VA Form 21-0960E-3 Thyroid and Parathyroid Conditions

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

THYROID AND PARATHYROID CONDITIONS
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 BEFORE
COMPLETING THIS FORM.
NAME OF PATIENT/VETERAN (First, Middle Initial, Last)

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 OR HAS HE OR SHE EVER HAD A THYROID OR PARATHYROID CONDITION? (This is the condition the veteran is claiming or for

which an exam has been requested)
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):
HYPERTHYROIDISM

ICD code:

Date of diagnosis:

TOXIC ADENOMA OF THYROID

ICD code:

Date of diagnosis:

NON-TOXIC ADENOMA OF THYROID (euthyroid)

ICD code:

Date of diagnosis:

EUTHYROID MULTINODULAR GOITER

ICD code:

Date of diagnosis:

HYPOTHYROIDISM

ICD code:

Date of diagnosis:

HYPERPARATHYROIDISM

ICD code:

Date of diagnosis:

HYPOPARATHYROIDISM

ICD code:

Date of diagnosis:

C-CELL HYPERPLASIA

ICD code:

Date of diagnosis:

BENIGN NEOPLASM OF THE THYROID

ICD code:

Date of diagnosis:

MALIGNANT NEOPLASM OF THE THYROID

ICD code:

Date of diagnosis:

BENIGN NEOPLASM PARATHYROID

ICD code:

Date of diagnosis:

MALIGNANT NEOPLASM PARATHYROID

ICD code:

Date of diagnosis:

ICD code:

Date of diagnosis:

ICD code:

Date of diagnosis:

OTHER (Specify):
OTHER DIAGNOSIS #1:
OTHER DIAGNOSIS #2:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO THYROID OR PARATHYROID CONDITION(S) LIST USING ABOVE FORMAT:

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 THYROID AND/OR PARATHYROID CONDITION(S) (brief summary):

3B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF A THYROID OR PARATHYROID CONDITION?
YES

NO

(If "Yes," specify the condition(s) and list only those medications required for the condition(s)):

3C. HAS THE VETERAN HAD RADIOACTIVE IODINE TREATMENT FOR A THYROID CONDITION?
YES

NO

(If "Yes," specify the condition and type of treatment):
(Date of treatment):

3D. HAS THE VETERAN HAD SURGERY FOR A THYROID OR PARATHYROID CONDITION?
YES

NO

(If "Yes," specify the condition and type of surgery):
(Date of surgery):

3E. HAS THE VETERAN HAD ANY OTHER TYPE OF TREATMENT FOR A THYROID OR PARATHYROID CONDITION?
YES
VA FORM
XXX XXXX

NO

(If "Yes," specify the condition and type of treatment):
(Date of treatment):

21-0960E-3

SUPERSEDES VA FORM 21-0960E-3, SEP 2016,
WHICH WILL NOT BE USED.

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PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

SECTION III - MEDICAL HISTORY (Continued)
3F. DOES THE VETERAN HAVE ANY RESIDUAL ENDOCRINE DYSFUNCTION FOLLOWING TREATMENT FOR THYROID OR PARATHYROID CONDITION?
YES

NO

(If "Yes," check all that apply):
Hypothyroid endocrine dysfunction

Hypoparathyroid endocrine dysfunction

Other (Describe):

SECTION IV - FINDINGS, SIGNS AND SYMPTOMS
4A. DOES THE VETERAN CURRENTLY HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO A HYPERTHYROID CONDITION?
YES

NO

(If "Yes," check all that apply):
Tachycardia (more than 100 beats per minute)
(If "Yes," indicate frequency of tachycardia):
Intermittent

Constant
Palpitations

Atrial fibrillation or other arrhythmia attributable to a thyroid condition

(If checked, indicate frequency):
Constant
Intermittent (paroxysmal)
(If "intermittent," indicate number of episodes in the past 12 months):
0

1-4

More than 4

(Indicate how these episodes were documented (check all that apply)):
EKG
Holter
Other (Specify):
Increased pulse pressure or blood pressure
Tremor
Emotional instability
Fatigability
Thyroid enlargement
Eye involvement (exophthalmos) (If checked, ALSO complete VA Form 21-0960N-2, Eye Conditions Disability Benefits Questionnaire)
Muscular weakness
Increased sweating
Flushing
Heat Intolerance
Frequent bowel movements
Irregular or absent menstrual periods in women
Weight loss attributable to a hyperthyroid condition

(If checked, provide baseline weight:
and current weight:
)
(For VA purposes, baseline weight is the average weight for a 2-year period preceding onset of disease)
Other

(For all checked conditions complete 4B)
4B. DESCRIBE THE CHECKED CONDITION(S):

4C. DOES THE VETERAN HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO A HYPOTHYROID CONDITION?
NO

YES

(If "Yes," check all that apply):
Fatigability
Constipation
Mental sluggishness
Mental disturbance (dementia, slowing of thought, depression)
Muscular weakness
Weight gain

(If checked, provide baseline weight:
and current weight:
)
(For VA purposes, baseline weight is the average weight for a 2-year period preceding onset of disease)
Sleepiness
Cold Intolerance
Bradycardia (less than 60 beats per minute)
Other

(For all checked conditions complete 4D)
4D. DESCRIBE THE CHECKED CONDITION(S):

VA FORM 21-0960E-3, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

SECTION IV - FINDINGS, SIGNS AND SYMPTOMS (Continued)
4E. DOES THE VETERAN CURRENTLY HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO A HYPERPARATHYROID CONDITION?
YES

NO

(If "Yes," check all that apply):
Weakness
Kidney stones (If checked, describe, providing dates and treatment):
Generalized decalcification of bones (If checked, has the veteran had a bone density test, such as a DEXA scan?)
YES

NO

(If "Yes," provide date of test

results:

)

Nausea
Vomiting
Constipation
Anorexia
Peptic Ulcer
Weight loss

(If checked, provide baseline weight:
and current weight:
)
(For VA purposes, baseline weight is the average weight for a 2-year period preceding onset of disease)
Other

(For all checked conditions complete 4F)
4F. DESCRIBE THE CHECKED CONDITION(S):

4G. DOES THE VETERAN CURRENTLY HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO A HYPOPARATHYROID CONDITION?
YES

NO

(If "Yes," check all that apply):
Paresthesias (of arms, legs or circumoral area)
Cataract (If checked, ALSO complete VA Form 21-0960N-2, Eye Conditions Disability Benefits Questionnaire)
Evidence of increased intracranial pressure (such as papilledema)
Marked neuromuscular excitability
Convulsions
Muscular spasms (tetany)
Laryngeal stridor
Other

(For all checked conditions complete 4H)
4H. DESCRIBE THE CHECKED CONDITION(S):

4I. DOES THE VETERAN CURRENTLY HAVE SYMPTOMS DUE TO PRESSURE ON ADJACENT ORGANS SUCH AS THE TRACHEA, LARYNX, OR ESOPHAGUS
ATTRIBUTABLE TO A THYROID CONDITION?
YES

NO

(If "Yes," indicate which adjacent organs are affected):
Larynx and/or trachea (If checked, report pulmonary function testing results in Section X, Diagnostic Testing)
Esophagus (If checked, indicate severity of pressure-related symptoms/swallowing difficulty - check all that apply)
Mild

Moderate

Severe, permitting the passage of liquids only

Causing marked impairment of health

(For all checked conditions complete 4J)
4J. DESCRIBE THE CHECKED CONDITION(S):

VA FORM 21-0960E-3, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

SECTION V - PHYSICAL EXAM
5A. EYES:
ABNORMAL (If checked, describe):

NORMAL, NO EXOPTHALMOS

(If "Abnormal," complete VA Form 21-0960N-2, Eye Conditions Disability Benefits Questionnaire)
5B. NECK:
NORMAL, NO PALPABLE THYROID ENLARGEMENT OR NODULES
ABNORMAL, DIFFUSELY ENLARGED THYROID GLAND
ABNORMAL, ENLARGED THYROID NODULE (If checked, describe location, size and consistency):
ABNORMAL, WITH DISFIGUREMENT OF THE HEAD OR NECK DUE TO ENLARGEMENT OF THE THYROID GLAND

(If checked, describe by completing Section VII, Scars or other Disfigurement of the Neck)
OTHER (Describe):
5C. PULSE
REGULAR

IRREGULAR

(Provide heart rate:

)

5D. BLOOD PRESSURE

(Provide blood pressure:

)
SECTION VI - REFLEX EXAM

6. REFLEXES (Rate deep tendon reflexes (DTRs) according to the following scale):
0 Absent
1+ Hypoactive
2+ Normal
3+ Hyperactive without clonus
4+ Hyperactive with clonus
ALL NORMAL
BICEPS:

KNEE:

Right

0

1+

2+

3+

4+

Right

0

1+

2+

3+

4+

Left

0

1+

2+

3+

4+

Left

0

1+

2+

3+

4+

ANKLE:

TRICEPS:
Right

0

1+

2+

3+

4+

Right

0

1+

2+

3+

4+

Left

0

1+

2+

3+

4+

Left

0

1+

2+

3+

4+

BRACHIORADIALIS:
Right

0

1+

2+

3+

4+

Left

0

1+

2+

3+

4+

SECTION VII - SCARS OR OTHER DISFIGUREMENT OF THE NECK
7A. DOES THE VETERAN HAVE ANY SCARS OR OTHER DISFIGUREMENT OF THE NECK RELATED TO TREATMENT FOR ANY THYROID OR PARATHYROID
CONDITION?
YES

NO

(If "Yes," complete the following):
1.Total number of unstable or painful scars:

0

1

2

3

4

5 or more

2. Is any scar 13 cm in length or longer?
YES

NO

3. Is any scar 0.6 cm in width or wider?
YES

NO

4. Is any scar elevated or depressed?
YES

NO

5. Is any scar adherent to underlying tissue?
YES

NO

7B. DOES THE VETERAN HAVE ANY AREAS OF SKIN OF THE NECK THAT ARE HYPO- OR HYPERPIGMENTED, THAT HAVE ABNORMAL TEXTURE, THAT HAVE
MISSING UNDERLYING SOFT TISSUE, OR THAT ARE INDURATED AND INFLEXIBLE RELATED TO THYROID OR PARATHYROID DISEASE OR THEIR TREATMENT?
YES

NO

(If "Yes," complete the following):
cm2

1. Approximate total area of skin with hypo- or hyperpigmentation:
2. Approximate total area of skin with abnormal texture:
3. Approximate total area of skin with missing underlying soft tissue:
4. Approximate total area of skin that is indurated and inflexible:
VA FORM 21-0960E-3, XXX XXXX

cm2
cm2
cm2

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PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

SECTION VIII - TUMORS AND NEOPLASMS
8A. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DIAGNOSIS?
YES

(If "Yes," complete Items 8B thru 8E)

NO

8B. IS THE NEOPLASM
BENIGN

MALIGNANT

8C. 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):

(Date(s) of surgery):
Radiation therapy

(Date of most recent treatment):

(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):
8D. 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?
YES

NO

(If "Yes," list residual conditions and complications - brief summary):

8E. IF THERE ARE ADDITIONAL BENIGN OR MALIGNANT NEOPLASMS OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DIAGNOSIS,
DESCRIBE USING THE FORMAT IN ITEM 8C:

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

NO

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

SECTION X - DIAGNOSTIC TESTING
NOTE: If diagnostic test results are in the medical record and reflect the veteran's current thyroid or parathyroid condition, repeat testing is not required.
10A. HAVE IMAGING STUDIES BEEN PERFORMED?
YES

NO

(If "Yes," check all that apply):
Magnetic resonance imaging (MRI)

Date:

Results:

Computed tomography (CT)

Date:

Results:

Thyroid scan

Date:

Results:

Thyroid ultrasound

Date:

Results:

Other:

Date:

Results:

10B. HAS LABORATORY TESTING BEEN PERFORMED?
YES

NO

(If "Yes," check all that apply and provide date of most recent test and results):

TSH

Date:

Results:

Free T4

Date:

Results:

Free T3

Date:

Results:

Thyroid antibodies

Date:

Results:

Parathyroid hormone (PTH)

Date:

Results:

Calcium

Date:

Results:

Ionized calcium

Date:

Results:

Other:

Date:

Results:

VA FORM 21-0960E-3, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

SECTION X - DIAGNOSTIC TESTING (Continued)
10C. HAVE PULMONARY FUNCTION TESTS (PFTs) BEEN PERFORMED?

(For VA purposes, PFTs should be performed if there is pressure on the larynx or trachea attributable to a thyroid condition)
YES

NO

(If "Yes," provide most recent results, if available):
FEV-1:

% predicted

Date:

FEV-1/FVC:

%

Date:

FVC :

% predicted

Date:

IS FLOW-VOLUME LOOP COMPATIBLE WITH UPPER AIRWAY OBSTRUCTION?
YES

NO

10D. HAS A BIOPSY BEEN PERFORMED?
YES

NO
Date of test:

Site of biopsy:

Results:

10E. 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 XI - FUNCTIONAL IMPACT
11. DOES THE VETERAN'S THYROID OR PARATHYROID CONDITION IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If Yes," describe impact of the veteran's thyroid and/or parathyroid condition, providing one or more examples):

SECTION XII - REMARKS
12. REMARKS (If any):

SECTION XIII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
13A. PHYSICIAN'S SIGNATURE

13D. PHYSICIAN'S PHONE/FAX NUMBERS

13B. PHYSICIAN'S PRINTED NAME

13C. DATE SIGNED

13E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER 13F. 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,
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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
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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
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to get information on where to send comments or suggestions about this form.
VA FORM 21-0960E-3, XXX XXXX

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