VA Form 21-0960N-1 Ear Conditions (including vestibular and infectious) Dis

OMB Control No. 2900-XXXX
Respondent Burden: 15 minutes

EAR CONDITIONS (INCLUDING VESTIBULAR AND INFECTIOUS)
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 THIS 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.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN HAVE OR HAS HE OR SHE HAD ANY EAR OR PERIPHERAL VESTIBULAR CONDITIONS?
YES

NO

(If "No," complete Item 1B)

(If "Yes," complete Item 1C)

1B. PROVIDE RATIONALE (e.g., Veteran does not currently have any known ear or peripheral vestibular conditions):

1C. SELECT VETERAN'S CONDITION (check all that apply):
Meniere's syndrome or endolymphatic hydrops

ICD Code:

Date of Diagnosis:

Peripheral vestibular disorder

ICD Code:

Date of Diagnosis:

Benign Paroxysmal Positional Vertigo (BPPV)

ICD Code:

Date of Diagnosis:

Chronic otitis externa

ICD Code:

Date of Diagnosis:

Chronic suppurative otitis media

ICD Code:

Date of Diagnosis:

Chronic nonsuppurative otitis media (serous otitis media)

ICD Code:

Date of Diagnosis:

Mastoiditis

ICD Code:

Date of Diagnosis:

Cholesteatoma

ICD Code:

Date of Diagnosis:

ICD Code:

Date of Diagnosis:

(If checked, a Hearing Loss and Tinnitus Questionnaire
must ALSO be completed.)
Otosclerosis

(If checked, a Hearing Loss and Tinnitus Questionnaire
must be completed in lieu of this Questionnaire.)

Benign neoplasm of the ear (other than skin only)
Malignant neoplasm of the ear (other than skin only)

(If checked, complete Tumors and Neoplasm
Questionnaire in lieu of this Questionnaire.)

Other, specify:
Other, diagnosis #1:

ICD Code:

Date of Diagnosis:

Other, diagnosis #2:

ICD Code:

Date of Diagnosis:

1D. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO EAR OR PERIPHERAL VESTIBULAR CONDITIONS, LIST USING ABOVE FORMAT:

NOTE: If the Veteran has hearing loss or tinnitus attributable to any ear condition listed above, a Hearing Loss and Tinnitus Questionnaire must ALSO be completed.
SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (INCLUDING ONSET AND COURSE) OF THE VETERAN'S EAR OR PERIPHERAL VESTIBULAR CONDITIONS (BRIEF SUMMARY):

2B. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING CONTINUOUS MEDICATION FOR THE DIAGNOSED CONDITION?
YES

VA FORM
FEB 2011

NO

(If "Yes," list only those medications used for the diagnosed condition):

21-0960N-1

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SECTION III - VESTIBULAR CONDITIONS
3. DOES THE VETERAN HAVE ANY FINDINGS, SIGNS, OR SYMPTOMS ATTRIBUTABLE TO MENIERE'S SYNDROME (ENDOLYMPHATIC HYDROPS), A PERIPHERAL
VESTIBULAR CONDITION OR ANOTHER DIAGNOSED CONDITION FROM SECTION 1?
YES

NO

(If "Yes," check all that apply):
Hearing impairment with vertigo

(If checked, indicate frequency):
(Indicate duration of episodes):

Less than once a month
< 1 hour

1 to 24 hours

1 to 4 times per month

More than once weekly

> 24 hours

Hearing impairment with attacks of vertigo and cerebellar gait

(If checked, indicate frequency):
(Indicate duration of episodes):

Less than once a month
< 1 hour

1 to 24 hours

1 to 4 times per month

More than once weekly

> 24 hours

Tinnitus, unilateral or bilateral

(If checked, indicate frequency):
(Indicate duration of episodes):

Less than once a month
< 1 hour

1 to 24 hours

1 to 4 times per month

More than once weekly

> 24 hours

Vertigo

(If checked, indicate frequency):
(Indicate duration of episodes):

Less than once a month
< 1 hour

1 to 24 hours

1 to 4 times per month

More than once weekly

> 24 hours

Staggering

(If checked, indicate frequency):
(Indicate duration of episodes):

Less than once a month
< 1 hour

1 to 24 hours

1 to 4 times per month

More than once weekly

> 24 hours

Nausea

(If checked, indicate frequency):
(Indicate duration of episodes):

Less than once a month
< 1 hour

1 to 24 hours

1 to 4 times per month

More than once weekly

> 24 hours

Vomiting

(If checked, indicate frequency):
(Indicate duration of episodes):

Less than once a month
< 1 hour

1 to 24 hours

1 to 4 times per month

More than once weekly

> 24 hours

Hearing impairment and/or tinnitus

(If checked, a Hearing Loss and Tinnitus Questionnaire must ALSO be completed)
Other, describe:

SECTION IV - INFECTIOUS, INFLAMMATORY AND OTHER EAR CONDITIONS
4A. DOES THE VETERAN HAVE ANY OF THE FOLLOWING FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO CHRONIC EAR INFECTION, INFLAMMATION,
CHOLESTEATOMA OR ANY OF THE DIAGNOSES IN SECTION 1?
YES

NO

(If "Yes," check all that apply):
Swelling

(If checked, describe):
Dry scaly discharge
Serous discharge
Itching
Effusion
Active suppuration
Aural polyps
Hearing impairment and/or tinnitus

(If checked, a Hearing Loss and Tinnitus Questionnaire must ALSO be completed)
Facial nerve paralysis

(If checked, ALSO complete Cranial Nerves Questionnaire)
Bone loss of skull

(If checked, indicate severity):
Area lost smaller than an American quarter (4.619 cm2)
Area lost greater than an American quarter but smaller than a 50-cent piece
Area lost larger than an American 50-cent piece (7.55 cm2)
Requiring frequent and prolonged treatment

(If checked, describe type and durations of treatment):
Other, describe:
4B. DOES THE VETERAN HAVE A BENIGN NEOPLASM OF THE EAR (OTHER THAN SKIN ONLY, SUCH AS KELOID OR OSTEOMA) THAT CAUSES ANY IMPAIRMENT
OF FUNCTION?
YES
NO

(If "Yes," describe impairment of function caused by this condition):

VA FORM 21-0960N-1, FEB 2011

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SECTION V - SURGICAL TREATMENT
5A. HAS THE VETERAN HAD SURGICAL TREATMENT FOR ANY EAR CONDITION?
YES

NO

(If "Yes," indicate type of surgery):

Date:
Side affected:

Right

Left

Both

5B. DOES THE VETERAN HAVE ANY RESIDUALS AS A RESULT OF THE SURGERY?
YES

NO

(If "Yes," describe):

SECTION VI - PHYSICAL EXAM
6A. EXTERNAL EAR
Exam or external ear not indicated
Normal
Deformity of auricle, with loss of less than one-third of substance

(If checked, specify side):

Right

Left

Deformity of auricle, with loss of one-third or more of the substance

(If checked, specify side):

Right

Left

Right

Left

Complete loss of auricle

(If checked, specify side):
Other abnormality, describe:

6B. EAR CANAL:
Exam of ear canal not indicated
Normal
Abnormal, describe:
6C. TYMPANIC MEMBRANE:
Exam of tympanic membrane not indicated
Normal
Perforated tympanic membrane

(If checked, specify side):

Right

Left

Evidence of a healed tympanic membrane perforation

(If checked, specify side):

Right

Left

Other abnormality, describe:

6D. GAIT:
Exam of gait not indicated
Normal
Unsteady, describe:
Other abnormality, describe:

6E. RHOMBERG TEST:
Exam using this test not indicated
Normal or negative
Abnormal or positive for unsteadiness
6F. DIX HALLPIKE TEST (NYLEN-BARANY TEST) FOR VERTIGO
Exam using this test not indicated
Normal, no vertigo or nystagmus during test
Abnormal, vertigo or nystagmus during test, describe:
6G. LIMB COORDINATION TEST (FINGER-NOSE-FINGER)
Exam using this test not indicated
Normal
Abnormal, describe:
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SECTION VII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
7A. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, SIGNS AND/OR SYMPTOMS?
YES

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

NO

7B. DOES THE VETERAN HAVE ANY SCARS (SURGICAL OR OTHERWISE) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED
IN THE DIAGNOSIS SECTION ABOVE?
YES

NO

(If "Yes," are any of the scars painful and/or unstable, or is the total area of all related scars greater than 39 square cm (6 square inches)?
YES

NO

(If "Yes," also complete a Scars Questionnaire.)
SECTION VIII - DIAGNOSTIC TESTING

NOTE: If testing has been performed and reflects Veteran's current condition, no further testing is required for this examination report. The diagnosis of gastric or
duodenal ulcer or stenosis can be made by upper gastrointestinal imaging series or endoscopy.
8A. HAVE DIAGNOSTIC IMAGING STUDIES OR OTHER DIAGNOSTIC PROCEDURES BEEN PERFORMED?
YES

NO

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

Date:

Results:

Computerized axial tomography (CT) Date:

Results:

Electronystagmography (ENG)

Date:

Results:

Date:

Results:

Other, specify:

8B. HAS THE VETERAN HAD AN AUDIOGRAM?
YES

NO

(If "Yes," attach or provide results):
(If the Veteran has hearing loss or tinnitus, a Hearing and Tinnitus exam must ALSO be scheduled.)
8C. 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 IX - FUNCTIONAL IMPACT
9. DO ANY OF THE VETERAN'S EAR OR PERIPHERAL VESTIBULAR CONDITIONS IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe impact of each of the Veteran's ear or peripheral vestibular conditions, providing one or more examples):
SECTION X - REMARKS
10. 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.
11A. PHYSICIAN'S SIGNATURE

11D. PHYSICIAN'S PHONE NUMBER

11B. PHYSICIAN'S PRINTED NAME

11E. PHYSICIAN'S MEDICAL LICENSE NUMBER

11C. DATE SIGNED

11F. 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: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application.
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 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 21-0960N-1, FEB 2011

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