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pdfOMB Approved No. 2900-0781
Respondent Burden: 30 Minutes
Expiration Date: XX/XX/XXXX
CRANIAL NERVES DISEASES 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 THIS 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 OR SHE EVER BEEN DIAGNOSED WITH A CRANIAL NERVE CONDITION? (This is the condition
the veteran is claiming or for which an exam has been requested)
YES
NO
(If "Yes," complete Item 1B)
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 CRANIAL NERVE CONDITIONS
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 CRANIAL NERVES, 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 etiology, onset and course) OF THE VETERAN'S CRANIAL NERVE CONDITION (brief summary):
3B. INDICATE THE CRANIAL NERVES AFFECTED BY THE VETERAN'S CONDITION (check all that apply)
CRANIAL NERVE I (olfactory) (If checked, complete VA Form 21-0960N-3, Loss of Sense of Smell and Taste Disability Benefits Questionnaire)
CRANIAL NERVES II - IV, VI (If checked, complete VA Form 21-0960N-2, Eye Conditions Disability Benefits Questionnaire)
CRANIAL NERVE V (trigeminal)
CRANIAL NERVE VII (facial)
CRANIAL NERVE VIII (If the veteran has hearing loss or tinnitus attributable to any cranial nerve condition, the VA regional office
will schedule a hearing loss or tinnitus exam, as appropriate)
CRANIAL NERVE IX (glossopharyngeal)
CRANIAL NERVE X (vagus)
CRANIAL NERVE XI (spinal accessory)
CRANIAL NERVE XII (hypoglossal)
VA FORM
XXX XXXX
21-0960C-3
SUPERSEDES VA FORM 21-0960C-3, SEP 2016,
WHICH WILL NOT BE USED.
Page 1
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION IV - FINDINGS, SIGNS AND SYMPTOMS
4. DOES THE VETERAN HAVE FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO ANY CONDITIONS AFFECTING CRANIAL NERVES, V, VII, AND/OR IX-XII?
YES
NO
(If "Yes," indicate symptoms (check all that apply))
A. CONSTANT PAIN, AT TIMES EXCRUCIATING (if checked, indicate location and severity):
Upper face, eye and/or forehead
Right:
Mild
Moderate
Severe
Left:
Mild
Moderate
Severe
Right:
Mild
Moderate
Severe
Left:
Mild
Moderate
Severe
Right:
Mild
Moderate
Severe
Left:
Mild
Moderate
Severe
Right:
Mild
Moderate
Severe
Left:
Mild
Moderate
Severe
Mid face
Lower face
Side of mouth and throat
B. INTERMITTENT PAIN (if checked, indicate location and severity):
Upper face, eye and/or forehead
Right:
Mild
Moderate
Severe
Left:
Mild
Moderate
Severe
Right:
Mild
Moderate
Severe
Left:
Mild
Moderate
Severe
Right:
Mild
Moderate
Severe
Left:
Mild
Moderate
Severe
Right:
Mild
Moderate
Severe
Left:
Mild
Moderate
Severe
Mid face
Lower face
Side of mouth and throat
C. DULL PAIN (if checked, indicate location and severity):
Upper face, eye and/or forehead
Right:
Mild
Moderate
Severe
Left:
Mild
Moderate
Severe
Right:
Mild
Moderate
Severe
Left:
Mild
Moderate
Severe
Right:
Mild
Moderate
Severe
Left:
Mild
Moderate
Severe
Right:
Mild
Moderate
Severe
Left:
Mild
Moderate
Severe
Mid face
Lower face
Side of mouth and throat
D. PARESTHESIAS AND/OR DYSESTHESIAS (if checked, indicate location and severity):
Upper face, eye and/or forehead
Right:
Mild
Moderate
Severe
Left:
Mild
Moderate
Severe
Right:
Mild
Moderate
Severe
Left:
Mild
Moderate
Severe
Right:
Mild
Moderate
Severe
Left:
Mild
Moderate
Severe
Right:
Mild
Moderate
Severe
Left:
Mild
Moderate
Severe
Mid face
Lower face
Side of mouth and throat
VA FORM 21-0960C-3, XXX XXXX
Page 2
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION IV - FINDINGS, SIGNS AND SYMPTOMS (Continued)
4. DOES THE VETERAN HAVE FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO ANY CONDITIONS AFFECTING CRANIAL NERVES, V, VII, AND/OR IX-XII?
(Continued)
E. NUMBNESS (if checked, indicate location and severity):
Upper face, eye and/or forehead
Right:
Mild
Moderate
Severe
Left:
Mild
Moderate
Severe
Right:
Mild
Moderate
Severe
Left:
Mild
Moderate
Severe
Right:
Mild
Moderate
Severe
Left:
Mild
Moderate
Severe
Mid face
Lower face
Side of mouth and throat
Right:
Mild
Moderate
Severe
Left:
Mild
Moderate
Severe
F. DIFFICULTY CHEWING (If checked, indicate severity):
Mild
Moderate
Severe
G. DIFFICULTY SWALLOWING (If checked, indicate severity):
Mild
Moderate
Severe
H. DIFFICULTY SPEAKING (If checked, indicate severity):
Mild
Moderate
Severe
I. INCREASED SALIVATION (If checked, indicate severity):
Mild
Moderate
Severe
J. DECREASED SALIVATION (If checked, indicate severity):
Mild
Moderate
Severe
K. GASTROINTESTINAL SYMPTOMS (If checked, indicate severity):
Mild
Moderate
Severe
L. OTHER SYMPTOMS (If checked, describe):
SECTION V - MUSCLE STRENGTH TESTING
5. MUSCLE STRENGTH TESTING (Rate strength using the following levels to estimate strength of muscle groups. This summary provides useful information for VA
purposes)
ALL NORMAL
A. Cranial nerve V: (Motor: muscles of mastication; clench jaw, palpate masseter, temporalis)
RIGHT:
Normal
Mild
Moderate
Severe
Complete paralysis
LEFT:
Normal
Mild
Moderate
Severe
Complete paralysis
B. Cranial nerve VII, upper portion of face: (Motor: muscles of facial expression, shuts eyes tightly)
RIGHT:
Normal
Mild
Moderate
Severe
Complete paralysis
LEFT:
Normal
Mild
Moderate
Severe
Complete paralysis
C. Cranial nerve VII, lower portion of face: (Motor: muscles of facial expression; grins)
RIGHT:
Normal
Mild
Moderate
Severe
Complete paralysis
LEFT:
Normal
Mild
Moderate
Severe
Complete paralysis
D. Cranial nerve IX, X: (Motor: swallow, cough, palate elevation; "say ah", gag reflex if indicated)
RIGHT:
Normal
Mild
Moderate
Severe
Complete paralysis
LEFT:
Normal
Mild
Moderate
Severe
Complete paralysis
E. Cranial nerve XI: (Motor: trapezius, sternocleidomastoid; shoulder shrug, turn head against resistance)
RIGHT:
Normal
Mild
Moderate
Severe
Complete paralysis
LEFT:
Normal
Mild
Moderate
Severe
Complete paralysis
F. Cranial nerve XII: (Motor: protrude tongue, move tongue from side to side)
RIGHT:
Normal
Mild
Moderate
Severe
Complete paralysis
LEFT:
Normal
Mild
Moderate
Severe
Complete paralysis
VA FORM 21-0960C-3, XXX XXXX
Page 3
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION VI - SENSORY EXAM
6. PROVIDE RESULTS FOR SENSATION TESTING TO LIGHT TOUCH FOR FACIAL SENSATION:
ALL NORMAL
Cranial nerve V:
Upper face and forehead
RIGHT:
Normal
Decreased
Absent
LEFT:
Normal
Decreased
Absent
RIGHT:
Normal
Decreased
Absent
LEFT:
Normal
Decreased
Absent
RIGHT:
Normal
Decreased
Absent
LEFT:
Normal
Decreased
Absent
Mid face
Lower face
SECTION VII - CRANIAL NERVE SUMMARY EVALUATION
7A. INDICATE THE CRANIAL NERVE(S) AFFECTED. FOR EACH NERVE, INDICATE SEVERITY ("degree of paralysis"), BASING THE RESPONSES ON SYMPTOMS
AND FINDINGS FROM THE ABOVE EXAM. THIS SECTION PROVIDES AN ESTIMATION OF THE SEVERITY OF THE VETERAN'S CRANIAL NERVE CONDITION,
WHICH IS USEFUL FOR VA PURPOSES.
NOTE: For VA purposes, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the description of complete paralysis
that is given below with each nerve, whether due to a varied level of the nerve lesion or to partial regeneration.
Cranial nerve V (trigeminal)
RIGHT:
Not affected
Incomplete, moderate
Incomplete, severe
Complete
LEFT:
Not affected
Incomplete, moderate
Incomplete, severe
Complete
Cranial nerve VII (facial)
RIGHT:
Not affected
Incomplete, moderate
Incomplete, severe
Complete
LEFT:
Not affected
Incomplete, moderate
Incomplete, severe
Complete
Cranial nerve IX (glossopharyngeal)
RIGHT:
Not affected
Incomplete, moderate
Incomplete, severe
Complete
LEFT:
Not affected
Incomplete, moderate
Incomplete, severe
Complete
Cranial nerve X (vagus)
RIGHT:
Not affected
Incomplete, moderate
Incomplete, severe
Complete
LEFT:
Not affected
Incomplete, moderate
Incomplete, severe
Complete
Cranial nerve XI (spinal accessory)
RIGHT:
Not affected
Incomplete, moderate
Incomplete, severe
Complete
LEFT:
Not affected
Incomplete, moderate
Incomplete, severe
Complete
Cranial nerve XII (hypoglossal)
RIGHT:
Not affected
Incomplete, moderate
Incomplete, severe
Complete
LEFT:
Not affected
Incomplete, moderate
Incomplete, severe
Complete
SECTION VIII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
8A. 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.
8B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN SECTION 1, DIAGNOSIS?
YES
NO
(If "Yes," describe (brief summary):
VA FORM 21-0960C-3, XXX XXXX
Page 4
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION IX - DIAGNOSTIC TESTING
NOTE - For the purpose of this examination, diagnostic or imaging studies are usually not required to diagnose specific cranial nerve conditions in
the appropriate clinical setting.
9A. HAVE IMAGING OR OTHER DIAGNOSTIC STUDIES BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES
NO
(If "Yes," provide type of study, date and results)
9B. 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 X - FUNCTIONAL IMPACT AND REMARKS
10. DOES THE VETERAN'S CRANIAL NERVE CONDITION IMPACT HIS OR HER ABILITY TO WORK?
YES
NO
(If "Yes," describe impact of each of the veteran's cranial nerve conditions, providing one or more examples)
SECTION XI - REMARKS
11. 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.
12A. PHYSICIAN'S SIGNATURE
12D. PHYSICIAN'S PHONE/FAX NUMBERS
12B. PHYSICIAN'S PRINTED NAME
12C. DATE SIGNED
12E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER
12F. 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, 58VA21/22/28, 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 low 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 30 minutes to review the instructions, find the information, and complete a 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-3, XXX XXXX
Page 5
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |