VA Form 21-0960N-4 Sinusitis/Rhinitis and Other Conditions of the Nose, Thr

OMB Approved No. 2900-0781
Respondent Burden: 30 Minutes
Expiration Date: XX/XX/XXXX

SINUSITIS/RHINITIS AND OTHER CONDITIONS OF THE NOSE, THROAT,
LARYNX AND PHARYNX 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 (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 NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH A SINUS, NOSE, THROAT, LARYNX OR PHARYNX 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)
CHRONIC SINUSITIS

ICD Code:

Date of diagnosis:

ALLERGIC RHINITIS

ICD Code:

Date of diagnosis:

NON-ALLERGIC RHINITIS

ICD Code:

Date of diagnosis:

BACTERIAL RHINITIS

ICD Code:

Date of diagnosis:

GRANULOMATOUS RHINITIS

ICD Code:

Date of diagnosis:

CHRONIC LARYNGITIS

ICD Code:

Date of diagnosis:

LARYNGECTOMY

ICD Code:

Date of diagnosis:

LARYNGEAL STENOSIS

ICD Code:

Date of diagnosis:

APHONIA

ICD Code:

Date of diagnosis:

DEVIATED NASAL SEPTUM (Traumatic)

ICD Code:

Date of diagnosis:

PHARYNGEAL INJURY (Describe):

ICD Code:

Date of diagnosis:

BENIGN OR MALIGNANT NEOPLASM OF
SINUS, NOSE, THROAT, LARYNX OR
PHARYNX

ICD Code:

Date of diagnosis:

ANATOMICAL LOSS OF PART OF NOSE

ICD Code:

Date of diagnosis:

Other diagnosis #1

ICD Code:

Date of diagnosis:

Other diagnosis #2

ICD Code:

Date of diagnosis:

(Complete VA Form 21-0960F-1, Scars/
Disfigurement Disability Benefits
Questionnaire in lieu of this questionnaire)
OTHER (specify)

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO THE SINUSES, NOSE, THROAT, LARYNX, OR PHARYNX 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 SINUS, NOSE, THROAT, LARYNX, OR PHARYNX CONDITION:

3B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF THE VETERAN'S SINUS, NOSE, THROAT, LARYNX, OR PHARYNX CONDITION?
YES

VA FORM
XXX XXXX

NO

(If "Yes," list only those medications required for the veteran's sinus, nose, throat, larynx, or pharynx condition):

21-0960N-4

SUPERSEDES VA FORM 21-0960N-4, SEP 2016,
WHICH WILL NOT BE USED.

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SECTION IV - NOSE, THROAT, LARYNX OR PHARYNX CONDITIONS
4. DOES THE VETERAN HAVE ANY OF THE FOLLOWING NOSE, THROAT, LARYNX OR PHARYNX CONDITIONS?
YES

NO

(If "No," proceed to Section V) (If "Yes," check all that apply):

Tumors or neoplasms

(If checked, complete Part A below)
(If checked, complete Part B below)
(If checked, complete Part C below)
(If checked, complete Part D below)
(If checked, complete Part E below)

Other pertinent physical findings or scars due to nose,
throat, larynx or pharynx conditions

(If checked, complete Part F below)

Sinusitis
Rhinitis
Larynx or pharynx condition
Deviated nasal septum (traumatic)

PART A - SINUSITIS
A1. INDICATE THE SINUSES/TYPE OF SINUSITIS CURRENTLY AFFECTED BY THE VETERAN'S CHRONIC SINUSITIS (Check all that apply):
NONE

MAXILLARY

FRONTAL

ETHMOID

SPHENOID

PANSINUSITIS

A2. DOES THE VETERAN CURRENTLY HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO CHRONIC SINUSITIS?
YES

NO

(If "Yes," check all that apply)
Chronic sinusitis detected only by imaging studies (See Section V, Diagnostic Testing)
Episodes of sinusitis
Near constant sinusitis (If checked, describe frequency):
Headaches
Pain and tenderness of affected sinus
Purulent discharge or crusting
Other (describe):
FOR ALL CHECKED CONDITIONS, DESCRIBE:

A3. HAS THE VETERAN HAD NON-INCAPACITATING EPISODES OF SINUSITIS CHARACTERIZED BY HEADACHES, PAIN AND PURULENT DISCHARGE OR
CRUSTING IN THE PAST 12 MONTHS?
NO

YES

(If "Yes," provide the total number of non-incapacitating episodes over the past 12 months):
1

2

3

4

5

6

7

7 or more

A4. HAS THE VETERAN HAD INCAPACITATING EPISODES OF SINUSITIS REQUIRING PROLONGED (4 to 6 weeks) OF ANTIBIOTICS TREATMENT IN THE PAST
12 MONTHS?

NOTE - For VA purposes, an incapacitating episode of sinusitis means one that requires bed rest and treatment prescribed by a physician.
YES

NO

(If "Yes," provide the total number of incapacitating episodes of sinusitis requiring prolonged (4 to 6 weeks) of antibiotic treatment over the past 12 months):
1

2

3 or more

A5. HAS THE VETERAN HAD SINUS SURGERY?
YES

NO

(If "Yes," specify type of surgery):
Radical (open sinus surgery)

Endoscopic

Other (describe):

(Type of procedure, sinuses operated on and side(s)):
(Date(s) of surgery (if repeated sinus surgery, provide all dates of surgery)):
A6. IF VETERAN HAS HAD RADICAL SINUS SURGERY, DID CHRONIC OSTEOMYELITIS FOLLOW THE SURGERY?
YES

NO

(If "Yes," complete VA Form 21-0960M-11, Osteomyelitis Disability Benefits Questionnaire)
PART B - RHINITIS

B1. IS THERE GREATER THAN 50% OBSTRUCTION OF THE NASAL PASSAGE ON BOTH SIDES DUE TO RHINITIS?
YES

NO

B2. IS THERE COMPLETE OBSTRUCTION ON ONE SIDE DUE TO RHINITIS?
YES

NO

B3. IS THERE PERMANENT HYPERTROPHY OF THE NASAL TURBINATES?
YES

NO

B4. ARE THERE NASAL POLYPS?
YES

NO

VA FORM 21-0960N-4, XXX XXXX

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SECTION IV - NOSE, THROAT, LARYNX OR PHARYNX CONDITIONS (Continued)
PART B - RHINITIS (Continued)
B5. DOES THE VETERAN HAVE ANY OF THE FOLLOWING GRANULOMATOUS CONDITIONS?
YES

NO

(If "Yes," check all that apply)

Granulomatous rhinitis

Rhinoscleroma

Wegener's granulomatosis

Lethal midline granuloma

Other granulomatous infection (Describe):

PART C - LARYNX AND PHARYNX CONDITIONS
C1. DOES THE VETERAN HAVE CHRONIC LARYNGITIS?
YES

NO

(If "Yes," does the veteran have any of the following symptoms due to chronic laryngitis?)
YES

NO

(If "Yes," check all that apply)

Hoarseness (If checked, describe frequency):
Inflammation of vocal cords or mucous membrane
Thickening or nodules of vocal chords
Submucous infiltration of vocal chords
Vocal chord polyps
Other (describe):
C2. HAS THE VETERAN HAD A LARYNGECTOMY?
YES

NO

(If "Yes," specify)

Total laryngectomy
Partial laryngectomy

(If checked, does the veteran have any residuals of the partial laryngectomy?)
YES

NO

(If "Yes," describe):
C3. DOES THE VETERAN HAVE LARYNGEAL STENOSIS, INCLUDING RESIDUALS OF LARYNGEAL TRAUMA (unilateral or bilateral)?
YES

NO

(If "Yes," assess for upper airway obstruction with pulmonary function testing to include Flow-Volume Loop, and provide results in Section V,
Diagnostic Testing)

C4. DOES THE VETERAN HAVE COMPLETE ORGANIC APHONIA?
YES

NO

(If "Yes," check all that apply)

Constant inability to speak above a whisper
Constant inability to communicate by speech
Other (describe):
C5. DOES THE VETERAN HAVE INCOMPLETE ORGANIC APHONIA?
YES

NO

(If "Yes," check all that apply)

Hoarseness (If checked, describe frequency):
Inflammation of vocal cords or mucous membrane
Thickening or nodules of vocal chords
Submucous infiltration of vocal chords
Vocal chord polyps
Other (describe):
C6. HAS THE VETERAN HAD A PERMANENT TRACHEOSTOMY?
YES

NO

(If "Yes," describe reason for tracheostomy and potential for decannulation):

C7. HAS THE VETERAN HAD AN INJURY TO THE PHARYNX?
YES

NO

(If "Yes," check all findings, signs and symptoms that apply):

Stricture or obstruction of the pharynx or nasopharynx
Absence of the soft palate secondary to trauma
Absence of the soft palate secondary to chemical burn
Absence of the soft palate secondary to granulomatous disease
Paralysis of the soft palate with swallowing difficulty (nasal regurgitation) and speech impairment
Other (describe):
C8. DOES THE VETERAN HAVE VOCAL CHORD PARALYSIS OR ANY OTHER PHARYNGEAL OR LARYNGEAL CONDITIONS?
YES

NO

(If "Yes," describe):

VA FORM 21-0960N-4, XXX XXXX

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SECTION IV - NOSE, THROAT, LARYNX OR PHARYNX CONDITIONS (Continued)
PART D - DEVIATED NASAL SEPTUM (TRAUMATIC)
D1. IS THERE AT LEAST 50% OBSTRUCTION OF THE NASAL PASSAGE ON BOTH SIDES DUE TO TRAUMATIC SEPTAL DEVIATION?
YES

NO

D2. IS THERE COMPLETE OBSTRUCTION ON ONE SIDE DUE TO TRAUMATIC SEPTAL DEVIATION?
YES

NO

PART E - TUMORS AND NEOPLASMS
E1. 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 7B through 7E)

NO

E2. IS THE NEOPLASM:
BENIGN

MALIGNANT

E3. HAS THE VETERAN COMPLETED TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT NEOPLASM OR
METASTASES?
YES

NO

(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

(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):
E4. 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)):

E5. 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:

PART F - OTHER PERTINENT PHYSICAL FINDINGS, SCARS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
F1. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) related 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.
F2. 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 (brief summary):

VA FORM 21-0960N-4, XXX XXXX

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SECTION V - DIAGNOSTIC TESTING
NOTE - If testing has been performed and reflects the veteran's current condition, repeat testing is not required. Specific diagnostic testing is not required for many
conditions, but if performed, record in this section.
5A. HAVE IMAGING STUDIES OF THE SINUSES OR OTHER AREAS BEEN PERFORMED?
YES

NO

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

Date:

Results:

Computed tomography (CT)

Date:

Results:

X-rays (describe):

Date:

Results:

Other (describe):

Date:

Results:

5B. HAS ENDOSCOPY BEEN PERFORMED?
YES

NO

(If "Yes," check all that apply):
Nasal endoscopy

Date:

Results:

Laryngeal endoscopy

Date:

Results:

Bronchoscopy

Date:

Results:

Other endoscopy

Date:

Results:

5C. HAS THE VETERAN HAD A BIOPSY OF THE LARYNX OR PHARYNX?
YES

NO

(If "Yes," complete the following):
Site of biopsy:
Results:

Date:
Benign

Pre-malignant

Malignant

Describe results:
5D. HAS THE VETERAN HAD PULMONARY FUNCTION TESTING TO ASSESS FOR UPPER AIRWAY OBSTRUCTION DUE TO LARYNGEAL STENOSIS?
YES

NO

(If "Yes," indicate results)
FEV-1 of 71 to 80% predicted
FEV-1 of 56 to 70% predicted
FEV-1 of 40 to 55% predicted
FEV-1 less than 40% predicted

(Is the Flow-Volume Loop compatible with upper airway obstruction?)
YES

NO

5E. 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)):

VA FORM 21-0960N-4, XXX XXXX

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SECTION VI - FUNCTIONAL IMPACT
6. DOES THE VETERAN'S SINUS, NOSE, THROAT, LARYNX OR PHARYNX CONDITION IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe impact of each of the veteran's sinus, nose, throat, larynx or pharynx conditions, providing one or more examples):

SECTION VII - REMARKS
7. REMARKS (If any)

SECTION VIII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
8A. PHYSICIAN'S SIGNATURE
8D. PHYSICIAN'S PHONE/FAX NUMBERS

8B. PHYSICIAN'S PRINTED NAME
8E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER

8C. DATE SIGNED
8F. 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
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get information on where to send comments or suggestions about this form.
VA FORM 21-0960N-4, XXX XXXX

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