VA Form 21-0960Q-1 Chronic Fatigue Syndrome Disability Benefits Questionnai

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

CHRONIC FATIGUE SYNDROME 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

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 NOW HAVE OR HAS HE/SHE EVER BEEN DIAGNOSED WITH CHRONIC FATIGUE SYNDROME?
YES

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

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

ICD code -__________________________________

DATE OF DIAGNOSIS -___________________

Other diagnosis # 1:____________________________

ICD code -__________________________________

DATE OF DIAGNOSIS -___________________

Other diagnosis # 2:____________________________

ICD code -__________________________________

DATE OF DIAGNOSIS -___________________

OTHER (Specify):

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO CHRONIC FATIGUE SYNDROME, LIST USING ABOVE FORMAT:

NOTE - For VA purposes, the diagnosis of chronic fatigue syndrome requires:
(A) New onset of debilitating fatigue severe enough to reduce daily activity to less than 50 percent of the usual level for at least 6 months; and
(B) The exclusion, by history, physical examination, and laboratory tests, of all other clinical conditions that may produce similar symptoms; and
(C) Six or more of the following:
1. Acute onset of the condition
2. Low grade fever
3. Non-exudative pharyngitis
4. Palpable or tender cervical or axillary lymph nodes
5. Generalized muscle aches or weakness
6. Fatigue lasting 24 hours or longer after exercise

7. Headaches (of a type, severity or pattern that is different from headaches in the pre-morbid state)
8. Migratory joint pains
9. Neuropsychological symptoms
10. Sleep disturbance

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 CHRONIC FATIGUE SYNDROME:

3B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF CHRONIC FATIGUE SYNDROME?
YES

NO

(If "Yes," are the veteran's symptoms controlled by continuous medication?)
No
Yes
(If "Yes," list only those medications required for the veteran's chronic fatigue syndrome)

3C. HAVE OTHER CLINICAL CONDITIONS THAT MAY PRODUCE SIMILAR SYMPTOMS BEEN EXCLUDED BY HISTORY, PHYSICAL EXAMINATION
AND/OR LABORATORY TESTS TO THE EXTENT POSSIBLE?
YES

NO

(If "NO," describe):

3D. DID THE VETERAN HAVE AN ACUTE ONSET OF CHRONIC FATIGUE SYNDROME?
YES

NO

3E. HAS THE DEBILITATING FATIGUE REDUCED DAILY ACTIVITY LEVEL TO LESS THAN 50% OF PRE-ILLNESS LEVEL?
YES

NO

(If "Yes," specify length of time daily activity level has been reduced to less than 50% of pre-illness level):
Less than 6 months
VA FORM
MAR 2011

21-0960Q-1

6 months or longer

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SECTION IV - FINDINGS, SIGNS AND SYMPTOMS

4A. DOES THE VETERAN NOW HAVE OR HAS THE VETERAN HAD ANY FINDINGS, SIGNS AND SYMPTOMS ATTRIBUTABLE TO CHRONIC FATIGUE SYNDROME?
YES

NO

(If, "Yes," check all that apply):
Debilitating fatigue
Low grade fever
Nonexudative pharyngitis
Palpable or tender cervical or axillary lymph nodes
Generalized muscle aches or weakness
Fatigue lasting 24 hours or longer after exercise
Headaches (of a type, severity or pattern that is different from headaches in the pre-morbid state)
Migratory joint pain
Neuropsychologic symptoms
Sleep disturbance
Other
(Note : Describe all checked conditions in Item 4B)
4B. PROVIDE A DESCRIPTION OF THE CONDITION(S):

4C. DOES THE VETERAN NOW HAVE OR HAS THE VETERAN HAD ANY COGNITIVE IMPAIRMENT ATTRIBUTABLE TO CHRONIC FATIGUE SYNDROME?
YES

NO

(If, "Yes," check all that apply):
Poor attention
Inability to concentrate
Forgetfullness
Confusion
Other cognitive impairments
(Note : Describe all checked conditions in Item 4D)
4D. PROVIDE A DESCRIPTION OF THE CONDITION(S):

4E. SPECIFY FREQUENCY OF SYMPTOMS:
Symptoms wax and wane
Symptoms are nearly constant
Other
(Note : Describe all checked conditions in Item 4F)
4F. PROVIDE A DESCRIPTION OF THE CONDITION(S):

4G. DO THE VETERAN'S SYMPTOMS DUE TO CHRONIC FATIGUE SYNDROME RESTRICT ROUTINE DAILY ACTIVITIES AS COMPARED TO THE PRE-ILLNESS LEVEL?
YES

NO

(If, "Yes," specify % of restriction (check all that apply))
Symptoms restrict routine daily activities by less than 25 % of the pre-illness level (more than 75% of the
pre-illness level of activities are not restricted)
Symptoms restrict routine daily activities to 50 % to 75% of the pre-illness level
Symptoms restrict routine daily activities to less than 50 % of the pre-illness level
Symptoms are so severe as to restrict routine daily activities almost completely
Symptoms are so severe as to occasionally preclude self-care (If checked, describe frequency with which this occurs):________________________
Other (describe):________________________________________________________________________________________________________

NOTE: For VA purposes, chronic fatigue syndrome is considered incapacitating only while it requires bed rest and treatment by a physician.
4H. DO THE VETERAN'S SYMPTOMS DUE TO CHRONIC FATIGUE SYNDROME RESULT IN PERIODS OF INCAPACITATION?
NO
YES
(If, "Yes," indicate total duration of periods of incapacitation over the past 12 months):
Less than 1 week
At least 1 but less than 2 weeks
At least 2 but less than 4 weeks
At least 4 but less than 6 weeks
At least 6 weeks total duration per year
Other (describe):_____________________________________________
VA FORM 21-0960Q-1, MAR 2011

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SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, SCARS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
5A. 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)
5B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS OF
CHRONIC FATIGUE SYNDROME?
YES

NO

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

SECTION VI - DIAGNOSTIC TESTING
NOTE: If testing has been performed and reflects the veteran's current condition, repeat testing is not required.
6. ARE THERE ANY SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES

NO

(If, "Yes," provide type of test or procedure, date and results (brief summary)

SECTION VII - FUNCTIONAL IMPACT
7. DOES THE VETERAN'S CHRONIC FATIGUE SYNDROME IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If, "Yes," describe the impact the veteran's chronic fatigue syndrome, providing one or more examples)

SECTION VIII - REMARKS

8. REMARKS (If any)

SECTION IX - PHYSICIAN'S CERTIFICATION AND SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
9B. PHYSICIAN'S PRINTED NAME

9A. PHYSICIAN'S SIGNATURE
9D. PHYSICIAN'S PHONE AND FAX NUMBER

9E. PHYSICIAN'S MEDICAL LICENSE NUMBER

9C. DATE SIGNED
9F. 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 21-0960Q-1, MAR 2011

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