VA Form 21-0960N-1 Ear Conditions (Including Vestibular and Infectious Cond

OMB Control No. 2900-0778
Respondent Burden: 15 Minutes
Expiration Date: XX/XX/XXXX

EAR CONDITIONS (INCLUDING VESTIBULAR AND INFECTIOUS
CONDITIONS) 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 OR SHE EVER BEEN DIAGNOSED WITH AN EAR OR PERIPHERAL VESTIBULAR CONDITION?
YES

NO

(If "Yes," complete Item 1B)

1B. SELECT THE VETERAN'S CONDITION (check all that apply):
Meniere's syndrome or endolymphatic hydrops

ICD code:

Date of diagnosis:

Peripheral vestibular disorder

ICD code:

Date of diagnosis:

Benign Paroxysmal Positional Vertigo (BPPV)

ICD code:

Date of diagnosis:

Chronic otitis externa

ICD code:

Date of diagnosis:

Chronic suppurative otitis media

ICD code:

Date of diagnosis:

Chronic nonsuppurative otitis media (serous otitis media)

ICD code:

Date of diagnosis:

Mastoiditis

ICD code:

Date of diagnosis:

Cholesteatoma
(If the veteran has hearing loss or tinnitus attributable to any
ear condition, the VA regional office will schedule a hearing
loss or tinnitus exam, as appropriate)

ICD code:

Date of diagnosis:

Otosclerosis
(If the veteran has hearing loss or tinnitus attributable to any
ear condition, the VA regional office will schedule a hearing
loss or tinnitus exam, as appropriate)

ICD code:

Date of diagnosis:

Benign neoplasm of the ear (other than skin only)

ICD Code:

Date of Diagnosis:

Malignant neoplasm of the ear (other than skin only)

ICD Code:

Date of Diagnosis:

Other, diagnosis #1:

ICD Code:

Date of Diagnosis:

Other, diagnosis #2:

ICD Code:

Date of Diagnosis:

Other, specify:

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO EAR OR PERIPHERAL VESTIBULAR CONDITIONS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S EAR OR PERIPHERAL VESTIBULAR CONDITIONS (brief summary):

2B. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING CONTINUOUS MEDICATION FOR THE DIAGNOSED CONDITION?
YES

NO

IF YES, LIST ONLY THOSE MEDICATIONS USED FOR THE DIAGNOSED CONDITION:

VA FORM
XXX XXXX

21-0960N-1

SUPERSEDES VA FORM 21-0960N-1, OCT 2014,
WHICH WILL NOT BE USED.

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SECTION III - VESTIBULAR CONDITIONS
3. DOES THE VETERAN HAVE ANY OF THE FOLLOWING FINDINGS, SIGNS, OR SYMPTOMS ATTRIBUTABLE TO MENIERE'S SYNDROME (ENDOLYMPHATIC
HYDROPS), A PERIPHERAL VESTIBULAR CONDITION OR ANOTHER DIAGNOSED CONDITION FROM SECTION 1, DIAGNOSIS?
YES

NO

IF YES, CHECK ALL THAT APPLY:
Hearing impairment with vertigo
If checked, indicate frequency:

Less than once a month

Indicate duration of episodes:

< 1 hour

1 to 24 hours

1 to 4 times per month

More than once weekly

> 24 hours

Hearing impairment with attacks of vertigo and cerebellar gait
If checked, indicate frequency:

Less than once a month

Indicate duration of episodes:

< 1 hour

1 to 24 hours

1 to 4 times per month

More than once weekly

> 24 hours

Tinnitus, unilateral or bilateral
If checked, indicate frequency:

Less than once a month

Indicate duration of episodes:

< 1 hour

1 to 24 hours

1 to 4 times per month

More than once weekly

> 24 hours

Vertigo
If checked, indicate frequency:

Less than once a month

Indicate duration of episodes:

< 1 hour

1 to 24 hours

1 to 4 times per month

More than once weekly

> 24 hours

Staggering
If checked, indicate frequency:

Less than once a month

Indicate duration of episodes:

< 1 hour

1 to 24 hours

1 to 4 times per month

More than once weekly

> 24 hours

Hearing impairment and/or tinnitus
If checked, the VA regional office will schedule a hearing loss or tinnitus exam as appropriate.
Other, describe:

SECTION IV - INFECTIOUS, INFLAMMATORY AND OTHER EAR CONDITIONS
4A. DOES THE VETERAN HAVE ANY OF THE FOLLOWING FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO CHRONIC EAR INFECTION, INFLAMMATION,
CHOLESTEATOMA OR ANY OF THE DIAGNOSES LISTED IN SECTION 1, DIAGNOSIS?
YES

NO

IF YES, CHECK ALL THAT APPLY:
Swelling (external ear canal)
If checked, describe:
Dry and scaly (external ear canal)
Serous discharge (external ear canal)
Itching (external ear canal)
Effusion
Active suppuration
Aural polyps
Hearing impairment and/or tinnitus
If checked, the VA regional office will schedule a hearing loss or tinnitus exam as appropriate.
Facial nerve paralysis
If checked, ALSO complete Cranial Nerves Questionnaire.
Bone loss of skull
If checked, indicate severity:
Area lost smaller than an American quarter (4.619 cm2)
Area lost larger than an American quarter but smaller than a 50-cent piece
Area lost larger than an American 50-cent piece (7.355 cm2)
Requiring frequent and prolonged treatment
If checked, describe type and durations of treatment:
Other, describe:
4B. DOES THE VETERAN HAVE A BENIGN NEOPLASM OF THE EAR (other than skin only, such as keloid) THAT CAUSES ANY IMPAIRMENT OF FUNCTION?
YES

NO

IF YES, DESCRIBE IMPAIRMENT OF FUNCTION CAUSED BY THIS CONDITION:

VA FORM 21-0960N-1, XXX XXXX

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SECTION V - SURGICAL TREATMENT
5A. HAS THE VETERAN HAD SURGICAL TREATMENT FOR ANY EAR CONDITION?
YES

NO

IF YES, INDICATE TYPE OF SURGERY:

Date:

Side affected:

Right

Left

Both

5B. DOES THE VETERAN HAVE ANY RESIDUALS AS A RESULT OF THE SURGERY?
YES

NO

IF YES, DESCRIBE:

SECTION VI - PHYSICAL EXAM
6A. EXTERNAL EAR:
Exam of external ear not indicated
Normal
Deformity of auricle, with loss of less than one-third of the substance
If checked, specify side:

Right

Left

Deformity of auricle, with loss of one-third or more of the substance
If checked, specify side:

Right

Left

Right

Left

Complete loss of auricle
If checked, specify side:
Other abnormality, describe:

6B. EAR CANAL:
Exam of ear canal not indicated
Normal
Abnormal, describe:

6C. TYMPANIC MEMBRANE:
Exam of tympanic membrane not indicated
Normal
Perforated tympanic membrane
If checked, specify side affected:

Right

Left

Evidence of a healed tympanic membrane perforation
If checked, specify side affected:

Right

Left

Other abnormality, describe:

6D. GAIT:
Exam of gait not indicated
Normal
Unsteady, describe:

Other abnormality, describe:

6E. ROMBERG TEST:
Exam using this test not indicated
Normal or negative
Abnormal or positive for unsteadiness
6F. DIX HALLPIKE TEST (Nylen-Barany test) FOR VERTIGO:
Exam using this test not indicated
Normal, no vertigo or nystagmus during test
Abnormal, vertigo or nystagmus during test, describe:

6G. LIMB COORDINATION TEST (finger-nose-finger):
Exam using this test not indicated
Normal
Abnormal, describe:

VA FORM 21-0960N-1, XXX XXXX

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SECTION VII - TUMORS AND NEOPLASMS
7A. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES LISTED IN SECTION 1, DIAGNOSIS?
YES

NO

IF YES, COMPLETE THE FOLLOWING:
7B. IS THE NEOPLASM
BENIGN

MALIGNANT

7C. HAS THE VETERAN COMPLETED TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT NEOPLASM
OR METASTASES?
YES

NO; WATCHFUL WAITING

IF YES, INDICATE TYPE OF TREATMENT THE VETERAN IS CURRENTLY UNDERGOING OR HAS COMPLETED (check all that apply):
Treatment completed; currently in watchful waiting status
Surgery
If checked, describe:
Date(s) of surgery:
Radiation therapy
Date of most recent treatment:
Date of completion of treatment or anticipated date of completion:
Antineoplastic chemotherapy
Date of most recent treatment:
Date of completion of treatment or anticipated date of completion:
Other therapeutic procedure
If checked, describe procedure:
Date of most recent procedure:
Other therapeutic treatment
If checked, describe treatment:
Date of completion of treatment or anticipated date of completion:
7D. DOES THE VETERAN CURRENTLY HAVE ANY RESIDUAL CONDITIONS OR COMPLICATIONS DUE TO THE NEOPLASM (including metastases) OR ITS
TREATMENT, OTHER THAN THOSE ALREADY DOCUMENTED IN THE REPORT ABOVE?
YES

NO

IF YES, LIST RESIDUAL CONDITIONS AND COMPLICATIONS (brief summary):

7E. IF THERE ARE ADDITIONAL BENIGN OR MALIGNANT NEOPLASMS OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION 1, DIAGNOSIS,
DESCRIBE USING THE ABOVE FORMAT:

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
SECTION 1, 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 VA FORM 21-0960F-1, SCARS/DISFIGUREMENT DISABILITY BENEFITS QUESTIONNAIRE.

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 21-0960N-1, XXX XXXX

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SECTION IX - DIAGNOSTIC TESTING
NOTE: If testing has been performed and reflects veteran's current condition, no further testing is required for this examination report.
9A. HAVE DIAGNOSTIC IMAGING STUDIES OR OTHER DIAGNOSTIC PROCEDURES BEEN PERFORMED?
YES

NO

IF YES, CHECK ALL THAT APPLY:
Magnetic resonance imaging (MRI)

Date:

Results:

Computerized axial tomography (CT)

Date:

Results:

Electronystagmography (ENG)

Date:

Results:

Date:

Results:

Other, specify:

9B. HAS THE VETERAN HAD AN AUDIOGRAM?
YES

NO

IF YES, ATTACH OR PROVIDE RESULTS:

NOTE - IF THE VETERAN HAS HEARING LOSS OR TINNITUS, THE VA REGIONAL OFFICE WILL SCHEDULE A HEARING LOSS OR TINNITUS EXAM, AS APPROPRIATE.
9C. 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
10. DO ANY OF THE VETERAN'S EAR OR PERIPHERAL VESTIBULAR CONDITIONS IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

IF YES, DESCRIBE IMPACT OF EACH OF THE VETERAN'S EAR OR PERIPHERAL VESTIBULAR 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 AND FAX NUMBER

12B. PHYSICIAN'S PRINTED NAME
12E. PHYSICIAN'S MEDICAL LICENSE NUMBER

12C. DATE SIGNED
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, 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
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get information on where to send comments or suggestions about this form.
VA FORM 21-0960N-1, XXX XXXX

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