VA Form 21-0960C-2 Amyotrophic Lateral Sclerosis (Lou Gehrig's Disease) Dis

OMB Control No. 2900-XXXX
Respondent Burden: 30 minutes

AMYOTROPHIC LATERAL SCLEROSIS (LOU GEHRIG'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 PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN 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 HAVE AMYOTROPHIC LATERAL SCLEROSIS (ALS)?
YES

NO

(If "No," complete Item 1B) (If "Yes," complete Item 1C)

1B. PROVIDE RATIONALE (e.g., veteran does not currently have ALS)

1C. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO AMYOTROPHIC LATERAL SCLEROSIS
DIAGNOSIS # 1 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 2 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 3 -

ICD CODE -

DATE OF DIAGNOSIS -

1D. IF ADDITIONAL DIAGNOSES THAT PERTAIN TO AMYOTROPHIC LATERAL SCLEROSIS, LIST USING ABOVE FORMAT

SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S ALS:

2B. DOMINANT HAND
RIGHT

LEFT

AMBIDEXTROUS

SECTION III - CONDITIONS, SIGNS AND SYMPTOMS DUE TO ALS
3A. DOES THE VETERAN HAVE ANY MUSCLE WEAKNESS IN THE UPPER AND/OR LOWER EXTREMITIES DUE TO ALS?
YES

NO

(If "Yes," check all that apply)
RIGHT UPPER EXTREMITY MUSCLE WEAKNESS:
NONE

MILD

MODERATE

SEVERE

WITH ATROPHY

COMPLETE (no remaining function)

SEVERE

WITH ATROPHY

COMPLETE (no remaining function)

SEVERE

WITH ATROPHY

COMPLETE (no remaining function)

SEVERE

WITH ATROPHY

COMPLETE (no remaining function)

LEFT UPPER EXTREMITY MUSCLE WEAKNESS:
NONE

MILD

MODERATE

RIGHT LOWER EXTREMITY MUSCLE WEAKNESS:
NONE

MILD

MODERATE

LEFT LOWER EXTREMITY MUSCLE WEAKNESS:
NONE

MILD

MODERATE

3B. DOES THE VETERAN HAVE ANY PHARYNX AND/OR LARYNX AND/OR SWALLOWING CONDITIONS DUE TO ALS?
YES

NO

(If "Yes," check all that apply)
CONSTANT INABILITY TO COMMUNICATE BY SPEECH
SPEECH NOT INTELLIGIBLE OR INDIVIDUAL IS APHONIC
PARALYSIS OF SOFT PALATE WITH SWALLOWING DIFFICULTY (nasal regurgitation) AND SPEECH IMPAIRMENT
HOARSENESS
MILD SWALLOWING DIFFICULTIES
MODERATE SWALLOWING DIFFICULTIES
SEVERE SWALLOWING DIFFICULTIES
REQUIRES FEEDING TUBE DUE TO SWALLOWING DIFFICULTIES
3C. DOES THE VETERAN HAVE ANY RESPIRATORY CONDITIONS DUE TO ALS?
YES

NO

(If "Yes," provide PFT results under "Diagnostic Testing" section)
VA FORM
DEC 2010

21-0960C-2

Page 1

SECTION III - CONDITIONS, SIGNS AND SYMPTOMS DUE TO ALS (Continued)
3D. DOES THE VETERAN HAVE SIGNS AND/OR SYMPTOMS OF SLEEP APNEA DUE TO ALS?
NOTE: If signs and/or symptoms of sleep apnea are due to ALS, these symptoms are due to weakness in the palatal, pharyngeal, laryngeal, and/or respiratory musculature. A sleep study is not
indicated to report symptoms of sleep apnea that are attributable to ALS.
YES

NO

(If "Yes," check all that apply)
PERSISTENT DAYTIME HYPERSOMNOLENCE
REQUIRES USE OF BREATHING ASSISTANCE DEVICE SUCH AS CONTINUOUS AIRWAY PRESSURE (CPAP) MACHINE
CHRONIC RESPIRATORY FAILURE WITH CARBON DIOXIDE RETENTION OR COR PULMONALE
REQUIRES TRACHEOSTOMY
3E. DOES THE VETERAN HAVE ANY BOWEL FUNCTIONAL CONDITIONS DUE TO ALS?
YES

NO

(If "Yes," check all that apply)
SLIGHT IMPAIRMENT OF SPHINCTER CONTROL, WITHOUT LEAKAGE
CONSTANT SLIGHT IMPAIRMENT OF SPHINCTER CONTROL, OR OCCASIONAL MODERATE LEAKAGE
OCCASIONAL INVOLUNTARY BOWEL MOVEMENTS, NECESSITATING WEARING OF A PAD
EXTENSIVE LEAKAGE AND FAIRLY FREQUENT INVOLUNTARY BOWEL MOVEMENTS
TOTAL LOSS OF BOWEL SPHINCTER CONTROL
CHRONIC CONSTIPATION
OTHER BOWEL IMPAIRMENT (describe):
3F. DOES THE VETERAN HAVE VOIDING DYSFUNCTION CAUSING URINE LEAKAGE?
YES

NO

(If "Yes," check all that apply)
DOES NOT REQUIRE/DOES NOT USE ABSORBENT MATERIAL
REQUIRES ABSORBENT MATERIAL THAT IS CHANGED LESS THAN 2 TIMES PER DAY
REQUIRES ABSORBENT MATERIAL THAT IS CHANGED 2 TO 4 TIMES PER DAY
REQUIRES ABSORBENT MATERIAL THAT IS CHANGED MORE THAN 4 TIMES PER DAY
3G. DOES THE VETERAN HAVE VOIDING DYSFUNCTION CAUSING SIGNS AND/OR SYMPTOMS OF URINARY FREQUENCY?
YES

NO

(If "Yes," check all that apply)
DAYTIME VOIDING INTERVAL BETWEEN 2 AND 3 HOURS
DAYTIME VOIDING INTERVAL BETWEEN 1 AND 2 HOURS
DAYTIME VOIDING INTERVAL LESS THAN 1 HOUR
NIGHTTIME AWAKENING TO VOID 2 TIMES
NIGHTTIME AWAKENING TO VOID 3 TO 4 TIMES
NIGHTTIME AWAKENING TO VOID 5 OR MORE TIMES
3H. DOES THE VETERAN HAVE VOIDING DYSFUNCTION CAUSING FINDINGS, SIGNS AND/OR SYMPTOMS OF OBSTRUCTED VOIDING?
YES

NO

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

(If checked, is hesitancy marked?)
YES

NO

SLOW OR WEAK STREAM

(If checked, is stream markedly slow or weak?)
YES

NO

DECREASED FORCE OF STREAM

(If checked, is force of stream markedly decreased?)
YES

NO

STRICTURE DISEASE REQUIRING DILATATION 1 TO 2 TIMES PER YEAR
STRICTURE DISEASE REQUIRING PERIODIC DILATATION EVERY 2 TO 3 MONTHS
RECURRENT URINARY TRACT INFECTIONS SECONDARY TO OBSTRUCTION
UROFLOWMETRY PEAK FLOW RATE LESS THAN 10cc/sec
POST VOID RESIDUALS GREATER THAN 150 cc
URINARY RETENTION REQUIRING INTERMITTENT OR CONTINUOUS CATHETERIZATION
3I. DOES THE VETERAN HAVE VOIDING DYSFUNCTION REQUIRING THE USE OF AN APPLIANCE?
YES

NO

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

VA FORM 21-0960C-2, DEC 2010

Page 2

SECTION III - CONDITIONS, SIGNS AND SYMPTOMS DUE TO ALS (Continued)
3J. DOES THE VETERAN HAVE A HISTORY OF RECURRENT SYMPTOMATIC URINARY TRACT INFECTIONS?
YES

NO

(If "Yes," check all of the following treatment modalities that apply)
NO TREATMENT
DRAINAGE
HOSPITALIZATION

(If checked, indicate frequency of hospitalization)
1 or 2 per year
More than 2 per year
INTENSIVE MANAGEMENT

(If checked, indicate frequency of management)
Continuous
Intermittent
Long-term drug therapy

(If "Intensive Management" is checked, indicate treatment dates for courses of treatment):
3K. DOES THE VETERAN HAVE ERECTILE DYSFUNCTION?
YES

NO

(If "Yes," is the erectile dysfunction as likely as not (at least a 50% probability) attributable to ALS?)
YES

NO

(If "No," provide the etiology of the erectile dysfunction):
(If "Yes," is the veteran able to achieve an erection (without medication) sufficient for penetration and ejaculation?)
YES

NO

(If "No," is the veteran able to achieve an erection (with medication) sufficient for penetration and ejaculation?)
YES

NO

SECTION IV - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND SYMPTOMS
4. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS?
YES

NO

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

SECTION V - HOUSEBOUND

5. IS THE VETERAN SUBSTANTIALLY CONFINED TO HIS OR HER DWELLING AND THE IMMEDIATE PREMISES (or if institutionalized, to the ward or clinical areas)?
YES

NO

(If "Yes," describe how often per day or week and under what circumstances the veteran is able to leave the home or immediate premises):

(If "Yes," does the veteran have more than one condition contributing to his or her being housebound)
YES

NO

(If "Yes," list conditions and describe how each condition contributes to causing the veteran to be permanently housebound)
PROVIDE CONDITIONS AND DESCRIBE HOW EACH CONDITION CONTRIBUTES TO THE VETERAN BEING PERMANENTLY HOUSEBOUND
CONDITION # 1 -

DESCRIPTION -

CONDITION # 2 -

DESCRIPTION -

CONDITION # 3 -

DESCRIPTION -

LIST ANY ADDITIONAL CONDITIONS -

DESCRIPTION -

LIST ANY ADDITIONAL CONDITIONS -

DESCRIPTION -

LIST ANY ADDITIONAL CONDITIONS -

DESCRIPTION -

LIST ANY ADDITIONAL CONDITIONS -

DESCRIPTION -

LIST ANY ADDITIONAL CONDITIONS -

DESCRIPTION -

VA FORM 21-0960C-2, DEC 2010

Page 3

SECTION VI - AID AND ATTENDANCE

6A. DOES THE VETERAN REQUIRE CARE AND/OR ASSISTANCE ON A REGULAR BASIS DUE TO HIS OR HER PHYSICAL AND/OR MENTAL DISABILITIES IN ORDER
TO PROTECT HIM OR HERSELF FROM THE HAZARDS AND/OR DANGERS INCIDENT TO HIS OR HER DAILY ENVIRONMENT?
YES

NO

6B. IS THE VETERAN ABLE TO DRESS OR UNDRESS HIM/HERSELF?
YES

NO

6C. DOES THE VETERAN HAVE SUFFICIENT UPPER EXTREMITY COORDINATION AND STRENGTH TO BE ABLE TO FEED HIM/HERSELF?
YES

NO

6D. IS THE VETERAN ABLE TO ATTEND TO THE WANTS OF NATURE?
YES

NO

6E. IS THE VETERAN ABLE TO KEEP HIM OR HERSELF ORDINARILY CLEAN AND PRESENTABLE?
YES

NO

6F. IS THE VETERAN ABLE TO TAKE HIS OR HER PRESCRIPTION MEDICATIONS IN A TIMELY MANNER AND WITH ACCURATE DOSAGE WITHOUT ASSISTANCE?
YES

NO

6G. DOES THE VETERAN NEED FREQUENT ASSISTANCE FOR ADJUSTMENT OF ANY SPECIAL PROSTHETIC OR ORTHOPEDIC APPLIANCE(S)?
YES

NO

(If "Yes," describe (brief summary):
6H. DOES THE VETERAN'S CONDITION(S) REQUIRE THAT THE VETERAN REMAIN IN BED (this does not include conditions for which the veteran has voluntarily
taken to his/her bed or that a physician has prescribed rest in bed for the greater or lesser part of the day to promote convalescence or cure)?
YES
NO

(If "Yes," is it due to the service-connected disabling condition(s))
YES

NO

6I. IS THE VETERAN BLIND?
YES

NO

(If "Yes," is it due to ALS?)
YES

NO

6J. DOES THE VETERAN REQUIRE HEALTH-CARE SERVICES SUCH AS PHYSICAL THERAPY, ADMINISTRATION OF INJECTIONS, PLACEMENT OF INDWELLING
CATHETERS, CHANGING OF STERILE DRESSINGS, AND/OR LIKE FUNCTIONS WHICH REQUIRE PROFESSIONAL HEALTH-CARE TRAINING OR THE
REGULAR SUPERVISION OF A TRAINED HEALTH-CARE PROFESSIONAL TO PERFORM?
YES

NO

(If "Yes," describe (brief summary):
SECTION VII- ASSISTIVE DEVICES AND REMAINING FUNCTION OF THE EXTREMITIES

7A. DOES THE VETERAN USE ANY ASSISTIVE DEVICE(S) AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER METHODS
MAY BE POSSIBLE?
YES

NO

(If "Yes," identify assistive device(s) used (check all that apply and indicate frequency))
WHEELCHAIR

Frequency of use:

occasional

regular

constant

BRACE(S)

Frequency of use:

occasional

regular

constant

CRUTCH(ES)

Frequency of use:

occasional

regular

constant

CANE(S)

Frequency of use:

occasional

regular

constant

WALKER

Frequency of use:

occasional

regular

constant

OTHER:

Frequency of use:

occasional

regular

constant

7B. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:

7C. DUE TO ALS, IS THERE FUNCTIONAL IMPAIRMENT OF AN EXTREMITY SUCH THAT NO EFFECTIVE FUNCTION REMAINS OTHER THAN THAT WHICH WOULD
BE EQUALLY WELL SERVED BY AN AMPUTATION WITH PROTHESIS? (Functions of the upper extremity include grasping, manipulation, etc., while functions for

the lower extremity include balance and propulsion, etc.)

YES, FUNCTIONING IS SO DIMINISHED THAT AMPUTATION WITH PROTHESIS WOULD EQUALLY SERVE THE VETERAN
NO

(If "Yes," indicate extremity(ies) (check all extremities for which this applies)):
RIGHT UPPER

LEFT UPPER

RIGHT LOWER

LEFT LOWER

SECTION VIII- FINANCIAL RESPONSIBILITY

8. 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

VA FORM 21-0960C-2, DEC 2010

Page 4

SECTION IX - DIAGNOSTIC TESTING
NOTE - If pulmonary function testing (PFT) is indicated due to respiratory disability, and results are in the medical record and reflect the veteran's current respiratory
function, repeat testing is not required. DLCO and bronchodilator testing is not indicated for a restrictive respiratory disability such as that caused by muscle weakness
due to ALS.
9A. HAS PULMONARY FUNCTION TESTING (PFT) BEEN PERFORMED?
YES

NO

(If "Yes," provide most recent results, if available):
FEV1:

% predicted

Date of test:

FEV1/FVC:

% predicted

Date of test:

FEV:

% predicted

Date of test:

9B. IF PFTs HAVE BEEN PERFORMED, IS THE FLOW-VOLUME LOOP COMPATIBLE WITH UPPER AIRWAY OBSTRUCTION?
YES

NO

9C. 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 X - FUNCTIONAL IMPACT AND REMARKS
10. DOES THE VETERAN'S ALS IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe the impact of the veteran's ALS, providing one or more examples)

11. 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.
12A. PHYSICIAN'S SIGNATURE

12D. PHYSICIAN'S PHONE NUMBER

12B. PHYSICIAN'S PRINTED NAME

12E. PHYSICIAN'S MEDICAL LICENSE NUMBER

12C. DATE SIGNED

12F. 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 low 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 30 minutes to review the instructions, find the information, and complete a 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 21-0960C-2, DEC 2010

Page 5