VA Form 21-0960P-1 Eating Disorders Disability Benefits Questionnaire

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

EATING DISORDERS 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.
Important - If the veteran experiences a mental health emergency during the interview, please terminate the interview and obtain help, using local resources as
appropriate. You may also contact the VA Suicide Prevention Hotline at 1-800-273-TALK. Stay on the Hotline until help can link the veteran to emergency care.
NOTE - In order to conduct an examination for eating disorders, the examiner must meet one of the following criteria: a board-certified or board-eligible psychiatrist; a
licensed doctorate-level psychologist; a doctorate-level mental health provider under the close supervision of a board-certified or board-eligible psychiatrist or licensed
doctorate-level psychologist; a psychiatry resident under close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist; or
a clinical or counseling psychologist completing a one-year internship or residency (for purposes of a doctorate-level degree) under close supervision of a boardcertified or board-eligible psychiatrist or licensed doctorate-level psychologist
In order to conduct a REVIEW examination for eating disorders, the examiner must meet one of the criteria from above, OR be a licensed clinical
social worker (LCSW), a nurse practitioner, a clinical nurse specialist, or a physician assistant, under close supervision of a board-certified or board-eligible psychiatrist
or doctorate-level psychologist.
SECTION I - DIAGNOSIS
1 . DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH AN EATING DISORDER(S)?
YES

NO

(If "Yes," check all diagnoses that apply)

BULIMIA
(DATE OF DIAGNOSIS):
(ICD CODE):
(NAME OF DIAGNOSING FACILITY OR CLINICIAN):

ANOREXIA
(DATE OF DIAGNOSIS):
(ICD CODE):
(NAME OF DIAGNOSING FACILITY OR CLINICIAN):

EATING DISORDER NOT OTHERWISE SPECIFIED
(DATE OF DIAGNOSIS):
(ICD CODE):
(NAME OF DIAGNOSING FACILITY OR CLINICIAN):

SECTION II - FINDINGS
NOTE - For VA purposes, an incapacitating episode is defined as a period during which bedrest and treatment by a physician are required.
2. FINDINGS
BINGE EATING FOLLOWED BY SELF-INDUCED VOMITING OR OTHER MEASURES TO PREVENT WEIGHT GAIN, OR RESISTANCE TO WEIGHT
GAIN EVEN WHEN BELOW EXPECTED MINIMUM WEIGHT, WITH DIAGNOSIS OF AN EATING DISORDER BUT WITHOUT INCAPACITATING EPISODES
BINGE EATING FOLLOWED BY SELF-INDUCED VOMITING OR OTHER MEASURES TO PREVENT WEIGHT GAIN, OR RESISTANCE TO WEIGHT
GAIN EVEN WHEN BELOW EXPECTED MINIMUM WEIGHT, WITH DIAGNOSIS OF AN EATING DISORDER AND INCAPACITATING EPISODES
OF UP TO TWO WEEKS TOTAL DURATION PER YEAR
SELF-INDUCED WEIGHT LOSS TO LESS THAN 85 PERCENT OF EXPECTED MINIMUM WEIGHT WITH INCAPACITATING EPISODES OF MORE THAN
TWO BUT LESS THAN SIX WEEKS TOTAL DURATION PER YEAR
SELF-INDUCED WEIGHT LOSS TO LESS THAN 85 PERCENT OF EXPECTED MINIMUM WEIGHT WITH INCAPACITATING EPISODES OF SIX OR MORE
WEEKS TOTAL DURATION PER YEAR
SELF-INDUCED WEIGHT LOSS TO LESS THAN 80 PERCENT OF EXPECTED MINIMUM WEIGHT WITH INCAPACITATING EPISODES OF AT LEAST SIX
WEEKS TOTAL DURATION PER YEAR, AND REQUIRING HOSPITALIZATION MORE THAN TWICE A YEAR FOR PARENTERAL NUTRITION OR TUBE
FEEDING
VA FORM
DEC 2010

21-0960P-1

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SECTION III - OTHER SYMPTOMS
3. DOES THE VETERAN HAVE ANY OTHER SYMPTOMS ATTRIBUTABLE TO AN EATING DISORDER?
YES

NO

(If "Yes," describe):

SECTION IV - FUNCTIONAL IMPACT AND REMARKS
4. DOES THE VETERAN'S EATING DISORDER(S) IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

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

5. REMARKS (If any)

SECTION V - PSYCHIATRIST/PSYCHOLOGIST/EXAMINER CERTIFICATION AND SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
6A. PSYCHIATRIST/PSYCHOLOGIST/EXAMINER SIGNATURE & TITLE

6B. PSYCHIATRIST/PSYCHOLOGIST/EXAMINER PRINTED NAME

6C. DATE SIGNED

6D. PSYCHIATRIST/PSYCHOLOGIST/EXAMINER PHONE NUMBER

6E. PSYCHIATRIST/PSYCHOLOGIST/EXAMINER MEDICAL LICENSE NUMBER

6F. PSYCHIATRIST/PSYCHOLOGIST/EXAMINER/ ADDRESS

NOTE - VA may obtain additional medical information, including an examination, if necessary to complete VA's review of the veteran's application.
IMPORTANT - Psychiatrist/psychologist 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 DEC 2010, 21-0960P-1

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