VA Form 21-0960I-2 HIV - Related Illnesses Disability Benefits Questionnair

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

HIV - RELATED ILLNESSES 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 NOW HAVE OR HAS HE/SHE EVER BEEN DIAGNOSED WITH AN HIV-RELATED ILLNESS?
YES

NO

(If "Yes," complete Item1B)

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. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO HIV-RELATED ILLNESSES OR COMPLICATIONS:
Diagnosis # 1 -

ICD code -

Date of diagnosis-

Diagnosis # 2 -

ICD code -

Date of diagnosis-

Diagnosis # 3 -

ICD code -

Date of diagnosis-

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO HIV-RELATED ILLNESS, 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 HIV-RELATED ILLNESS(ES) (brief summary):

3B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF HIV-RELATED ILLNESS(ES)?
YES

NO

(If "Yes," list only those medications required for the veteran's HIV-related illness(es)) (If the veteran has more than one HIV-related illness(es),
specify the condition for which each medication is required)

3C. DOES THE VETERAN HAVE ANY COMPLICATIONS DUE TO CURRENT OR PREVIOUS MEDICATIONS TAKEN FOR HIV-RELATED ILLNESS(ES)?
YES

VA FORM
XXX XXXX

NO

(If "Yes," list medication and describe complication(s) due to medication(s)):

21-0960I-2

SUPERSEDES VA FORM 21-0960I-2, OCT 2012,
WHICH WILL NOT BE USED.

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SECTION IV - SIGNS, SYMPTOMS AND FINDINGS
4. DOES THE VETERAN HAVE ANY SIGNS, SYMPTOMS OR FINDINGS ATTRIBUTABLE TO AN HIV-RELATED ILLNESS?
YES

NO

(If "Yes," check all that apply)

A. CONSTITUTIONAL SYMPTOMS (fever, weight loss, fatigue, malaise, decreased appetite, etc.) ATTRIBUTABLE TO AN HIV-RELATED ILLNESS

(If checked, indicate frequency and severity):
Refractory

Recurrent

(Describe constitutional symptoms):

B. DIARRHEA ATTRIBUTABLE TO AN HIV-RELATED ILLNESS.

(If checked, indicate frequency and severity):
Refractory

Intermittent

(Describe):

C. WEIGHT LOSS ATTRIBUTABLE TO AN HIV-RELATED ILLNESS
and current weight:

If checked, provide baseline weight:

(NOTE: For VA purposes, baseline weight is the average weight for 2-year period preceding onset of disease)

D. NAUSEA ATTRIBUTABLE TO AN HIV-RELATED ILLNESS

(If checked, indicate severity):
Mild

Transient

Recurrent

Periodic

(Indicate frequency of episodes of nausea per year)
1

2

3

4 or more

E. VOMITING ATTRIBUTABLE TO AN HIV-RELATED ILLNESS

(If checked, indicate severity):
Mild

Transient

Recurrent

Periodic

(Indicate frequency of episodes of vomiting per year)
1

2

3

4 or more

(Indicate average duration of episodes of vomiting)
Less than 1 day

1-9 days

10 days or more

F. ANEMIA OF CHRONIC DISEASE ATTRIBUTABLE TO AN HIV-RELATED ILLNESS

(If checked, describe):
(Provide hemoglovin/hematocrit in Section 10, Diagnostic Testing)

G. HAIRY CELL LEUKOPLAKIA

(If checked, is veteran currently affected by hairy cell leukoplakia?)
Yes

No

(Provide date(s) of onset, treatment and course):

H. ORAL CANDIDIASIS

(If checked, is veteran currently affected by oral candidiasis?)
Yes

No

(Provide date(s) of onset, treatment and course):
I. OTHER (Describe):

VA FORM 21-0960I-2, XXX XXXX

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SECTION V - COMPLICATIONS
5A. DOES THE VETERAN HAVE ANY COMPLICATIONS ATTRIBUTABLE TO AN HIV-RELATED ILLNESS?
YES

(If "Yes," check all that apply)

NO

HIV-associated neuropathy, radiculopathy or myelopathy (If checked, ALSO complete VA Form 21-0960C-10, Peripheral Nerves Disability Benefits Questionnaire)
HIV-associated retinopathy (If checked, ALSO complete VA Form 21-0960N-2, Eye Conditions Disability Benefits Questionnaire)
HIV-associated cardiopathy (If checked, ALSO complete VA Form 21-0960A-4, Heart Disease (including arrhythmias and surgery) Disability Benefits Questionnaire)
HIV-associated pulmonary hypertension (If checked, ALSO complete VA Form 21-0960L-1, Respiratory Conditions Disability Benefits Questionnaire)
HIV-associated enteropathy (If checked, ALSO complete VA Form 21-0960G-3, Intestinal Conditions (other than surgical or infectious) Disability Benefits

Questionnaire or VA Form 21-0960G-4, Intestinal Conditions (surgical or infectious) Disability Benefits Questionnaire)
HIV-associated nephropathy (If checked, ALSO complete VA Form 21-0960J-1, Kidney Conditions Disability Benefits Questionnaire)
HIV-associated impaired lipid and glucose metabolism
HIV-associated wasting
Lipodystrophy
Myopathy
Other, describe:

5B. FOR EACH CHECKED CONDITION IN ITEM 5A, (except those for which an additional DBQ is completed) DESCRIBE (providing date of onset, and a brief

summary of symptoms, treatment and course).

SECTION VI - INFECTIOUS AND ONCOLOGIC COMPLICATIONS
6A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER HAD ANY HIV-RELATED OPPORTUNISTIC INFECTIOUS OR ONCOLOGIC CONDITIONS?
YES

NO

(If "Yes," check all that apply)

Oral candidiasis

Viral meningoencephalitis

Tuberculosis

Cytomegalovirus

Hepatitis

Herpes simplex virus

Pneumocystosis

Varicella zoster virus

Toxoplasmosis

Progressive multifocal leukoencephalopathy

Cryptococcosis

Neurosyphilis

Cerebral toxoplasmosis

Primary central nervous system lymphoma

Cryptococcal meningoencephalitis

Other, describe:

6B. FOR EACH CHECKED CONDITION IN ITEM 6A, (except those for which an additional DBQ is completed), DESCRIBE (providing date of onset, and brief summary

of symptoms, treatment and course):

6C. DOES THE VETERAN HAVE RECURRENT OPPORTUNISTIC INFECTION(S)?
YES

NO

(If "Yes," provide type of infection(s), date(s) of first onset, date(s) of recurrences, treatment and course (brief summary)):
(NOTE : ALSO complete the appropriate questionnaire for each recurrent opportunistic infection)

VA FORM 21-0960I-2, XXX XXXX

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SECTION VII - MENTAL HEALTH MANIFESTATIONS DUE TO HIV-RELATED ILLNESS OR ITS TREATMENT
7A. DOES THE VETERAN HAVE DEPRESSION, HIV-ASSOCIATED NEUROCOGNITIVE DISORDER, DEMENTIA, OR ANY OTHER MENTAL HEALTH CONDITIONS
ATTRIBUTABLE TO HIV-RELATED ILLNESS OR ITS TREATMENT?
YES

NO

7B. DOES THE VETERAN'S MENTAL HEALTH CONDITION(S), RESULT IN GROSS IMPAIRMENT IN THOUGHT PROCESSES OR COMMUNICATION (such that an

interview with the veteran would not yield useful information)?
NO (If "No," ALSO complete VA Form 21-0960P-2, Mental Health Disorders (other than PTSD) Disability Benefits Questionnaire)
YES
(If "Yes," briefly describe the veteran's mental health condition):

SECTION VIII - SUMMARY
8. BASED ON SYMPTOMS AND FINDINGS FROM THIS EXAM, COMPLETE THE FOLLOWING, ITEMS 8A THRU 8E TO PROVIDE A SUMMARY OF THE SEVERITY
OF THE VETERAN'S HIV-RELATED CONDITION (NOTE: This summary provides useful information for VA purposes)

(Check all that apply from each level):
A. LEVEL I
Asymptomatic, with or without lymphadenopathy or decreased T4 cell count
B. LEVEL II
Symptomatic, with current T4 cell of 200 or more and less than 500, and on approved medication(s)

(For VA purposes, approved medications include medications prescribed as part of a research protocol at an accredited medical institution)
Evidence of depression with employment limitations
Evidence of memory loss with employment limitations
C. LEVEL III
Recurrent constitutional symptoms, intermittent diarrhea, and on approved medications
Current T4 cell count less than 200
Hairy cell leukoplakia
Oral candidiasis
D. LEVEL IV
Refractory constitutional symptoms
Diarrhea and pathological weight loss
Development of AIDS-related opportunistic infection or neoplasm
E. LEVEL V
AIDS with recurrent opportunistic infections
Secondary diseases afflicting multiple body systems
HIV-related illness with debility and progressive weight loss, without remission or few or brief remissions

SECTION IX - OTHER PERTINENT PHYSICAL FINDINGS, SCARS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
9A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN THE
DIAGNOSIS SECTION?
YES

NO

IF "YES," ARE ANY OF THESE SCARS PAINFUL AND/OR UNSTABLE; HAVE A TOTAL AREA EQUAL TO OR GREATER THAN 39 SQUARE CM
6 square inches); OR ARE LOCATED ON THE HEAD, FACE, OR NECK?
YES

NO

IF "YES," ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT DISABILITY BENEFITS QUESTIONNAIRE (DBQ).
IF "NO," PROVIDE LOCATION AND MEASUREMENTS OF SCAR IN CENTIMETERS.
LOCATION:__________________________________ MEASUREMENTS: Length_____________ cm X width _____________ cm.
NOTE: An "unstable scar" is one where, for any reason, there is frequent loss of covering of the skin over the scar. If there are multiple scars, enter additional
locations and measurements in the "Remarks" section. It is not necessary to also complete a Scars/Disfigurement DBQ.
9B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, SCARS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO
ANY CONDITIONS LISTED IN SECTION I, DIAGNOSIS?
YES

NO

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

VA FORM 21-0960I-2, XXX XXXX

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SECTION X - DIAGNOSTIC TESTING
NOTE - If testing has been performed and reflects the veteran's current condition, repeat testing is not required.
10A. HAS LABORATORY TESTING BEEN PERFORMED?
YES

NO

(If "Yes," check all that apply):
Date:

CD4 (T4 cell) lymphocyte count:

Lowest (nadir) CD4 (T4 cell) lymphocyte count, if available:

Date; if know:

CBC (if anemia of chronic disease attributable to HIV-related illness is suspected or present):
Date:

Hematocrit:

Hemoglobin:

Other test, specify:

Date of test:

White blood cell count:

Platelets:

Results:

10B. HAVE IMAGING STUDIES OR DIAGNOSTIC PROCEDURES BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

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

10C. HAS A HIV DEMENTIA SCALE BEEN ADMINISTERED (If indicated)?
YES

NO

(If "Yes," provide results and date)
Date:

Results:

10D. HAS NEUROPSYCHIATRIC TESTING BEEN PERFORMED FOR COGNITIVE IMPAIRMENT (If indicated)?
YES

NO

(If "Yes," provide results and date)

Results:

Date:

10E. 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 XI - FUNCTIONAL IMPACT
11. DO ANY OF THE VETERAN'S HIV-RELATED ILLNESSES OR COMPLICATIONS IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe impact of each of the veteran's HIV-related illness(es), providing one or more examples)

SECTION XII - REMARKS
12. REMARKS (If any)

SECTION XII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
13A. PHYSICIAN'S SIGNATURE

13D. PHYSICIAN'S PHONE AND FAX NUMBERS

13B. PHYSICIAN'S PRINTED NAME

13E. PHYSICIAN'S MEDICAL LICENSE NUMBER

13C. DATE SIGNED

13F. 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 21-0960I-2, XXX XXXX

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