VA Form 21-0960C-1 Seizure Disorders (Epilepsy) Disability Benefits Questio

OMB Approved No. 2900-0781
Respondent Burden: 15 Minutes
Expiration Date: XX/XX/XXXX

SEIZURE DISORDERS (EPILEPSY) 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. VA reserves the right to confirm the authenticity of ALL DBQs completed by
private health care providers.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH A SEIZURE DISORDER (epilepsy)? (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 APPROPRIATE DIAGNOSIS: (check all that apply):
TONIC-CLONIC SEIZURES OR GRAND MAL
EPILEPSY (generalized convulsive seizures)

ICD Code:

Date of diagnosis:

ABSENCE SEIZURES OR PETIT MAL OR ATONIC
SEIZURES (generalized non-convulsive seizures)

ICD Code:

Date of diagnosis:

JACKSONIAN (simple partial seizures)

ICD Code:

Date of diagnosis:

FOCAL MOTOR

ICD Code:

Date of diagnosis:

FOCAL SENSORY

ICD Code:

Date of diagnosis:

DIENCEPHALIC EPILEPSY

ICD Code:

Date of diagnosis:

PSYCHOMOTOR EPILEPSY (complex partial

ICD Code:

Date of diagnosis:

Other diagnosis #1

ICD Code:

Date of diagnosis:

Other diagnosis #2

ICD Code:

Date of diagnosis:

seizures, temporal lobe seizures)
OTHER (specify)

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO SEIZURE DISORDERS (epilepsy), LIST USING ABOVE FORMAT:

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 SEIZURE DISORDER (epilepsy) (brief summary):

3B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF EPILEPSY OR SEIZURE ACTIVITY?
YES

NO

(If "Yes," list only those medications required for the veteran's epilepsy or seizure activity)

3C. HAS THE VETERAN HAD ANY OTHER TREATMENT (such as surgery) FOR EPILEPSY OR SEIZURE ACTIVITY?
YES

NO

(If "Yes," describe):

3D. HAS THE DIAGNOSIS OF A SEIZURE DISORDER BEEN CONFIRMED?
YES

NO

(If "Yes," describe):

3E. HAS THE VETERAN HAD A WITNESSED SEIZURE?
YES

VA FORM
XXX XXXX

NO

(If "Yes," describe, including relationship of witnesses to veteran):

21-0960C-11

SUPERSEDES VA FORM 21-0960C-11, OCT 2012,
WHICH WILL NOT BE USED.

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SECTION IV - FINDINGS, SIGNS AND SYMPTOMS
4. DOES THE VETERAN HAVE OR HAS HE OR SHE HAD ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO SEIZURE DISORDER (epilepsy) ACTIVITY?
YES

NO

(If "Yes," check all that apply)

Generalized tonic-clonic convulsion
Episodes of unconsciousness
Brief interruption in consciousness or conscious control
Episodes of staring
Episodes of rhythmic blinking of the eyes
Episodes of nodding of the head
Episodes of sudden jerking movement of the arms, trunk or head (myoclonic type)
Episodes of sudden loss of postural control (akinetic type)
Episodes of complete or partial loss of use of one or more extremities
Episodes of random motor movements
Episodes of psychotic manifestations
Episodes of hallucinations
Episodes of perceptual illusions
Episodes of abnormalities of thinking
Episodes of abnormalities of memory
Episodes of abnormalities of mood
Episodes of autonomic disturbances
Episodes of speech disturbances
Episodes of impairment of vision
Episodes of disturbances of gait
Episodes of tremors
Episodes of visceral manifestations
Residuals of Injury during seizure
Other

(For all checked conditions describe):

SECTION V - TYPE AND FREQUENCY OF SEIZURE ACTIVITY
5.A. DOES THE VETERAN HAVE OR HAS HE OR SHE EVER HAD ANY TYPE OF SEIZURE ACTIVITY, INCLUDING MAJOR, MINOR, PETIT MAL OR PSYCHOMOTOR
SEIZURE ACTIVITY?
YES

NO

(If "Yes," complete Items 5B through 5H)

5B. PROVIDE APPROXIMATE DATE OF FIRST SEIZURE ACTIVITY (Month, Year)
PROVIDE DATE OF MOST RECENT SEIZURE ACTIVITY (Month, Year)
5C. HAS THE VETERAN EVER HAD MINOR SEIZURES (characterized by a brief interruption in consciousness or conscious control associated with staring or rhythmic

blinking of the eyes or nodding of the head ("pure" petit mal) or sudden jerking movements of the arms, trunk or head (myoclonic type) or sudden loss of postural
control (akinetic type))?
YES

NO

(If "Yes," complete the following):

Number of minor seizures over past 6 months:
0-1
2 or more
If 2 or more over the past 6 months, indicate the average frequency of minor seizures:
0-4 per week

5-8 per week

9-10 per week

More than 10 per week

4D. HAS THE VETERAN EVER HAD MAJOR SEIZURES (characterized by the generalized tonic-clonic convulsion with unconsciousness)?
YES

NO

(If "Yes," complete the following):

Number of major seizures:
None in past 2 years

At least 1 in past 2 years

At least 2 in past year

Average frequency of major seizures:
Less than 1 in past 6 months
At least 1 in past 6 months
At least 1 in 4 months over past year
At least 1 in 3 months over past year
At least 1 per month over past year
VA FORM 21-0960C-11, XXX XXXX

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SECTION IV - TYPE AND FREQUENCY OF SEIZURE ACTIVITY (Continued)
5E. HAS THE VETERAN EVER HAD MINOR PSYCHOMOTOR SEIZURES (characterized by brief transient episodes of random motor movements, hallucinations,

perceptual illusions, abnormalities of thinking, memory or mood, or autonomic disturbances)?
YES

(If "Yes," complete the following):

NO

Number of minor psychomotor seizures over past 6 months:
0

1

2 or more

If 2 or more over the past 6 months, indicate the average frequency of minor psychomotor seizures:
0-4 per week
5-8 per week
9-10 per week
More than 10 per week
5F. HAS THE VETERAN EVER HAD MAJOR PSYCHOMOTOR SEIZURES (major psychomotor seizures are characterized by automatic states and/or generalized

convulsions with unconsciousness)?
YES

NO

(If "Yes," complete the following):

Number of major psychomotor seizures:
None in past 2 years
At least 1 in past 2 years
At least 2 in past year
Average frequency of major psychomotor seizures:
Less than 1 in past 6 months
At least 1 in past 6 months
At least 1 in 4 months over past year
At least 1 in 3 months over past year
At least 1 per month over past year
5G. HAS THE VETERAN EVER HAD EPILEPSY ASSOCIATED WITH A NONPSYCHOTIC ORGANIC BRAIN SYNDROME?
YES

NO

(If "Yes," describe):

5H. HAS THE VETERAN EVER HAD EPILEPSY ASSOCIATED WITH A PSYCHOTIC DISORDER, PSYCHONEUROTIC DISORDER OR PERSONALITY DISORDER?
YES

NO

(If "Yes," the appropriate Mental Disorder Questionnaire must ALSO be completed)

SECTION VI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
6A. 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 or equal to 39 square cm (6 square inches))?
YES
NO (If "Yes," also complete the VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)
6B. 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 VII - DIAGNOSTIC TESTING
NOTE - If diagnostic test results are in the medical record and reflect the veteran's current seizure (epilepsy) disorder, repeat testing is not required.
7A. HAVE ANY IMAGING STUDIES OR DIAGNOSTIC PROCEDURES BEEN PERFORMED?
YES

NO

(If "Yes," check all that apply)

Magnetic resonance imaging (MRI)

Date:

Results:

Computed tomography (CT)

Date:

Results:

Cerebrospinal fluid CSF examination

Date:

Results:

Electroencephalography (EEG)

Date:

Results:

Neuropsychologic testing

Date:

Other (describe):

Results:
Date:

Results:

7B. 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)):

VA FORM 21-0960C-11, XXX XXXX

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SECTION VIII - FUNCTIONAL IMPACT
8. DOES THE VETERAN'S EPILEPSY OR SEIZURE (epilepsy) DISORDER IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe the impact of the veteran's seizure (epilepsy) disorder, providing one or more examples):

SECTION IX - REMARKS
9. REMARKS (If any)

SECTION X - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
10A. PHYSICIAN'S SIGNATURE

10D. PHYSICIAN'S PHONE AND FAX NUMBER

10B. PHYSICIAN'S PRINTED NAME

10E. PHYSICIAN'S MEDICAL LICENSE NUMBER

10C. DATE SIGNED

10F. 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.benefits.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 voluntary. 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 21-0960C-11, XXX XXXX

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