VA Form 21-0960F-2 Skin Diseases Disability Benefits Questionnaire

OMB Approved No. 2900-0776
Respondent Burden: 15 minutes
Expiration Date: XX/XX/XXXX

SKIN 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 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.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS THE VETERAN HAD A SKIN CONDITION?
YES

NO (If, "Yes," complete Item 1B)

1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO SKIN CONDITIONS (Indicate the category of skin condition, and then provide specific diagnosis in that category)

(Check all that apply)
Dermatitis or eczema

ICD Code:

DIAGNOSIS:

Infectious skin conditions (including bacterial, fungal, viral, treponemal and parasitic skin conditions)
ICD Code:
DIAGNOSIS:

Date of Diagnosis:
Date of Diagnosis:

Bullous disorders
DIAGNOSIS:

ICD Code:

Date of Diagnosis:

Psoriasis
DIAGNOSIS:

ICD Code:

Date of Diagnosis:

ICD Code:

Date of Diagnosis:

ICD Code:

Date of Diagnosis:

DIAGNOSIS:

ICD Code:

Date of Diagnosis:

Vitiligo
DIAGNOSIS:

ICD Code:

Date of Diagnosis:

DIAGNOSIS:

ICD Code:

Date of Diagnosis:

Urticaria
DIAGNOSIS:

ICD Code:

Date of Diagnosis:

Primary cutaneous vasculitis
DIAGNOSIS:

ICD Code:

Date of Diagnosis:

DIAGNOSIS:

ICD Code:

Date of Diagnosis:

Acne
DIAGNOSIS:

ICD Code:

Date of Diagnosis:

DIAGNOSIS:

ICD Code:

Date of Diagnosis:

Alopecia
DIAGNOSIS:

ICD Code:

Date of Diagnosis:

Hyperhidrosis
DIAGNOSIS:

ICD Code:

Date of Diagnosis:

Tumors and neoplasms of the skin, including malignant melanoma
ICD Code:

Date of Diagnosis:

Exfoliative dermatitis (erythroderma)
DIAGNOSIS:
Cutaneous manifestations of collagen-vascular diseases
DIAGNOSIS:
Palpulosquamous skin disorders

Keratinization skin disorders

Erythema multiforme

Chloracne

DIAGNOSIS:

Other skin condition
Other diagnosis #1:

ICD Code:

Date of Diagnosis:

Other diagnosis #2:

ICD Code:

Date of Diagnosis:

Other diagnosis #3:

ICD Code:

Date of Diagnosis:

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO THE SKIN CONDITIONS, LIST USING ABOVE FORMAT:

VA FORM
MAR 2014

21-0960F-2

SUPERSEDES VA FORM 21-0960F-2, OCT 2012,
WHICH WILL NOT BE USED.

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SECTION II - MEDICAL HISTORY

2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S SKIN CONDITIONS (brief summary):

2B. DO ANY OF THE VETERAN'S SKIN CONDITIONS CAUSE SCARRING OR DISFIGUREMENT OF THE HEAD, FACE OR NECK?
NO (If "Yes," indicate skin condition and describe scarring and/or disfigurement and complete VA Form 21-0960F-1, Scars/Disfigurement
YES

Disability Benefits Questionnaire if appropriate)

2C. DOES THE VETERAN HAVE ANY BENIGN OR MALIGNANT SKIN NEOPLASMS (including malignant melanoma)?
YES

NO

(If "Yes," complete Section VII, Tumors and Neoplasms, below)

2D. DOES THE VETERAN HAVE ANY SYSTEMIC MANIFESTATIONS DUE TO ANY SKIN DISEASES (such as fever, weight loss or hypoproteinemia associated with
skin conditions such as erythroderma)?
YES

NO

(If "Yes," describe and complete additional questionnaires if appropriate)
SECTION III - TREATMENT

3A. HAS THE VETERAN BEEN TREATED WITH ORAL OR TOPICAL MEDICATIONS IN THE PAST 12 MONTHS FOR ANY SKIN CONDITION?
YES

NO

(If "Yes," check all that apply):
Systemic corticosteroids or other immunosuppressive medications
(If checked, list medication(s):
(Specify condition medication used for):
(Total duration of medication use in past 12 months):
<6 weeks

6 weeks or more, but not constant

Constant/near-constant

Antihistamines
(If checked, list medication(s):
(Specify condition medication used for):
(Total duration of medication use in past 12 months):
<6 weeks

6 weeks or more, but not constant

Constant/near-constant

Immunosuppressive retinoids
(If checked, list medication(s):
(Specify condition medication used for):
(Total duration of medication use in past 12 months):
<6 weeks
6 weeks or more, but not constant

Constant/near-constant

Sympathomimetics
(If checked, list medication(s):
(Specify condition medication used for):
(Total duration of medication use in past 12 months):
<6 weeks

6 weeks or more, but not constant

Constant/near-constant

Other oral medications
(If checked, list medication(s):
(Specify condition medication used for):
(Total duration of medication use in past 12 months):
<6 weeks

6 weeks or more, but not constant

Constant/near-constant

Topical corticosteroids
(If checked, list medication(s):
(Specify condition medication used for):
(Total duration of medication use in past 12 months):
<6 weeks
6 weeks or more, but not constant

Constant/near-constant

Other topical medications
(If checked, list medication(s):
(Specify condition medication used for):
(Total duration of medication use in past 12 months):
<6 weeks
6 weeks or more, but not constant
VA FORM 21-0960F-2, MAR 2014

Constant/near-constant
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SECTION III - TREATMENT (Continued)
NOTE - If a medication is used for more than one condition, provide names of all conditions, name of medication used for each condition, and
frequency of use for each condition in Section 10, "Remarks".
3B. HAS THE VETERAN HAD ANY TREATMENTS OR PROCEDURES OTHER THAN SYSTEMIC OR TOPICAL MEDICATIONS IN THE PAST 12 MONTHS
FOR EXFOLIATIVE DERMATITIS OR PAPULOSQUAMOUS DISORDERS?
NO (If "Yes," check all that apply)

YES

PUVA (photo-chemotherapy with psoralen and ultraviolet A) treatment
(If checked, date of most recent treatment):
(Specify condition treated):
(Total duration of medication use in past 12 months):
<6 weeks

6 weeks or more, but not constant

Constant/near-constant

UVB (ultraviolet B phototherapy) treatment
(If checked, date of most recent treatment):
(Specify condition treated):
(Total duration of medication use in past 12 months):
<6 weeks

6 weeks or more, but not constant

Constant/near-constant

Electron beam therapy
(If checked, date of most recent treatment):
(Specify condition treated):
(Total duration of medication use in past 12 months):
<6 weeks
6 weeks or more, but not constant

Constant/near-constant

Intensive light therapy
(If checked, date of most recent treatment):
(Specify condition treated):
(Total duration of medication use in past 12 months):
<6 weeks

6 weeks or more, but not constant

Constant/near-constant

Other treatment (Specify treatment):
(If checked, date of most recent treatment):
(Specify condition treated):
(Total duration of medication use in past 12 months):
<6 weeks
6 weeks or more, but not constant

Constant/near-constant

SECTION IV - DEBILITATING AND NON-DEBILITATING EPISODES
4A. HAS THE VETERAN HAD ANY DEBILITATING EPISODES IN THE PAST 12 MONTHS DUE TO URTICARIA, PRIMARY CUTANEOUS VASCULITIS, ERYTHEMA
MULTIFORME, OR TOXIC EPIDERMAL NECROLYSIS?
YES
NO
If "Yes," specify condition causing debilitating episodes (for example, urticaria, vasculitis, erythema multiforme, or toxic epidermal necrolysis):
Describe debilitating episodes (brief summary):
Number of debilitating episodes in past 12 months:
None

1

2

3

4 or more

Characteristics of debilitating episodes:
Occurred despite ongoing immunosuppressive therapy
Required treatment with intermittent systemic immunosuppressive therapy
Responded to treatment with antihistamines or sympathomimetics
4B. HAS THE VETERAN HAD ANY NON-DEBILITATING EPISODES OF UTICARIA, PRIMARY CUTANEOUS VASCULITIS, ERYTHEMA MULTIFORME, OR TOXIC
EPIDERMAL NECROLYSIS IN THE PAST 12 MONTHS?
YES
NO
If "Yes," specify condition causing non-debilitating episodes:
Urticaria
Primary cutaneous vasculitis
Erythema multiforme
Toxic epidermal necrolysis
Describe episodes (brief summary):
Number of non-debilitating episodes in past 12 months:
None
4 or more
3
1
2
Characteristics of non-debilitating episodes:
Occurred despite ongoing immunosuppressive therapy
Required treatment with intermittent systemic immunosuppressive therapy
Responded to treatment with antihistamines or sympathomimetics

NOTE - If the veteran's debilitating and/or non-debilitating episodes are due to more than one condition, provide names of all conditions, indicating
severity and frequency of episodes for each condition in Section 10, "Remarks".
VA FORM 21-0960F-2, MAR 2014

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SECTION V - PHYSICAL EXAM
5A. INDICATE THE VETERAN'S VISIBLE SKIN CONDITIONS; INDICATE THE APPROXIMATE TOTAL BODY AREA AND APPROXIMATE TOTAL EXPOSED BODY AREA
(face, neck and hands) AFFECTED ON CURRENT EXAMINATION (check all that apply)
Dermatitis

Eczema

Total body area

None

<5%

5% to <20%

20% to 40%

>40%

EXPOSED area

None

<5%

5% to <20%

20% to 40%

>40%

Total body area

None

<5%

5% to <20%

20% to 40%

>40%

EXPOSED area

None

<5%

5% to <20%

20% to 40%

>40%

Total body area

None

<5%

5% to <20%

20% to 40%

>40%

EXPOSED area

None

<5%

5% to <20%

20% to 40%

>40%

Total body area

None

<5%

5% to <20%

20% to 40%

>40%

EXPOSED area

None

<5%

5% to <20%

20% to 40%

>40%

Infections
of the skin

Total body area

None

<5%

5% to <20%

20% to 40%

>40%

EXPOSED area

None

<5%

5% to <20%

20% to 40%

>40%

Cutaneous manifestations
of collagen-vascular
diseases

Total body area

None

<5%

5% to <20%

20% to 40%

>40%

EXPOSED area

None

<5%

5% to <20%

20% to 40%

>40%

Papulosquamous
disorder

Total body area

None

<5%

5% to <20%

20% to 40%

>40%

EXPOSED area

None

<5%

5% to <20%

20% to 40%

>40%

Bullous
disorders
Psoriasis

The veteran does not have any of the above listed visible skin conditions
5B. FOR EACH SKIN CONDITION CHECKED IN ITEM 5A, GIVE SPECIFIC DIAGNOSIS AND DESCRIBE APPEARANCE AND LOCATION:

SECTION VI - SPECIFIC SKIN CONDITIONS
6. DOES THE VETERAN HAVE ANY OF THE FOLLOWING SKIN CONDITIONS: ACNE, CHLORACNE, VITILIGO, ALOPECIA OR HYPERHIDROSIS?
YES

NO

(If "Yes," indicate the skin condition and complete appropriate sections)
Acne or chloracne
(If checked, indicate severity and location (check all that apply)):
Superficial acne (comedones, papules, pustules, superficial cysts) of any extent
Deep acne (deep inflamed nodules and pus-filled cysts
Affects less than 40% of face and neck
Affects 40% or more of face and neck
Affects body areas other than face and neck

Vitiligo
(If checked, indicate areas affected by vitiligo):
Exposed areas affected
No exposed areas affected

Scarring alopecia
(If checked, indicate percent of scalp affected):
<20%

20% to 40%

>40%

Alopecia areata
(If checked, indicate amount of hair loss):
Hair loss limited to scalp and face

Loss of all body hair

Other, describe:

Hyperhidrosis
(If checked, indicate severity):
Able to handle paper or tools after treatment
VA FORM 21-0960F-2, MAR 2014

Unresponsive to treatment; unable to handle paper or tools

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SECTION VII - TUMORS AND NEOPLASMS
7A. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DIAGNOSIS?
YES
NO (If "Yes," complete Items 7B through 7E)
7B. IS THE NEOPLASM
BENIGN

MALIGNANT

7C. 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
Date(s) of surgery:

Surgery, if checked describe:
Radiation therapy, if checked date of most recent treatment:

Date of completion of treatment or anticipated date of completion:

Antineoplastic chemotherapy, if checked 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:
Date of completion of treatment or anticipated date of completion:

Other therapeutic treatment, if checked describe treatment:

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.
YES
NO (If "Yes," list residual conditions and complications - brief summary)

7E. 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 VIII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
8. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN SECTION I, DIAGNOSIS?
YES

NO (If "Yes," describe):

SECTION IX - FUNCTIONAL IMPACT
9. DO ANY OF THE VETERAN'S SKIN CONDITIONS IMPACT HIS OR HER ABILITY TO WORK?
YES

NO (If "Yes," describe impact of each of the veteran's skin conditions, providing one or more examples):

SECTION X - REMARKS
10. REMARKS (If any)

SECTION XI - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
11A. PHYSICIAN'S SIGNATURE
11D. PHYSICIAN'S PHONE AND FAX NUMBER

11C. DATE SIGNED

11B. PHYSICIAN'S PRINTED NAME
11E. PHYSICIAN'S MEDICAL LICENSE NUMBER

11F. 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 21-0960F-2, MAR 2014

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