VA Form 21-0960C-9 MULTIPLE SCLEROSIS (MS)

OMB Control No. 2900-0778
Respondent Burden: 45 Minutes
Expiration Date: XX/XX/XXXX

MULTIPLE SCLEROSIS (MS)
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 HAVE MULTIPLE SCLEROSIS (MS)?
YES

(If "Yes," complete Item 1B)

NO

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. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO MS:
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 MS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S MS (Brief summary):

2B. DOMINANT HAND
RIGHT

LEFT

AMBIDEXTROUS

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

NO

(If "Yes," report under strength testing in neurologic exam section)

3B. DOES THE VETERAN HAVE ANY PHARYNX AND/OR LARYNX AND/OR SWALLOWING CONDITIONS DUE TO MS?
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 ATTRIBUTABLE TO MS?
YES

VA FORM
XXX XXXX

NO

(If "Yes," provide PFT results under "Diagnostic Testing" section and complete VA Form 21-0960L-1, Respiratory Conditions (other than
Tuberculosis and Sleep Apnea) Disability Benefits Questionnaire)

21-0960C-9

SUPERSEDES VA FORM 21-0960C-9, OCT 2012,
WHICH WILL NOT BE USED.

Page 1

SECTION III - CONDITIONS, SIGNS AND SYMPTOMS DUE TO MS (Continued)
3D. DOES THE VETERAN HAVE SLEEP DISTURBANCES ATTRIBUTABLE TO MS?
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
3E. DOES THE VETERAN HAVE ANY BOWEL FUNCTIONAL IMPAIRMENT ATTRIBUTABLE TO MS?
YES

NO

(If "Yes," check all that apply):
Slight impairment of sphincter control, without leakage
Constant slight leakage
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 ATTRIBUTABLE TO MS?
YES

NO

(If "Yes," check all that apply):
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 URINARY FREQUENCY ATTRIBUTABLE TO MS?
YES

NO

(If "Yes," check all that apply):
Daytime voiding interval between 2 and 3 hours
Daytime voiding interval between 1 and 2 hours
Daytime voiding interval less than 1 hour
Nighttime awakening to void 2 times
Nighttime awakening to void 3 to 4 times
Nighttime awakening to void 5 or more times
3H. DOES THE VETERAN HAVE VOIDING DYSFUNCTION CAUSING OBSTRUCTED VOIDING ATTRIBUTABLE TO MS?
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

VA FORM 21-0960C-9, XXX XXXX

Page 2

SECTION III - CONDITIONS, SIGNS AND SYMPTOMS DUE TO MS (Continued)
3I. DOES THE VETERAN HAVE VOIDING DYSFUNCTION REQUIRING THE USE OF AN APPLIANCE ATTRIBUTABLE TO MS?
NO

YES

(If "Yes," describe):

3J. DOES THE VETERAN HAVE A HISTORY OF RECURRENT SYMPTOMATIC URINARY TRACT INFECTIONS ATTRIBUTABLE TO MS?
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):
3K. DOES THE VETERAN (if male) HAVE ERECTILE DYSFUNCTION?
YES

NO

(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

3L. VISUAL DISTURBANCES
DOES THE VETERAN HAVE ANY VISUAL DISTURBANCES ATTRIBUTABLE TO MS?
YES

NO

(If "Yes," check all that apply, also complete VA Form 21-0960N-2, Eye Conditions Disability Benefits Questionnaire and schedule with appropriate examiner):
Diplopia
Blurring of vision
Internuclear ophthalmoplegia
Decreased visual acuity
Visual scotoma

(If checked, specify):
(If checked, specify):

unilateral

bilateral

unilateral

bilateral

Nystagmus
Optic neuritis
Other (describe):

SECTION IV - NEUROLOGIC EXAM
4A. 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):

VA FORM 21-0960C-9, XXX XXXX

Page 3

SECTION IV - NEUROLOGIC EXAM (Continued)
4B. STRENGTH - RATE STRENGTH ACCORDING TO THE FOLLOWING SCALE:
0/5 No muscle movement

2/5 No movement against gravity

4/5 Less than normal strength

1/5 Visible muscle movement, but no joint movement

3/5 No movement against resistance

5/5 Normal strength

Shoulder Extension

RIGHT:

5/5

4/5

3/5

2/5

1/5

LEFT:

5/5

4/5

3/5

2/5

1/5

0/5

Shoulder Flexion

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 Flexion

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

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

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

Hip 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

Hip Flexion

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

Ankle Plantar Flexion

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

Wrist Flexion
Wrist Extension
Grip
Pinch

(thumb to index finger)

Ankle Dorsiflexion

0/5

IF THERE ARE OTHER WEAKNESSES, PLEASE SPECIFY USING THE ABOVE FORMAT:

4C. DEEP TENDON REFLEXES (DTRs) - RATE REFLEXES ACCORDING TO THE FOLLOWING SCALE:
0 - Absent

2+ Normal

1+ Decreased

3+ Increased without clonus

Biceps

4+ Increased with clonus

RIGHT:

0

1+

2+

3+

LEFT:

0

1+

2+

3+

4+

Triceps

RIGHT:

0

1+

2+

3+

4+

LEFT:

0

1+

2+

3+

4+

Brachioradialis

RIGHT:

0

1+

2+

3+

4+

Knee
Ankle

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+

VA FORM 21-0960C-9, XXX XXXX

Page 4

SECTION IV - NEUROLOGIC EXAM (Continued)
4D. SENSATION TESTING RESULTS:
Shoulder area (C5)
Inner/outer forearm (C6/T1)
Hand/fingers (C6-8)

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

RIGHT:

Normal

Decreased

Absent

LEFT:

Normal

Decreased

Absent

Thorax:
Anterior:
Posterior:
Trunk:
Anterior:
Posterior:
Thigh/knee (L3/4)
Lower leg/ankle (L4/L5/S1)
Foot/toes (L5)

4E. DOES THE VETERAN HAVE MUSCLE ATROPHY ATTRIBUTABLE TO MS?
YES

NO

(If muscle atrophy is present, indicate location):

(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 MS (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

NOTE: 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:

SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
5A. 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.
VA FORM 21-0960C-9, XXX XXXX

Page 5

SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS (Continued)
5B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN THE DIAGNOSIS SECTION?
YES

NO

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

SECTION VI - MENTAL HEALTH MANIFESTATIONS DUE TO MULTIPLE SCLEROSIS OR ITS TREATMENT
6A. DOES THE VETERAN HAVE SIGNS OR SYMPTOMS OF DEPRESSION, COGNITIVE IMPAIRMENT OR DEMENTIA, OR ANY OTHER MENTAL HEALTH
CONDITIONS ATTRIBUTABLE TO MS AND/OR ITS TREATMENT?
YES

NO

(If "Yes," briefly describe):

(If "Yes," also complete VA Form 21-0960P-2, Mental Disorders (other than PTSD and Eating Disorders) Disability Benefits Questionnaire and schedule with
appropriate provider)
6B. DOES THE VETERAN'S MENTAL DISORDER(S), AS IDENTIFIED IN ITEM 6A, 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 and schedule with
appropriate provider).
(If "Yes," briefly describe the signs and symptoms of the veteran's mental disorder):

SECTION VII - HOUSEBOUND
7A. IS THE VETERAN SUBSTANTIALLY CONFINED TO HIS OR HER DWELLING AND THE IMMEDIATE PREMISES (or if institutionalized, to the ward or clinical areas)?
YES

NO

(If "Yes," describe how often per day or week and under what circumstances the veteran is able to leave the home or immediate premises):

7B. IF YES, DOES THE VETERAN HAVE MORE THAN ONE CONDITION CONTRIBUTING TO HIS OR HER BEING HOUSEBOUND?
YES

NO

(If "Yes," list conditions and describe how each condition contributes to causing the veteran to be housebound)

PROVIDE CONDITIONS AND DESCRIBE HOW EACH CONDITION CONTRIBUTES TO THE VETERAN BEING HOUSEBOUND
CONDITION # 1 -

DESCRIPTION -

CONDITION # 2 -

DESCRIPTION -

CONDITION # 3 -

DESCRIPTION -

7C. IF THE VETERAN HAS ADDITIONAL CONDITIONS CONTRIBUTING TO CAUSING THE VETERAN TO BE HOUSEBOUND, LIST USING ABOVE FORMAT:

SECTION VIII - AID AND ATTENDANCE
8A. IS THE VETERAN ABLE TO DRESS OR UNDRESS WITHOUT ASSISTANCE?
YES

NO

(If "No," is this limitation caused by the veteran's MS?)
YES

NO

8B. DOES THE VETERAN HAVE SUFFICIENT UPPER EXTREMITY COORDINATION AND STRENGTH TO BE ABLE TO FEED HIM OR HERSELF WITHOUT
ASSISTANCE?
YES

NO

(If "No," is this limitation caused by the veteran's MS?)
YES

NO

VA FORM 21-0960C-9, XXX XXXX

Page 6

SECTION VIII - AID AND ATTENDANCE (Continued)
8C. IS THE VETERAN ABLE TO PREPARE MEALS WITHOUT ASSISTANCE?
YES

NO

(If "No," is this limitation caused by the veteran's MS?)
YES

NO

8D. IS THE VETERAN ABLE TO ATTEND TO THE WANTS OF NATURE (toileting) WITHOUT ASSISTANCE?
YES

NO

(If "No," is this limitation caused by the veteran's MS?)
YES

NO

8E. IS THE VETERAN ABLE TO BATHE HIM OR HERSELF WITHOUT ASSISTANCE?
YES

NO

(If "No," is this limitation caused by the veteran's MS?)
YES

NO

8F. IS THE VETERAN ABLE TO KEEP HIM OR HERSELF ORDINARILY CLEAN AND PRESENTABLE WITHOUT ASSISTANCE?
YES

NO

(If "No," is this limitation caused by the veteran's MS?)
YES

NO

8G. IS THE VETERAN ABLE TO TAKE PRESCRIPTION MEDICATIONS IN A TIMELY MANNER AND WITH ACCURATE DOSAGE WITHOUT ASSISTANCE?
YES

NO

(If "No," is this limitation caused by the veteran's MS?)
YES

NO

8H. DOES THE VETERAN NEED FREQUENT ASSISTANCE FOR ADJUSTMENT OF ANY SPECIAL PROSTHETIC OR ORTHOPEDIC APPLIANCE(S)?
YES

NO

(If "Yes," describe):

NOTE: For VA purposes, "bedridden" will be that condition which actually requires that the claimant remain in bed. The fact that the claimant has voluntarily taken to
bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure will not suffice.
8I. IS THE VETERAN BEDRIDDEN?
YES

NO

(If "Yes," is it due to the veteran's MS?)
YES

NO

8J. IS THE VETERAN LEGALLY BLIND?
YES

NO

(If "Yes," is it due to the veteran's MS?)
YES

NO

Provide best corrected vision, if known:

Left Eye:

Right Eye:

8K. DOES THE VETERAN REQUIRE CARE AND/OR ASSISTANCE ON A REGULAR BASIS DUE TO HIS OR HER PHYSICAL AND/OR MENTAL DISABILITIES IN ORDER
TO PROTECT HIM OR HERSELF FROM THE HAZARDS AND/OR DANGERS INCIDENT TO HIS OR HER DAILY ENVIRONMENT?
YES

NO

(If "Yes," is it due to the veteran's MS?)
YES

NO

8L. LIST ANY CONDITION(S), IN ADDITION TO THE VETERAN'S MS, THAT CAUSES ANY OF THE ABOVE LIMITATIONS:

SECTION IX - NEED FOR HIGHER LEVEL (i.e., more skilled) A&A
9. DOES THE VETERAN REQUIRE A HIGHER, MORE SKILLED LEVEL OF A&A?
YES

NO

NOTE: For VA purposes, this skilled, higher level care includes (but is not limited to) health-care services such as physical therapy, administration of injections,
placement of indwelling catheters, changing of sterile dressings, and/or like functions which require professional health-care training or the regular supervision of a
trained health-care professional to perform. In the absence of this higher level of care provided in the home, the veteran would require hospitalization, nursing home
care, or other residential institutional care.
VA FORM 21-0960C-9, XXX XXXX

Page 7

SECTION X - ASSISTIVE DEVICES
10A. 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

BRACE(S)

Frequency of use:

Occasional

Regular

Constant
Constant

CRUTCH(ES)

Frequency of use:

Occasional

Regular

Constant

CANE(S)

Frequency of use:

Occasional

Regular

Constant

WALKER

Frequency of use:

Occasional

Regular

Constant

Frequency of use:

Occasional

Regular

Constant

OTHER:

10B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSITIVE DEVICE USED FOR EACH CONDITION:

SECTION XI - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES
11. DUE TO MULTIPLE SCLEROSIS, 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 in a brief summary):

SECTION XII - FINANCIAL RESPONSIBILITY
12. IN YOUR JUDGMENT, IS THE VETERAN ABLE TO MANAGE HIS/HER BENEFIT PAYMENTS IN HIS/HER OWN BEST INTEREST, OR ABLE TO DIRECT SOMEONE
ELSE TO DO SO?
YES

(If "No," provide reason):

NO

SECTION XIII - DIAGNOSTIC TESTING
NOTE: If the results of MRI, other imaging studies or other diagnostic tests are in the medical record and reflect the veteran’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 MS.
13A. HAVE IMAGING STUDIES BEEN PERFORMED?
YES

NO

(If "Yes," provide most recent results, if available):

13B. HAVE PFT's BEEN PERFORMED?
YES

NO

(If "Yes," provide most recent results, if available):
FEV1:

% predicted

Date of test:

FEV1/FVC:

%

Date of test:

FVC:

% predicted

Date of test:

13C. IF PFT's HAVE BEEN PERFORMED, IS THE FLOW-VOLUME LOOP COMPATIBLE WITH UPPER AIRWAY OBSTRUCTION?
YES

NO

VA FORM 21-0960C-9, XXX XXXX

Page 8

SECTION XIII - DIAGNOSTIC TESTING (Continued)
13D. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES

NO

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

SECTION XIV - FUNCTIONAL IMPACT
14. DOES THE VETERAN'S MS IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe impact of the veteran's MS, providing one or more examples):

SECTION XV - REMARKS
15. REMARKS (If any)

SECTION XVI - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
16A. PHYSICIAN'S SIGNATURE

16D. PHYSICIAN'S PHONE AND FAX NUMBER

16B. PHYSICIAN'S PRINTED NAME

16E. PHYSICIAN'S MEDICAL LICENSE NUMBER

16C. DATE SIGNED

16F. 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 45 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-9, XXX XXXX

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