VA Form 21-0960C-1 Parkinson's Disease Disability Benefits Questionnaire

OMB Approved No. 2900-0749
Respondent Burden: 15 minutes

PARKINSON'S DISEASE 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 ON
REVERSE 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 use the information you provide on
this questionnaire to process the Veteran's claim.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER BEEN DIAGNOSED WITH
PARKINSON'S DISEASE?
YES

1B. ICD CODES(S)

1C. DATE OF DIAGNOSIS

NO

2. DOMINANT HAND
RIGHT

LEFT

AMBIDEXTROUS

SECTION II - MOTOR MANIFESTATIONS
3. MOTOR MANIFESTATIONS DUE TO PARKINSON'S OR ITS TREATMENT (Check all that apply)
NONE

MOTOR MANIFESTATIONS

MILD

MODERATE

SEVERE

A. STOOPED POSTURE
B. BALANCE IMPAIRMENT
C. BRADYKINESIA OR SLOWED MOTION (Difficulty initiating

movement, "freezing," short shuffling steps)

D. LOSS OF AUTOMATIC MOVEMENTS (Such as blinking, leading to

fixed gaze, typical Parkinson's facies)

E. SPEECH CHANGES (Monotone, slurring words, soft or rapid speech)
F. TREMOR (Characteristic hand shaking, "pill-rolling")

YES

NO

EXTREMITIES AFFECTED:
RIGHT UPPER
NOT AFFECTED

MILD

MODERATE

SEVERE

MILD

MODERATE

SEVERE

MILD

MODERATE

SEVERE

MILD

MODERATE

SEVERE

LEFT UPPER
NOT AFFECTED
RIGHT LOWER
NOT AFFECTED
LEFT LOWER
NOT AFFECTED
G. MUSCLE RIGIDITY AND STIFFNESS

YES

NO

EXTREMITIES AFFECTED:
RIGHT UPPER
NOT AFFECTED

MILD

MODERATE

SEVERE

MILD

MODERATE

SEVERE

MILD

MODERATE

SEVERE

MILD

MODERATE

SEVERE

LEFT UPPER
NOT AFFECTED
RIGHT LOWER
NOT AFFECTED
LEFT LOWER
NOT AFFECTED

SECTION lII - MENTAL MANIFESTATIONS
4. MENTAL MANIFESTATIONS DUE TO PARKINSON'S OR ITS TREATMENT (Check all that apply)
MENTAL MANIFESTATIONS
A. DEPRESSION
B. COGNITIVE IMPAIRMENT OR DEMENTIA
VA FORM
MAY 2010

21-0960C-1

NONE

MILD

MODERATE

SEVERE

SECTION IV - ADDITIONAL MANIFESTATIONS/COMPLICATIONS
5. ADDITIONAL MANIFESTATIONS/COMPLICATIONS DUE TO PARKINSON'S OR ITS TREATMENT (Check all that apply)
ADDITIONAL MANIFESTATIONS/COMPLICATIONS

NONE

MILD

MODERATE

SEVERE

A. LOSS OF SENSE OF SMELL
PARTIAL

COMPLETE

B. SLEEP DISTURBANCE (Insomnia or daytime "sleep attacks")
C. DIFFICULTY CHEWING/SWALLOWING
D. URINARY PROBLEMS (Incontinence or urinary retention) - (Indicate
"None" or, if absorbent material required due to incontinence, specify
pads/day):
OR, IF APPLICABLE, USE OF AN
0

1

2-4

>4

APPLIANCE

E. CONSTIPATION (DUE TO SLOWING OF GI TRACT OR
SECONDARY TO PARKINSON'S MEDICATIONS)
F. SEXUAL DYSFUNCTION

(Precludes intercourse, including
erectile dysfunction)

G. OTHER MANIFESTATIONS/COMPLICATIONS

(Specify):

H. OTHER MANIFESTATIONS/COMPLICATIONS

(Specify):

6. FINANCIAL RESPONSIBILITY - In your judgment, is the veteran able to manage his/her benefit payments in his/her own best interest, or able to direct someone
else to do so?
YES

NO

SECTION V - FUNCTIONAL IMPACT AND REMARKS
7. DOES THE VETERAN'S PARKINSON'S IMPACT THE VETERAN'S ABILITY TO WORK?
YES

NO

(If "Yes," describe impact and provide one or more examples)

8. REMARKS (If any)

SECTION VI - 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 NUMBER

9B. PHYSICIAN'S PRINTED NAME

9E. PHYSICIAN'S MEDICAL LICENSE NUMBER

9C. DATE SIGNED

9F. PHYSICIAN'S ADDRESS

NOTE - VA may obtain additional medical information, including an examination, 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.vba.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, 58VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment
Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. 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 MAY 2010, 21-0960C-1