Form VA Form 21-0960C-5 VA Form 21-0960C-5 CENTRAL NERVOUS SYSTEM AND NEUROMUSCULAR DISEASES

OMB Approved No. 2900-0778
Respondent Burden: 30 Minutes
Expiration Date: XX/XX/XXXX

CENTRAL NERVOUS SYSTEM AND NEUROMUSCULAR DISEASES
(EXCEPT TRAUMATIC BRAIN INJURY, AMYOTROPHIC LATERAL SCLEROSIS, PARKINSON'S
DISEASE, MULTIPLE SCLEROSIS, HEADACHES, TMJ CONDITIONS, EPILEPSY, NARCOLEPSY,
PERIPHERAL NEUROPATHY, SLEEP APNEA, CRANIAL NERVE DISORDERS, FIBROMYALGIA,
CHRONIC FATIGUE SYNDROME) 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. 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 CENTRAL NERVOUS SYSTEM (CNS) CONDITION?
YES
NO (If "Yes," complete Item 1B)
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.
1B. SELECT THE VETERAN'S CONDITION: (check all that apply)
CNS INFECTIONS:

ICD code(s):

Date of diagnosis:

Meningitis
Specify organism:
Brain abscess
Specify organism:
HIV
Neurosyphilis
Lyme disease
Encephalitis, epidemic, chronic, including poliomyelitis, anterior (anterior horn cells)
Other (specify):
ICD code(s):

Date of diagnosis:

ICD code(s):

Date of diagnosis:

BRAIN TUMOR:

ICD code(s):

Date of diagnosis:

SPINAL CORD CONDITIONS:

ICD code(s):

Date of diagnosis:

VASCULAR DISEASES:
Thrombosis, TIA or cerebral infarction
Hemorrhage (specify type):
Cerebral arteriosclerosis
Other (specify):
HYDROCEPHALUS:
Obstructive
Communicating
Normal pressure (NPH)

Syringomyelia
Myelitis
Hematomyelia
Spinal Cord Injuries
Radiation injury
Electric or lightning injury
Decompression sickness (DCS)
Other (specify):
Spinal cord tumor
Other (specify):
BRAIN STEM CONDITIONS:

ICD code(s):

Date of diagnosis:

Bulbar palsy
Pseudobulbar palsy
Other (specify):

VA FORM
XXX XXXX

21-0960C-5

SUPERSEDES VA FORM 21-0960C-5, OCT 2012,
WHICH WILL NOT BE USED.

Page 1

SECTION I - DIAGNOSIS (Continued)

1B. SELECT THE VETERAN'S CONDITION: (Continued) (check all that apply)
MOVEMENT DISORDERS:

ICD code(s):

Date of diagnosis:

ICD code(s):

Date of diagnosis:

ICD code(s):

Date of diagnosis:

Athetosis, acquired
Myoclonus I
Paramyoclonus multiplex (convulsive state, myoclonic type)
Tic convulsive (Gilles de la Tourette Syndrome)
Dystonia (specify type):
Essential tremor
Tardive dyskinesia or other neuroleptic induced syndromes
Other (specify):
NEUROMUSCULAR DISORDERS:
Myasthenia gravis
Myasthenic syndrome
Botulism
Hereditary muscular disorders (specify):
Familial periodic paralysis
Myoglobinuria
Dermatomyositis or polyomiositis (specify):
Other (specify):
INTOXICATIONS:
Heavy metal intoxication (specify):
Solvents (specify):
Insecticides, pesticides, others (specify):
Nerve gas agents
Herbicides/defoliants (specify):
Other (specify):
OTHER CENTRAL NERVOUS CONDITION
Other diagnosis # 1
ICD code:

Date of diagnosis:

Other diagnosis # 2
ICD code:

Date of diagnosis:

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO CENTRAL NERVOUS SYSTEM CONDITIONS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S CENTRAL NERVOUS SYSTEM CONDITION(S) (Brief summary) (Continued on Page 3)

VA FORM 21-0960C-5, XXX XXXX

Page 2

SECTION II - MEDICAL HISTORY (Continued)

2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S CENTRAL NERVOUS SYSTEM CONDITION(S) (Brief summary) (Continued)

2B. DOES THE VETERAN'S CENTRAL NERVOUS SYSTEM CONDITION (S) REQUIRE CONTINUOUS MEDICATIONS FOR CONTROL?
YES

NO

IF YES, LIST MEDICATIONS USED FOR CENTRAL NERVOUS SYSTEM CONDITIONS:

2C. DOES THE VETERAN HAVE AN INFECTIOUS CONDITION?
YES

NO

IF YES, IS IT ACTIVE?
No

Yes

IF NO, DESCRIBE RESIDUALS IF ANY:

2D. DOMINANT HAND
RIGHT

LEFT

AMBIDEXTROUS

SECTION III - CONDITIONS, SIGNS AND SYMPTOMS
3A. DOES THE VETERAN HAVE ANY MUSCLE WEAKNESS IN THE UPPER AND/OR LOWER EXTREMITIES?
YES

NO

IF YES, REPORT UNDER STRENTH TESTING IN SECTION IV, NEUROLOGIC EXAM.
3B. DOES THE VETERAN HAVE ANY PHARYNX AND/OR LARYNX AND/OR SWALLOWING CONDITIONS?
YES

NO

IF YES, CHECK ALL THAT APPLY:
Constant inability to communicate by speech
Speech not intelligible or individual is aphonic
Paralysis of soft palate with swallowing difficulty (nasal regurgitation) and speech impairment
Hoarseness
Mild swallowing difficulties
Moderate swallowing difficulties
Severe swallowing difficulties, permitting passage of liquids only
Requires feeding tube due to swallowing difficulties
Other, (describe):
3C. DOES THE VETERAN HAVE ANY RESPIRATORY CONDITIONS (such as rigidity of the diaphragm, chest wall or laryngeal muscles)?
YES

NO

IF YES, PROVIDE PFT RESULTS IN SECTION XI, DIAGNOSTIC TESTING.
3D. DOES THE VETERAN HAVE SLEEP DISTURBANCES?
YES

NO

IF YES, CHECK ALL THAT APPLY:
Insomnia
Hypersomnolence and/or daytime "sleep attacks"
Persistent daytime hypersomnolence
Sleep apnea requiring the use of breathing assistance device such as continuous airway pressure (CPAP) machine
Sleep apnea causing chronic respiratory failure with carbon dioxide retention or cor pulmonale
Sleep apnea requiring tracheostomy
VA FORM 21-0960C-5, XXX XXXX

Page 3

SECTION III - CONDITIONS, SIGNS AND SYMPTOMS (Continued)
3E. DOES THE VETERAN HAVE ANY BOWEL FUNCTIONAL IMPAIRMENT?
YES

NO

IF YES, CHECK ALL THAT APPLY:
Slight impairment of sphincter control, without leakage
Constant slight impairment of sphincter control, or occasional moderate leakage
Occasional involuntary bowel movements, necessitating wearing of a pad
Extensive leakage and fairly frequent involuntary bowel movements
Total loss of bowel sphincter control
Chronic constipation
Other bowel impairment (describe):
3F. DOES THE VETERAN HAVE VOIDING DYSFUNCTION CAUSING URINE LEAKAGE?
YES

NO

IF YES, CHECK ONE:
Does not require/does not use absorbent material
Requires absorbent material that is changed less than 2 times per day
Requires absorbent material that is changed 2 to 4 times per day
Requires absorbent material that is changed more than 4 times per day
3G. DOES THE VETERAN HAVE VOIDING DYSFUNCTION CAUSING SIGNS AND/OR SYMPTOMS OF URINARY FREQUENCY?
YES

NO

IF YES, CHECK ONE DAY TIME AND ONE NIGHT TIME.
Daytime voiding interval between 2 and 3 hours

Nighttime awakening to void 2 times

Daytime voiding interval between 1 and 2 hours

Nighttime awakening to void 3 to 4 times

Daytime voiding interval less than 1 hour

Nighttime awakening to void 5 or more times

3H. DOES THE VETERAN HAVE VOIDING DYSFUNCTION CAUSING FINDINGS, SIGNS AND/OR SYMPTOMS OF OBSTRUCTED VOIDING?
YES

NO

IF YES, CHECK ALL SIGNS AND SYMPTOMS THAT APPLY:
Hesitancy (If checked, is hesitancy marked?)
Yes

No

Slow or weak stream (If checked, is stream markedly slow or weak?)
Yes

No

Decreased force of stream (If checked, is force of stream markedly decreased?)
Yes

No

Stricture disease requiring dilatation 1 to 2 times per year
Stricture disease requiring periodic dilatation every 2 to 3 months
Recurrent urinary tract infections secondary to obstruction
Uroflowmetry peak flow rate less than 10 cc/sec
Post void residuals greater than 150 cc
Urinary retention requiring intermittent or continuous catheterization
3I. DOES THE VETERAN HAVE VOIDING DYSFUNCTION REQUIRING THE USE OF AN APPLIANCE?
YES

NO

IF YES, DESCRIBE:
3J. DOES THE VETERAN HAVE A HISTORY OF RECURRENT SYMPTOMATIC URINARY TRACT INFECTIONS?
YES

NO

IF YES, CHECK ALL TREATMENTS THAT APPLY:
No treatment
Long-term drug therapy

(If checked, list medications used for urinary tract infection and indicate dates for courses of treatment over the past 12 months)
Hospitalization

(If checked, indicate frequency of hospitalization)
1 or 2 per year
More than 2 per year

Drainage
IF CHECKED, INDICATE DATES WHEN DRAINAGE PERFORMED OVER PAST 12 MONTHS:
Other management/treatment not listed above (Description of management/treatment including dates of treatment):
VA FORM 21-0960C-5, XXX XXXX

Page 4

SECTION III - CONDITIONS, SIGNS, AND SYMPTOMS (Continued)
3K. DOES THE VETERAN (if male) HAVE ERECTILE DYSFUNCTION?
YES
NO
IF YES, IS THE ERECTILE DYSFUNCTION AS LIKELY AS NOT (AT LEAST 50% PROBABILITY) ATTRIBUTABLE TO A CNS DISEASE (INCLUDING TREATMENT OR
RESIDUALS OF TREATMENT?
YES
NO
IF NO, PROVIDE THE ETIOLOGY OF THE ERECTILE DYSFUNCTION:
IF YES, IS THE VETERAN ABLE TO ACHIEVE AN ERECTION (WITHOUT MEDICATION) SUFFICIENT FOR PENETRATION AND EJACULATION?
YES

NO

IF NO, IS THE VETERAN ABLE TO ACHIEVE AN ERECTION (WITH MEDICATION) SUFFICIENT FOR PENETRATION AND EJACULATION?
YES

NO

SECTION IV - NEUROLOGIC EXAM
4A. SPEECH
NORMAL

ABNORMAL

If speech is abnormal, describe:

4B. GAIT
NORMAL

ABNORMAL, DESCRIBE:

If gait is abnormal and the veteran has more than one medical condition contributing to the abnormal gait, identify the conditions and describe each condition's contribution to
the abnormal gait:

4C. STRENGTH - Rate strength according to the following scale:
0/5 No muscle movement
1/5 Visible muscle movement, but no joint movement
2/5 No movement against gravity
3/5 No movement against resistance
4/5 Less than normal strength
5/5 Normal strength
ALL NORMAL
Elbow flexion:

RIGHT:

5/5

4/5

3/5

2/5

1/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

Pinch (thumb to
index finger):

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

Knee extension:

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

RIGHT:

5/5

4/5

3/5

2/5

1/5

0/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

Elbow extension:
Wrist flexion:
Wrist extension:
Grip:

Ankle plantar flexion:
Ankle dorsiflexion:

VA FORM 21-0960C-5, XXX XXXX

0/5

Page 5

SECTION IV - NEUROLOGIC EXAM (Continued)
4D. DEEP TENDON REFLEXES (DTRs) - Rate reflexes according to the following scale:
0 Absent
1+ Decreased
2+ Normal
3+ Increased without clonus
4+ Increased with clonus
ALL NORMAL
Biceps:
Triceps:
Brachioradialis:
Knee:
Ankle:

RIGHT:

0

1+

2+

3+

4+

LEFT:

0

1+

2+

3+

4+

RIGHT:

0

1+

2+

3+

4+

LEFT:

0

1+

2+

3+

4+

RIGHT:

0

1+

2+

3+

4+

LEFT:

0

1+

2+

3+

4+

RIGHT:

0

1+

2+

3+

4+

LEFT:

0

1+

2+

3+

4+

RIGHT:

0

1+

2+

3+

4+

LEFT:

0

1+

2+

3+

4+

4E. DOES THE VETERAN HAVE MUSCLE ATROPHY ATTRIBUTABLE TO A CNS CONDITION?
YES

NO

IF MUSCLE ATROPHY IS PRESENT, INDICATE LOCATION(S): (If more than 1 location, please use Section XIII: Remarks.)

When possible, provide difference measured in cm between normal and atrophied side, measured at maximum muscle bulk:

cm

4F. SUMMARY OF MUSCLE WEAKNESS IN THE UPPER AND/OR LOWER EXTREMITIES ATTRIBUTABLE TO A CNS CONDITION (check all that apply):
Right upper extremity muscle weakness:
None

Mild

Moderate

Severe

With atrophy

Complete (no remaining function)

Severe

With atrophy

Complete (no remaining function)

Severe

With atrophy

Complete (no remaining function)

Severe

With atrophy

Complete (no remaining function)

Left upper extremity muscle weakness:
None

Mild

Moderate

Right lower extremity muscle weakness:
None

Mild

Moderate

Left lower extremity muscle weakness:
None

Mild

Moderate

4G. IF THE VETERAN HAS MORE THAN ONE MEDICAL CONDITION CONTRIBUTING TO THE MUSCLE WEAKNESS, IDENTIFY THE CONDITION(S) AND
DESCRIBE EACH CONDITION'S CONTRIBUTION TO THE MUSCLE WEAKNESS:

VA FORM 21-0960C-5, XXX XXXX

Page 6

SECTION V - TUMORS AND NEOPLASMS
5A. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES LISTED
IN SECTION I, DIAGNOSIS?
YES
NO
IF YES, COMPLETE THE FOLLOWING:
5B. IS THE NEOPLASM?
BENIGN

MALIGNANT

5C. HAS THE VETERAN COMPLETED TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT NEOPLASM OR
METASTASES?
YES

NO; 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 - Date of most recent treatment

Date(s) of surgery:
Date of completion of treatment or anticipated date of completion:

Antineoplastic chemotherapy - Date of most recent treatment:

Date of completion of treatment or anticipated date of completion:

Other therapeutic procedure - If checked, describe procedure:

Date of most recent procedure:

Other therapeutic treatment - If checked, describe treatment:

Date of completion of treatment or anticipated date of completion:

5D. 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?
YES

NO

IF YES, LIST RESIDUAL CONDITIONS AND COMPLICATIONS (brief summary):

5E. 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:

SECTION VI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
6A. 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?
YES

NO

IF YES, ARE ANY OF THESE 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?
YES

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.
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.
6B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN THE DIAGNOSIS SECTION?
YES

NO

IF YES, DESCRIBE (brief summary):

VA FORM 21-0960C-5, XXX XXXX

Page 7

SECTION VII - MENTAL HEALTH MANIFESTATIONS DUE TO CNS CONDITION OR ITS TREATMENT
7A. DOES THE VETERAN HAVE DEPRESSION, COGNITIVE IMPAIRMENT OR DEMENTIA, OR ANY OTHER MENTAL HEALTH CONDITIONS ATTRIBUTABLE TO A
CNS DISEASE AND/OR ITS TREATMENT?
YES

NO

7B. DOES THE VETERAN'S MENTAL HEALTH CONDITION(S), AS IDENTIFIED IN ITEM 7A, RESULT IN GROSS IMPAIRMENT IN THOUGHT PROCESSES OR
COMMUNICATION?
YES

NO

IF NO, ALSO COMPLETE VA FORM 21-0960P-2, MENTAL DISORDERS (Other than PTSD and Eating Disorders) DISABILITY BENEFITS QUESTIONNAIRE
(SCHEDULE WITH APPROPRIATE PROVIDER).
IF YES, BRIEFLY DESCRIBE THE VETERAN'S MENTAL HEALTH CONDITION:

SECTION VIII - DIFFERENTIATION OF SYMPTOMS OR NEUROLOGIC EFFECTS
8. ARE YOU ABLE TO DIFFERENTIATE WHAT PORTION OF THE SYMPTOMATOLOGY OR NEUROLOGIC EFFECTS DESCRIBED IN ITEM 7B IS CAUSED BY
EACH DIAGNOSIS?
YES

NO

IF YES, LIST WHICH SYMPTOMS OR NEUROLOGIC EFFECTS ARE ATTRIBUTABLE TO EACH DIAGNOSIS, WHERE POSSIBLE:

SECTION IX - ASSISTIVE DEVICES
9. DOES THE VETERAN USE ANY ASSISTIVE DEVICE(S) AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS
MAY BE POSSIBLE?
YES

NO

IF YES, IDENTIFY ASSISTIVE DEVICE(S) USED (Check all that apply and indicate frequency):
Wheelchair

Frequency of use:

Occasional

Regular

Constant

Brace(s)

Frequency of use:

Occasional

Regular

Constant

Crutch(es)

Frequency of use:

Occasional

Regular

Constant

Cane(s)

Frequency of use:

Occasional

Regular

Constant

Walker

Frequency of use:

Occasional

Regular

Constant

Other:

Frequency of use:

Occasional

Regular

Constant

9B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:

SECTION X - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
10. DUE TO A CNS CONDITION, IS THERE FUNCTIONAL IMPAIRMENT OF AN EXTREMITY SUCH THAT NO EFFECTIVE FUNCTION REMAINS OTHER THAN THAT
WHICH WOULD BE EQUALLY WELL SERVED BY AN AMPUTATION WITH PROSTHESIS? (Functions of the upper extremity include grasping, manipulation, etc.,

while functions for the lower extremity include balance and propulsion, etc.)

YES, FUNCTIONING IS SO DIMINISHED THAT AMPUTATION WITH PROSTHESIS WOULD EQUALLY SERVE THE VETERAN
NO
IF YES, INDICATE EXTREMITY(IES) (Check all extremities for which this applies):
Right upper

Left upper

Right lower

Left lower

FOR EACH CHECKED EXTREMITY, DESCRIBE LOSS OF EFFECTIVE FUNCTION, IDENTIFY THE CONDITION CAUSING LOSS OF FUNCTION, AND PROVIDE
SPECIFIC EXAMPLES (brief summary):

VA FORM 21-0960C-5, XXX XXXX

Page 8

SECTION XI - DIAGNOSTIC TESTING
NOTE - If the results of MRI, other imaging studies or other diagnostic tests are in the medical record and reflect the veterans's current condition, repeat testing is not
required. If pulmonary function testing (PFT) is indicated due to respiratory disability, and results are in the medical record and reflect the veteran's current respiratory
function, repeat testing is not required. DLCO and bronchodilator testing is not indicated for a restrictive respiratory disability such as that caused by muscle weakness
due to CNS conditions.
11A. HAVE IMAGING STUDIES BEEN PERFORMED?
YES

NO

IF YES, PROVIDE MOST RECENT RESULTS, IF AVAILABLE:
11B. HAVE PFTs BEEN PERFORMED?
YES
NO
IF YES, PROVIDE MOST RECENT RESULTS, IF AVAILABLE:
% predicted

FEV1:
FEV1/FVC:

Date of test:
Date of test:

% predicted

FEV:

Date of test:

11C. IF PFTs HAVE BEEN PERFORMED, IS THE FLOW-VOLUME LOOP COMPATIBLE WITH UPPER AIRWAY OBSTRUCTION?
YES

NO

11D. 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 XII - FUNCTIONAL IMPACT
12. DO THE VETERAN'S CENTRAL NERVOUS SYSTEM DISORDERS IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

IF YES, DESCRIBE IMPACT OF EACH OF THE VETERAN'S CENTRAL NERVOUS SYSTEM DISORDER CONDITION(S) PROVIDING ONE OR MORE EXAMPLES:

SECTION XIII - REMARKS

13. REMARKS (If any)

SECTION XIV- PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
14A. PHYSICIAN'S SIGNATURE

14B. PHYSICIAN'S PRINTED NAME

14D. PHYSICIAN'S PHONE NUMBER AND FAX NUMBER 14E. PHYSICIAN'S MEDICAL LICENSE NUMBER

14C. DATE SIGNED

14F. 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.
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, 58VA21/22/28, 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 30 minutes to review the instructions, find the information, and complete a 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.
VA FORM 21-0960C-5, XXX XXXX

Page 9