Form VA Form 21-0960C-3 VA Form 21-0960C-3 Cranial Nerve Conditions Disability Benefits Questionnai

OMB Approved No. 2900-0781
Respondent Burden: 30 Minutes
Expiration Date: XX/XX/XXXX

CRANIAL NERVES DISEASES 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 THIS 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. VA reserves the right to confirm the authenticity of ALL DBQs completed by private
health care providers.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH A CRANIAL NERVE 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. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO CRANIAL NERVE CONDITIONS
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 CRANIAL NERVES, 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
3A. DESCRIBE THE HISTORY (including etiology, onset and course) OF THE VETERAN'S CRANIAL NERVE CONDITION (brief summary):

3B. INDICATE THE CRANIAL NERVES AFFECTED BY THE VETERAN'S CONDITION (check all that apply)
CRANIAL NERVE I (olfactory) (If checked, complete VA Form 21-0960N-3, Loss of Sense of Smell and Taste Disability Benefits Questionnaire)
CRANIAL NERVES II - IV, VI (If checked, complete VA Form 21-0960N-2, Eye Conditions Disability Benefits Questionnaire)
CRANIAL NERVE V (trigeminal)
CRANIAL NERVE VII (facial)
CRANIAL NERVE VIII (If the veteran has hearing loss or tinnitus attributable to any cranial nerve condition, the VA regional office

will schedule a hearing loss or tinnitus exam, as appropriate)
CRANIAL NERVE IX (glossopharyngeal)
CRANIAL NERVE X (vagus)
CRANIAL NERVE XI (spinal accessory)
CRANIAL NERVE XII (hypoglossal)
VA FORM
XXX XXXX

21-0960C-3

SUPERSEDES VA FORM 21-0960C-3, OCT 2012,
WHICH WILL NOT BE USED.

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SECTION IV - FINDINGS, SIGNS AND SYMPTOMS
4. DOES THE VETERAN HAVE FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO ANY CONDITIONS AFFECTING CRANIAL NERVES, V, VII, AND/OR IX-XII?
YES

NO

(If "Yes," indicate symptoms (check all that apply))

A. CONSTANT PAIN, AT TIMES EXCRUCIATING (if checked, indicate location and severity):
Upper face, eye and/or forehead
Right:

Mild

Moderate

Severe

Left:

Mild

Moderate

Severe

Right:

Mild

Moderate

Severe

Left:

Mild

Moderate

Severe

Right:

Mild

Moderate

Severe

Left:

Mild

Moderate

Severe

Right:

Mild

Moderate

Severe

Left:

Mild

Moderate

Severe

Mid face

Lower face

Side of mouth and throat

B. INTERMITTENT PAIN (if checked, indicate location and severity):
Upper face, eye and/or forehead
Right:

Mild

Moderate

Severe

Left:

Mild

Moderate

Severe

Right:

Mild

Moderate

Severe

Left:

Mild

Moderate

Severe

Right:

Mild

Moderate

Severe

Left:

Mild

Moderate

Severe

Right:

Mild

Moderate

Severe

Left:

Mild

Moderate

Severe

Mid face

Lower face

Side of mouth and throat

C. DULL PAIN (if checked, indicate location and severity):
Upper face, eye and/or forehead
Right:

Mild

Moderate

Severe

Left:

Mild

Moderate

Severe

Right:

Mild

Moderate

Severe

Left:

Mild

Moderate

Severe

Right:

Mild

Moderate

Severe

Left:

Mild

Moderate

Severe

Right:

Mild

Moderate

Severe

Left:

Mild

Moderate

Severe

Mid face

Lower face

Side of mouth and throat

D. PARESTHESIAS AND/OR DYSESTHESIAS (if checked, indicate location and severity):
Upper face, eye and/or forehead
Right:

Mild

Moderate

Severe

Left:

Mild

Moderate

Severe

Right:

Mild

Moderate

Severe

Left:

Mild

Moderate

Severe

Right:

Mild

Moderate

Severe

Left:

Mild

Moderate

Severe

Right:

Mild

Moderate

Severe

Left:

Mild

Moderate

Severe

Mid face

Lower face

Side of mouth and throat

VA FORM 21-0960C-3, XXX XXXX

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SECTION IV - FINDINGS, SIGNS AND SYMPTOMS (Continued)
4. DOES THE VETERAN HAVE FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO ANY CONDITIONS AFFECTING CRANIAL NERVES, V, VII, AND/OR IX-XII?

(Continued)

E. NUMBNESS (if checked, indicate location and severity):
Upper face, eye and/or forehead
Right:

Mild

Moderate

Severe

Left:

Mild

Moderate

Severe

Right:

Mild

Moderate

Severe

Left:

Mild

Moderate

Severe

Right:

Mild

Moderate

Severe

Left:

Mild

Moderate

Severe

Mid face

Lower face

Side of mouth and throat
Right:

Mild

Moderate

Severe

Left:

Mild

Moderate

Severe

F. DIFFICULTY CHEWING (If checked, indicate severity):
Mild

Moderate

Severe

G. DIFFICULTY SWALLOWING (If checked, indicate severity):
Mild

Moderate

Severe

H. DIFFICULTY SPEAKING (If checked, indicate severity):
Mild

Moderate

Severe

I. INCREASED SALIVATION (If checked, indicate severity):
Mild

Moderate

Severe

J. DECREASED SALIVATION (If checked, indicate severity):
Mild

Moderate

Severe

K. GASTROINTESTINAL SYMPTOMS (If checked, indicate severity):
Mild

Moderate

Severe

L. OTHER SYMPTOMS (If checked, describe):

SECTION V - MUSCLE STRENGTH TESTING
5. MUSCLE STRENGTH TESTING (Rate strength using the following levels to estimate strength of muscle groups. This summary provides useful information for VA

purposes)

ALL NORMAL
A. Cranial nerve V: (Motor: muscles of mastication; clench jaw, palpate masseter, temporalis)
RIGHT:

Normal

Mild

Moderate

Severe

Complete paralysis

LEFT:

Normal

Mild

Moderate

Severe

Complete paralysis

B. Cranial nerve VII, upper portion of face: (Motor: muscles of facial expression, shuts eyes tightly)
RIGHT:

Normal

Mild

Moderate

Severe

Complete paralysis

LEFT:

Normal

Mild

Moderate

Severe

Complete paralysis

C. Cranial nerve VII, lower portion of face: (Motor: muscles of facial expression; grins)
RIGHT:

Normal

Mild

Moderate

Severe

Complete paralysis

LEFT:

Normal

Mild

Moderate

Severe

Complete paralysis

D. Cranial nerve IX, X: (Motor: swallow, cough, palate elevation; "say ah", gag reflex if indicated)
RIGHT:

Normal

Mild

Moderate

Severe

Complete paralysis

LEFT:

Normal

Mild

Moderate

Severe

Complete paralysis

E. Cranial nerve XI: (Motor: trapezius, sternocleidomastoid; shoulder shrug, turn head against resistance)
RIGHT:

Normal

Mild

Moderate

Severe

Complete paralysis

LEFT:

Normal

Mild

Moderate

Severe

Complete paralysis

F. Cranial nerve XII: (Motor: protrude tongue, move tongue from side to side)
RIGHT:

Normal

Mild

Moderate

Severe

Complete paralysis

LEFT:

Normal

Mild

Moderate

Severe

Complete paralysis

VA FORM 21-0960C-3, XXX XXXX

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SECTION VI - SENSORY EXAM
6. PROVIDE RESULTS FOR SENSATION TESTING TO LIGHT TOUCH FOR FACIAL SENSATION:
ALL NORMAL
Cranial nerve V:
Upper face and forehead
RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

Mid face

Lower face

SECTION VII - CRANIAL NERVE SUMMARY EVALUATION

7A. INDICATE THE CRANIAL NERVE(S) AFFECTED. FOR EACH NERVE, INDICATE SEVERITY ("degree of paralysis"), BASING THE RESPONSES ON SYMPTOMS
AND FINDINGS FROM THE ABOVE EXAM. THIS SECTION PROVIDES AN ESTIMATION OF THE SEVERITY OF THE VETERAN'S CRANIAL NERVE CONDITION,
WHICH IS USEFUL FOR VA PURPOSES.

NOTE: For VA purposes, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the description of complete paralysis
that is given below with each nerve, whether due to a varied level of the nerve lesion or to partial regeneration.
Cranial nerve V (trigeminal)
RIGHT:

Not affected

Incomplete, moderate

Incomplete, severe

Complete

LEFT:

Not affected

Incomplete, moderate

Incomplete, severe

Complete

Cranial nerve VII (facial)
RIGHT:

Not affected

Incomplete, moderate

Incomplete, severe

Complete

LEFT:

Not affected

Incomplete, moderate

Incomplete, severe

Complete

Cranial nerve IX (glossopharyngeal)
RIGHT:

Not affected

Incomplete, moderate

Incomplete, severe

Complete

LEFT:

Not affected

Incomplete, moderate

Incomplete, severe

Complete

Cranial nerve X (vagus)
RIGHT:

Not affected

Incomplete, moderate

Incomplete, severe

Complete

LEFT:

Not affected

Incomplete, moderate

Incomplete, severe

Complete

Cranial nerve XI (spinal accessory)
RIGHT:

Not affected

Incomplete, moderate

Incomplete, severe

Complete

LEFT:

Not affected

Incomplete, moderate

Incomplete, severe

Complete

Cranial nerve XII (hypoglossal)
RIGHT:

Not affected

Incomplete, moderate

Incomplete, severe

Complete

LEFT:

Not affected

Incomplete, moderate

Incomplete, severe

Complete

SECTION VII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS

8A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
SECTION I, DIAGNOSIS?
NO

YES

(If "Yes," are any of the scars painful and/or unstable, or is the total area of all related scars greater than 39 square cm (6 square inches)?
YES

NO

(If "Yes," also complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)
8B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN SECTION 1, DIAGNOSIS?
YES

NO

(If "Yes," describe (brief summary):

VA FORM 21-0960C-3, XXX XXXX

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SECTION IX - DIAGNOSTIC TESTING

NOTE - For the purpose of this examination, diagnostic or imaging studies are usually not required to diagnose specific cranial nerve conditions in
the appropriate clinical setting.
9A. HAVE IMAGING OR OTHER DIAGNOSTIC STUDIES BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

(If "Yes," provide type of study, date and results)

9B. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES

NO

(If "Yes," provide type of test or procedure, date and results - brief summary)

SECTION X - FUNCTIONAL IMPACT AND REMARKS
10. DOES THE VETERAN'S CRANIAL NERVE CONDITION IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe impact of each of the veteran's cranial nerve conditions, providing one or more examples)

SECTION XI - REMARKS
11. REMARKS (If any)

SECTION XII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
12A. PHYSICIAN'S SIGNATURE

12D. PHYSICIAN'S PHONE NUMBER

12B. PHYSICIAN'S PRINTED NAME

12E. PHYSICIAN'S MEDICAL LICENSE NUMBER

12C. DATE SIGNED

12F. PHYSICIAN'S ADDRESS

NOTE - VA may request additional medical information, including additional examinations if necessary to complete VA's review of the veteran's application.

IMPORTANT - Physician please fax the completed form to
(VA Regional Office FAX No.)

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.
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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, 58VA21/22/28, Compensation,
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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
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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
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get information on where to send comments or suggestions about this form.
VA FORM 21-0960C-3, XXX XXXX

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