VA Form 21-0960Q-1 Chronic Fatigue Syndrome Disability Benefits Questionnai

OMB Control No. 2900-0781
Respondent Burden: 15 Minutes
Expiration Date: XX/XX/XXXX

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 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 CHRONIC FATIGUE SYNDROME?
YES

NO

(If "Yes," complete Item 1B)

NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed above. 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 appropriate date determined through record review or
reported history.
1B. SELECT THE VETERAN'S CONDITION (check all that apply)
CHRONIC FATIGUE SYNDROME

ICD Code:

Date of diagnosis:

ICD Code:

Date of diagnosis:

OTHER (specify)
Other diagnosis #1

Other diagnosis #2
ICD Code:
Date of diagnosis:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO CHRONIC FATIGUE SYNDROME, LIST USING ABOVE FORMAT:

NOTE - For VA purposes, the diagnosis of chronic fatigue syndrome requires:
(A) New onset of debilitating fatigue severe enough to reduce daily activity to less than 50 percent of the usual level for at least 6 months; and
(B) The exclusion, by history, physical examination, and laboratory tests, of all other clinical conditions that may produce similar symptoms; and
(C) Six or more of the following:
1. Acute onset of the condition
2. Low grade fever
3. Non-exudative pharyngitis
4. Palpable or tender cervical or axillary lymph nodes
5. Generalized muscle aches or weakness
6. Fatigue lasting 24 hours or longer after exercise

7. Headaches (of a type, severity or pattern that is different from headaches in the pre-morbid state)
8. Migratory joint pains
9. Neuropsychological symptoms
10. Sleep disturbance

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 onset and course) OF THE VETERAN'S CHRONIC FATIGUE SYNDROME (brief summary):

3B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF CHRONIC FATIGUE SYNDROME?
YES

NO

(If "Yes," are the veteran's symptoms controlled by continuous medication?)
YES

NO

(If "Yes," list only those medications required for the veteran's chronic fatigue syndrome):

3C. HAVE OTHER CLINICAL CONDITIONS THAT MAY PRODUCE SIMILAR SYMPTOMS BEEN EXCLUDED BY HISTORY, PHYSICAL EXAMINATION AND/OR
LABORATORY TESTS TO THE EXTENT POSSIBLE?
YES

NO

(If "No," describe):

3D. DID THE VETERAN HAVE AN ACUTE ONSET OF CHRONIC FATIGUE SYNDROME?
YES

NO

3E. HAS THE DEBILITATING FATIGUE REDUCED DAILY ACTIVITY LEVEL TO LESS THAN 50% OF PRE-ILLNESS LEVEL?
YES

NO

(If "Yes," specify length of time daily activity level has been reduced to less than 50% of pre-illness level):
Less than 6 months
VA FORM
XXX XXXX

21-0960Q-1

6 months or longer
SUPERSEDES VA FORM 21-0960Q-1, OCT 2012,
WHICH WILL NOT BE USED.

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SECTION IV - FINDINGS, SIGNS AND SYMPTOMS
4A. DOES THE VETERAN NOW HAVE OR HAS THE VETERAN HAD ANY FINDINGS, SIGNS AND SYMPTOMS ATTRIBUTABLE TO CHRONIC FATIGUE SYNDROME?
YES

NO

(If "Yes," check all that apply):
Debilitating fatigue
Low grade fever
Nonexudative pharyngitis
Palpable or tender cervical or axillary lymph nodes
Generalized muscle aches or weakness
Fatigue lasting 24 hours or longer after exercise
Headaches (of a type, severity or pattern that is different from headaches in the pre-morbid state)
Migratory joint pain
Neuropsychologic symptoms
Sleep disturbance
Other

(Note: Describe all checked conditions in Item 4B)
4B. PROVIDE A DESCRIPTION OF THE CONDITION(S):

4C. DOES THE VETERAN NOW HAVE OR HAS THE VETERAN HAD ANY COGNITIVE IMPAIRMENT ATTRIBUTABLE TO CHRONIC FATIGUE SYNDROME?
YES

NO

(If "Yes," check all that apply):
Poor attention
Inability to concentrate
Forgetfulness
Confusion
Other cognitive impairments

(Note: Describe all checked conditions in Item 4D)
4D. PROVIDE A DESCRIPTION OF THE CONDITION(S):

4E. SPECIFY FREQUENCY OF SYMPTOMS:
Symptoms wax and wane
Symptoms are nearly constant
Other

(Note: Describe frequency in Item 4F)
4F. PROVIDE A DESCRIPTION OF THE FREQUENCY:

4G. DO THE VETERAN'S SYMPTOMS DUE TO CHRONIC FATIGUE SYNDROME RESTRICT ROUTINE DAILY ACTIVITIES AS COMPARED TO THE PRE-ILLNESS LEVEL?
YES

NO

(If "Yes," specify % of restriction (check all that apply)):
Symptoms restrict routine daily activities by less than 25 % of the pre-illness level (more than 75% of the pre-illness level of activities are not restricted)
Symptoms restrict routine daily activities to 50% to 75% of the pre-illness level
Symptoms restrict routine daily activities to less than 50% of the pre-illness level
Symptoms are so severe as to restrict routine daily activities almost completely
Symptoms are so severe as to occasionally preclude self-care (If checked, describe frequency with which this occurs):
Other (describe):

NOTE: For VA purposes, chronic fatigue syndrome is considered incapacitating only while it requires bed rest and treatment by a physician.
4H. DO THE VETERAN'S SYMPTOMS DUE TO CHRONIC FATIGUE SYNDROME RESULT IN PERIODS OF INCAPACITATION?
YES

NO

(If "Yes," indicate total duration of periods of incapacitation over the past 12 months):
Less than 1 week
At least 1 but less than 2 weeks
At least 2 but less than 4 weeks
At least 4 but less than 6 weeks
At least 6 weeks total duration per year
Other (describe):
VA FORM 21-060Q-1, XXX XXXX

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SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, SCARS, 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 AND/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 (DBQ).
IF "NO," PROVIDE LOCATION AND MEASUREMENTS 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. It is not necessary to also complete a Scars/Disfigurement DBQ.
5B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS OF CHRONIC
FATIGUE SYNDROME?
YES

NO

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

SECTION VI - DIAGNOSTIC TESTING
NOTE: If testing has been performed and reflects the veteran's current condition, repeat testing is not required.
6. ARE THERE ANY SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES

NO

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

SECTION VII - FUNCTIONAL IMPACT
7. DOES THE VETERAN'S CHRONIC FATIGUE SYNDROME IMPACT ON HIS OR HER ABILITY TO WORK?
YES

NO

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

SECTION VIII - REMARKS

8. REMARKS (If any):

SECTION IX - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
9A. PHYSICIAN'S SIGNATURE
9D. PHYSICIAN'S PHONE AND FAX NUMBERS

9B. PHYSICIAN'S PRINTED NAME
9E. PHYSICIAN'S MEDICAL LICENSE NUMBER

9C. DATE SIGNED
9F. 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, 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.
VA FORM 21-0960Q-1, XXX XXXX

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