VA Form 21-0960E-2 Endocrine Diseases (Other than Thyroid, Parathyroid or D

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

ENDOCRINE DISEASES (Other than Thyroid, Parathyroid or Diabetes
Mellitus) 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.
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

NAME OF PATIENT/VETERAN

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/SHE EVER HAD AN ENDOCRINE CONDITION? (This is the condition the veteran is claiming or for which an exam has been
requested)
YES

NO (If "Yes," complete Item 1B)

1B. SELECT THE VETERAN'S CONDITION (Check all that apply)
CUSHING'S SYNDROME
ACROMEGALY

ICD code - _____________

Date of diagnosis - ______________

ICD code - _____________

Date of diagnosis - ______________

ICD code - _____________

Date of diagnosis - ______________

ICD code - _____________

Date of diagnosis - ______________

ICD code - _____________

Date of diagnosis - ______________

ICD code - _____________

Date of diagnosis - ______________

ICD code - _____________

Date of diagnosis - ______________

ICD code - _____________

Date of diagnosis - ______________

ICD code - _____________

Date of diagnosis - ______________

ICD code - _____________

Date of diagnosis - ______________

ICD code - _____________

Date of diagnosis - ______________

OTHER DIAGNOSIS #1:___________________________
_______________________________________________

ICD code - _____________

Date of diagnosis - ______________

OTHER DIAGNOSIS #2:___________________________
_______________________________________________

ICD code - _____________

Date of diagnosis - ______________

DIABETES INSIPIDUS
ADDISON'S DISEASE
POLYGLANDULAR (Pluriglandular) SYNDROME
HYPOPITUITARISM
HYPERPITUITARISM
HYPERALDOSTERONISM
PHEOCHROMOCYTOMA
HYPOGONADISM
OSTEOPOROSIS
OTHER (specify):

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO ENDOCRINE CONDITION(S), LIST USING ABOVE FORMAT:

NOTE: If there are any cardiovascular, psychiatric, eye, skin or skeletal complications attributable to an endocrine condition, ALSO complete appropriate questionnaires if
indicated.

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 ENDOCRINE CONDITION (brief summary):

3B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF AN ENDOCRINE CONDITION?
YES

NO

(If "Yes," specify the condition and list only those medications required for the veteran's endocrine condition):________________________________________________
_______________________________________________________________________________________________________________________________________
3C. HAS THE VETERAN HAD SURGERY FOR AN ENDOCRINE CONDITION?
YES
NO
(If "Yes," specify the condition and type of surgery):__________________________________________________
(Date of surgery):_____________
3D. HAS THE VETERAN HAD ANY OTHER TYPE OF TREATMENT FOR AN ENDOCRINE CONDITION?
YES

NO

(If "Yes," specify the condition and type of treatment):__________________________________________________
(Date of treatment):_____________
VA FORM
MAR 2011

21-0960E-2

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SECTION IV - FINDINGS, SIGNS AND SYMPTOMS
4A. DOES THE VETERAN HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO CUSHING'S SYNDROME:
YES

NO

(If "Yes," check all that apply)
STRIAE
OBESITY
MOON FACE
GLUCOSE INTOLERANCE
VASCULAR FRAGILITY
LOSS OF MUSCLE STRENGTH
ENLARGEMENT OF PITUITARY OR ADRENAL GLAND
AS ACTIVE, PROGRESSIVE DISEASE INCLUDING LOSS OF MUSCLE STRENGTH
OSTEOPOROSIS
HYPERTENSION
WEAKNESS
OTHER (Specify)____________________________
(FOR ALL CHECKED CONDITIONS COMPLETE ITEM 4B)
4B. DESCRIBE ANY CHECKED CONDITIONS:

SECTION V - ACROMEGALY

5A. DOES THE VETERAN CURRENTLY HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO ACROMEGALY?
YES

NO

(If "Yes," check all that apply)
ENLARGEMENT OF ACRAL PARTS
OVERGROWTH OF LONG BONES
ENLARGED SELLA TURCICA
ARTHROPATHY
GLUCOSE INTOLERANCE
HYPERTENSION (If checked, provide BPx3):_________________________________________________________
EVIDENCE OF INCREASED INTRACRANIAL PRESSURE (such as visual field defect)
CARDIOMEGALY
OTHER (Specify):_________________________________________
(FOR ALL CHECKED CONDITIONS COMPLETE ITEM 5B)
5B. DESCRIBE ANY CHECKED CONDITIONS:

SECTION VI - DIABETES INSIPIDUS
6A. DOES THE VETERAN CURRENTLY HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO DIABETES INSIPIDUS?
YES

NO

(If "Yes," check all that apply)
POLYURIA
NEAR-CONTINUOUS THIRST
EPISODES OF DEHYDRATION NOT REQUIRING PARENTERAL HYDRATION IN PAST 12 MONTHS
(If checked, indicate frequency of documented episodes in past 12 months)

0

1

2

More than 2

EPISODES OF DEHYDRATION REQUIRING PARENTERAL HYDRATION IN PAST 12 MONTHS
(If checked, indicate frequency of documented episodes in past 12 months)

0

1

2

More than 2

OTHER (Specify):_________________________________________
(FOR ALL CHECKED CONDITIONS COMPLETE ITEM 6B)
6B. DESCRIBE ANY CHECKED CONDITIONS:

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SECTION VII - ADDISON'S DISEASE (ADRENAL CORTICAL HYPOFUNCTION)
7A. DOES THE VETERAN CURRENTLY HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO ADDISON'S DISEASE?
YES

NO

(If "Yes," check all that apply)
CORTICOSTEROID THERAPY REQUIRED FOR CONTROL
WEAKNESS
FATIGABILITY
ADDISONIAN CRISIS (acute adrenal insufficiency)
(If checked, indicate frequency of Addisonian crises in past 12 months)

0

1

2

3

4

5

More than 5

ADDISONIAN "EPISODES"
(If checked, indicate frequency of Addisonian "episodes" in past 12 months)

0

1

2

3

4

5

More than 5

OTHER (Specify):__________________________
(FOR ALL CHECKED CONDITIONS COMPLETE ITEM 7B)
7B. DESCRIBE ANY CHECKED CONDITIONS:

NOTE: An Addisonian crisis consists of the rapid onset of peripheral vascular collapse (with acute hypotension and shock), with findings that may include anorexia; nausea;
vomiting; dehydration; profound weakness; pain in the abdomen; legs and back; fever; apathy and depressed mentation with possible progression to coma, renal shutdowh
and death.
For VA purposes, an Addisonian "episode" is a less acute and less severe event than an Addisonian crisis and may consist of anorexia, nausea, vomiting, diarrhea,
dehydration, weakness, malaise, orthostatic hypotension or hypoglycemia, but no peripheral vascular collapse.

SECTION VIII - OTHER ENDOCRINE CONDITIONS
8A. DOES THE VETERAN HAVE ANY OTHER ENDOCRINE CONDITIONS?
NO (If "Yes," complete Item 8B)
YES
8B. SPECIFY CONDITION AND DESCRIBE ANY CURRENT FINDINGS, SIGNS AND SYMPTOMS:

SECTION IX - TUMORS AND NEOPLASMS
9A. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DIAGNOSIS ?
YES

NO (If "Yes," complete Items 9B, 9C, 9D & 9E)

9B. IS THE NEOPLASM:
BENIGN

MALIGNANT

9C. 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," complete Item 9C)

9C. 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:_________________
9D. 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)):

9E. IF THERE ARE ADDITIONAL BENIGN OR MALIGNANT NEOPLASMS OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DESCRIBE USING
THE ABOVE FORMAT:

VA FORM 21-0960E-2, MAR 2011

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SECTION X - OTHER PERTINENT PHYSICAL FINDINGS, SCARS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
10A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
SECTION I, DIAGNOSIS?
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 VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)

10B. 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))

SECTION XI - DIAGNOSTIC TESTING
NOTE: If diagnostic test results are in the medical record and reflect the veteran's current endocrine condition, repeat testing is not required.
11A. HAVE IMAGING STUDIES BEEN PERFORMED?
YES
NO
(If "Yes," check all that apply)
Magnetic resonance imaging (MRI) Date:________________ Results:______________________________________
Computed tomography (CT)

Date:________________ Results:______________________________________

Other:_______________________ Date:________________

Results:______________________________________

11B. HAS LABORATORY TESTING BEEN PERFORMED?
YES

NO (If "Yes," indicate type of test, date and results)
Type of test:_______________________ Date:________________ Results:______________________________________

11C. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES

NO (If "Yes," indicate type of test, date and results)
Type of test or procedure:_______________________ Date:________________ Results:______________________________________

SECTION XII - FUNCTIONAL IMPACT
12. DOES THE VETERAN'S ENDOCRINE CONDITION IMPACT HIS OR HER ABILITY TO WORK?
YES

NO (If "Yes," describe the impact of each of the veteran's endocrine conditions providing one or more examples)

SECTION XIII - REMARKS
13. REMARKS (If any)

SECTION XIV - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
14A. PHYSICIAN'S SIGNATURE

14B. PHYSICIAN'S PRINTED NAME

14D. PHYSICIAN'S PHONE AND FAX NUMBER 14E. PHYSICIAN'S MEDICAL LICENSE NUMBER

14C. DATE SIGNED

14F. 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.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, 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 21-0960E-2, MAR 2011

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