VA Form 21-0960C-6 Narcolepsy Disability Benefits Questionnaire

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

NARCOLEPSY 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 NARCOLEPSY? (This is the condition the veteran is claiming or for which an
exam has been requested)
YES

(If "Yes," complete Item 1B)

NO

NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed above. If there is no diagnosis, if the diagnosis is different
from a previous diagnosis for this condition, or if there is a diagnosis of a complication due to the claimed condition, explain your findings and reasons in the "Remarks"
section. Date of diagnosis can be the date of the evaluation if the clinician is making the initial diagnosis, or an appropriate date determined through record review or
reported history.
1B. DIAGNOSES (check all that apply):
NARCOLEPSY

ICD code:

OTHER (specify):

Date of diagnosis:

Other diagnosis #1:
ICD code:
Date of diagnosis:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO NARCOLEPSY, 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 NARCOLEPSY (brief summary):

3B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF NARCOLEPSY?
YES

NO

(If "Yes," list only those medications required for the veteran's narcolepsy):

SECTION IV- FINDINGS, SIGNS AND SYMPTOMS
4A. DOES THE VETERAN HAVE A CONFIRMED DIAGNOSIS OF NARCOLEPSY?
YES

NO

(If "Yes," complete Items 4A & 4B)

4B. DOES THE VETERAN REPORT ANY OF THE FOLLOWING FINDINGS, SIGNS OR SYMPTOMS?
YES

NO

(If "Yes," check all that apply):
Excessive daytime sleepiness
Sleep attacks (strong urge to sleep followed by short nap)
Cataplexy (sudden loss of muscle tone while awake, resulting in brief inability to move)
Sleep paralysis (inability to move on first awakening)
Sleep onset/sleep offset hallucinations
Other

(For all checked conditions in item 4B, provide a description below):

4C. INDICATE FREQUENCY OF CATAPLECTIC (NARCOLEPTIC) EPISODES (check all that apply):
Number of cataplectic (narcoleptic) episodes over past 6 months
0-1
2 or more

(If 2 or more over the past 6 months, indicate the "average frequency" of narcoleptic episodes):
0-4 per week

5-8 per week

9-10 per week

More than 10 per week

(If the Veteran has cataplectic (narcoleptic) episodes, provide a description below):

VA FORM
XXX XXXX

21-0960C-6

SUPERSEDES VA FORM 21-0960C-6, OCT 2012,
WHICH WILL NOT BE USED.

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SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
5. 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 VI - DIAGNOSTIC TESTING
NOTE - If diagnostic test results are in the medical record and reflect the veteran's current narcolepsy condition, repeat testing is not required.
6A. HAVE ANY IMAGING STUDIES OR DIAGNOSTIC PROCEDURES BEEN PERFORMED?
YES

NO

(If "Yes," check all that apply)

Polysomnogram (PSG)

Date:

Results:

Multiple Sleep Latency Test (MSLT)

Date:

Results:

Hypocretin level in cerebrospinal fluid (CSF)

Date:

Results:

Other (describe):

Date:

Results:

6B. 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 VII - FUNCTIONAL IMPACT
7. DOES THE VETERAN'S NARCOLEPSY IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe impact, 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.
9A. PHYSICIAN'S SIGNATURE

9D. PHYSICIAN'S PHONE AND FAX NUMBERS

9B. PHYSICIAN'S PRINTED NAME

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.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-6, XXX XXXX

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