VA Form 21-0960P-1 Eating Disorders Disability Benefits Quesitonnaire

OMB Approved No. 2900-0779
Respondent Burden: 15 Minutes
Expiration Date: XXXXXXX

EATING DISORDERS 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.
IMPORTANT- If the veteran experiences a mental health emergency during the interview, please terminate the interview and obtain help, using local resources as
appropriate. You may also contact the VA Suicide Prevention Hotline at 1-800-273-TALK. Stay on the Hotline until help can link the veteran to emergency care.
NOTE - In order to conduct an INITIAL examination for eating disorders, the examiner must meet one of the following criteria: a board-certified or board-eligible
psychiatrist; a licensed doctorate-level psychologist; a doctorate-level mental health provider under the close supervision of a board-certified or board-eligible
psychiatrist or licensed doctorate-level psychologist; a psychiatry resident under close supervision of a board-certified or board-eligible psychiatrist or licensed
doctorate-level psychologist; or a clinical or counseling psychologist completing a one-year internship or residency (for purposes of a doctorate-level degree) under
close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist. In order to conduct a REVIEW examination for eating
disorders, the examiner must meet one of the criteria from above, OR be a licensed clinical social worker (LCSW), a nurse practitioner, a clinical nurse specialist, or a
physician assistant, under close supervision of a board-certified or board-eligible psychiatrist or doctorate-level psychologist.
SECTION I - DIAGNOSIS
1. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH AN EATING DISORDER(S)?
YES

NO

(If "Yes," check all diagnoses that apply):
BULIMIA
DATE OF DIAGNOSIS:

ICD CODE:

NAME OF DIAGNOSING FACILITY OR CLINICIAN:
ANOREXIA
DATE OF DIAGNOSIS:

ICD CODE:

NAME OF DIAGNOSING FACILITY OR CLINICIAN:
EATING DISORDER NOT OTHERWISE SPECIFIED
DATE OF DIAGNOSIS:

ICD CODE:

NAME OF DIAGNOSING FACILITY OR CLINICIAN:

SECTION II - MEDICAL HISTORY
2. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S EATING DISORDER (brief summary):

SECTION III - FINDINGS
NOTE - For VA purposes, an incapacitating episode is defined as a period during which bed rest and treatment by a physician are required.
BINGE EATING FOLLOWED BY SELF-INDUCED VOMITING OR OTHER MEASURES TO PREVENT WEIGHT GAIN, OR RESISTANCE TO WEIGHT GAIN EVEN
WHEN BELOW EXPECTED MINIMUM WEIGHT, WITH DIAGNOSIS OF AN EATING DISORDER BUT WITHOUT INCAPACITATING EPISODES
BINGE EATING FOLLOWED BY SELF-INDUCED VOMITING OR OTHER MEASURES TO PREVENT WEIGHT GAIN, OR RESISTANCE TO WEIGHT GAIN EVEN
WHEN BELOW EXPECTED MINIMUM WEIGHT, WITH DIAGNOSIS OF AN EATING DISORDER AND INCAPACITATING EPISODES OF UP TO TWO WEEKS
TOTAL DURATION PER YEAR
SELF-INDUCED WEIGHT LOSS TO LESS THAN 85 PERCENT OF EXPECTED MINIMUM WEIGHT WITH INCAPACITATING EPISODES OF MORE THAN TWO
BUT LESS THAN SIX WEEKS TOTAL DURATION PER YEAR
SELF-INDUCED WEIGHT LOSS TO LESS THAN 85 PERCENT OF EXPECTED MINIMUM WEIGHT WITH INCAPACITATING EPISODES OF SIX OR MORE WEEKS
TOTAL DURATION PER YEAR
SELF-INDUCED WEIGHT LOSS TO LESS THAN 80 PERCENT OF EXPECTED MINIMUM WEIGHT WITH INCAPACITATING EPISODES OF AT LEAST SIX WEEKS
TOTAL DURATION PER YEAR, AND REQUIRING HOSPITALIZATION MORE THAN TWICE A YEAR FOR PARENTERAL NUTRITION OR TUBE FEEDING
VA FORM
XXXX

21-0960P-1

SUPERSEDES VA FORM 21-0960P-1, FEB 2015,
WHICH WILL NOT BE USED.

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION IV - OTHER SYMPTOMS
4. DOES THE VETERAN HAVE ANY OTHER SYMPTOMS ATTRIBUTABLE TO AN EATING DISORDER?
YES

NO

(If "Yes," describe):

SECTION V - FUNCTIONAL IMPACT
5. DOES THE VETERAN'S EATING DISORDER(S) IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe impact, providing one or more examples):

SECTION VI - REMARKS
6. REMARKS (If any)

SECTION VII - PSYCHIATRIST/PSYCHOLOGIST/EXAMINER CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
7A. PSYCHIATRIST/PSYCHOLOGIST/EXAMINER SIGNATURE & TITLE

7B. PSYCHIATRIST/PSYCHOLOGIST/EXAMINER PRINTED NAME

7C. DATE SIGNED

7D. PSYCHIATRIST/PSYCHOLOGIST/EXAMINER PHONE AND FAX NUMBER

7E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER

7F. PSYCHIATRIST/PSYCHOLOGIST/EXAMINER/ADDRESS

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

IMPORTANT - Psychiatrist/psychologist 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 21-0960P-1, XXXX

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