIS SECTION?
NOYES
If checked, describe procedure:
Other therapeutic treatment
If checked, describe treatment:
Date of completion of treatment or anticipated date of completion:
NOYES
IF YES, ARE ANY OF THE SCARS PAINFUL OR UNSTABLE; HAVE A TOTAL AREA EQUAL TO OR GREATER THAN 39 SQUARE CM (6 square inches);OR ARE
LOCATED ON THE HEAD, FACE OR NECK?
IF YES, DESCRIBE
(brief summary):
NOYES
8B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN THE DIAGNOSIS SECTION?
VA FORM 21-0960N-1, SEP 2016
NOTE: An "unstable scar" is one where, for any reason, there is frequent loss of covering of the skin over the scar. If there are multiple scars, enter additional locations and measurements
in the Remarks section below. It is not necessary to also complete a Scars DBQ.
PATIENT/VETERAN'S SOCIAL SECURITY NO.
NOTE - IF THE VETERAN HAS HEARING LOSS OR TINNITUS, THE VA REGIONAL OFFICE WILL SCHEDULE A HEARING LOSS OR TINNITUS EXAM, AS APPROPRIATE.
12C. DATE SIGNED
12E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER12F. PHYSICIAN'S ADDRESS
12B. PHYSICIAN'S PRINTED NAME12A. PHYSICIAN'S SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
NOTE - A list of VA Regional Office FAX Numbers can be found at www.benefits.va.gov/disabilityexamsor obtained by calling 1-800-827-1000.
SECTION XII - PHYSICIAN'S CERTIFICATION AND SIGNATURE
12D. PHYSICIAN'S PHONE AND FAX NUMBER
(VA Regional Office FAX No.)
IMPORTANT - Physician please fax the completed form to
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.
NOTE - VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.
SECTION XI - REMARKS
11. REMARKS (If any)
SECTION X - FUNCTIONAL IMPACT
10. DO ANY OF THE VETERAN'S EAR OR PERIPHERAL VESTIBULAR CONDITIONS IMPACT HIS OR HER ABILITY TO WORK?
NO
YES
IF YES, DESCRIBE IMPACT OF EACH OF THE VETERAN'S EAR OR PERIPHERAL VESTIBULAR CONDITIONS, PROVIDING ONE OR MORE EXAMPLES:
NO
YES
9B. HAS THE VETERAN HAD AN AUDIOGRAM?
IF YES, ATTACH OR PROVIDE RESULTS:
9C. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
NO
YES
IF YES, PROVIDE TYPE OF TEST OR PROCEDURE, DATE AND RESULTS (brief summary):
Page 5
SECTION IX - DIAGNOSTIC TESTING
NOTE: If testing has been performed and reflects veteran's current condition, no further testing is required for this examination report.
9A. HAVE DIAGNOSTIC IMAGING STUDIES OR OTHER DIAGNOSTIC PROCEDURES BEEN PERFORMED?
NO
YES
IF YES, CHECK ALL THAT APPLY:
Magnetic resonance imaging
(MRI)
Date:Results:
Computerized axial tomography (CT)
Date:Results:
Electronystagmography (ENG)
Date:Results:
Other, specify:
Date:Results:
VA FORM 21-0960N-1, SEP 2016
PATIENT/VETERAN'S SOCIAL SECURITY NO.
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