21 0960C 7 Form PDF Details

The form 21-0960C-7, recognized as the Fibromyalgia Disability Benefits Questionnaire, is a crucial document for veterans seeking disability benefits from the Department of Veterans Affairs (VA) due to fibromyalgia. This detailed form serves as a structured method for documenting the severity and impact of fibromyalgia, a condition often characterized by widespread musculoskeletal pain, fatigue, sleep disturbances, and memory issues. Completion of this form by a physician is essential for the VA to consider a veteran's claim for benefits, as it provides comprehensive information regarding the diagnosis, medical history, treatments, symptoms, and the functional impact of fibromyalgia on the veteran's life. It specifically inquires about the presence of symptoms like widespread pain, stiffness, muscle weakness, as well as any psychological symptoms such as depression and anxiety that are often associated with the condition. Additionally, the form addresses treatments undertaken by the veteran, including any continuous medication required to manage fibromyalgia symptoms, showcasing the VA's thorough approach in evaluating the extent of the veteran's disability and its impact on their ability to work. As a meticulously structured document, the 21-0960C-7 form plays a pivotal role in the benefits determination process, underlining the VA's commitment to ensuring veterans receive the support and compensation they are entitled to for conditions incurred in or aggravated by military service.

QuestionAnswer
Form Name21 0960C 7 Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesva fibromyalgia, how to form 21 7, va form 21 7, how to va form 7

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OMB Approved No. 2900-0781

Respondent Burden: 15 minutes

FIBROMYALGIA 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 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.

SECTION I - DIAGNOSIS

NOTE - Fibromyalgia may also be called fibrositis or primary fibromyalgia syndrome.

1A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER BEEN DIAGNOSED WITH FIBROMYALGIA? (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 VETERAN'S CONDITION (check all that apply)

 

 

 

 

 

 

FIBROMYALGIA

ICD CODE:

 

DATE OF DIAGNOSIS:

 

 

 

 

 

OTHER (specify)

 

 

 

 

 

 

 

 

 

 

 

OTHER DIAGNOSIS #1

 

 

 

 

 

 

 

 

 

 

 

 

ICD CODE:

 

DATE OF DIAGNOSIS:

 

 

 

 

 

OTHER DIAGNOSIS #2

 

 

 

 

 

 

 

 

 

 

 

 

ICD CODE:

 

DATE OF DIAGNOSIS:

 

 

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO FIBROMYALGIA, 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 FIBROMYALGIA CONDITION:

3B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF FIBROMYALGIA SYMPTOMS?

 

 

YES

 

NO (If "Yes," list only those medications required for the veteran's fibromyalgia condition):

 

 

 

3C. IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR THIS CONDITION?

 

 

 

YES

 

NO (If "Yes," describe):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3D. ARE THE VETERAN'S FIBROMYALGIA SYMPTOMS REFRACTORY TO THERAPY?

 

 

 

YES

 

NO (If "Yes," describe):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION IV - FINDINGS, SIGNS AND SYMPTOMS

 

 

 

4. DOES THE VETERAN CURRENTLY HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO FIBROMYALGIA?

 

 

 

YES

 

NO (If "Yes," complete items 4A thru 4C)

 

 

 

 

 

WIDESPREAD MUSCULOSKELETAL PAIN (NOTE: For VA purposes widespread musculoskeletal pain means that pain occurs in both sides of the body, both above and below the waist and affecting both the axial skeleton (i.e., cervical spine, anterior chest, thoracic spine or low back) and the extremities)

STIFFNESS

MUSCLE WEAKNESS (If checked, describe):

FATIGUE

SLEEP DISTURBANCES

PARESTHESIAS

HEADACHE

DEPRESSION

ANXIETY

IRRITABLE BOWEL SYMPTOMS

RAYNAUD'S-LIKE SYMPTOMS

OTHER (describe):

(For all checked conditions, describe)

VA FORM

21-0960C-7

SUPERSEDES VA FORM 21-0960C-7, MAR 2011,

Page 1

OCT 2012

WHICH WILL NOT BE USED.

 
(If checked, indicate side):

SECTION IV - FINDINGS, SIGNS AND SYMPTOMS (CONTINUED)

NOTE - If Mental Health conditions, such as depression due to fibromyalgia are identified, a VA Form 21-0960P-2, Mental Disorders (Other than PTSD) Disability Benefits Questionnaire must ALSO be completed.

B. FREQUENCY OF FIBROMYALGIA SYMPTOMS (check all that apply)

NO SYMPTOMS

EPISODIC WITH EXACERBATIONS

PRESENT MORE THAN ONE-THIRD OF THE TIME

CONSTANT OR NEARLY CONSTANT

OFTEN PRECIPITATED BY ENVIRONMENTAL OR EMOTIONAL STRESS OR OVEREXERTION (If checked, describe):

OTHER (describe):

C. TENDER POINTS (trigger points) FOR PAIN (check all that apply)

None

All bilaterally

Low cervical region: at anterior aspect of the interspaces between transverse processes of C5-C7 (If checked, indicate side):

Second rib: at second costochondral junction (If checked, indicate side):

Occiput: at suboccipital muscle insertion (If checked, indicate side):

Trapezius muscle: midpoint of upper border (If checked, indicate side):

Supraspinatus Muscle: above medial border of the scapular spine (If checked, indicate side):

Lateral epicondyle: 2 cm distal to lateral epicondyle (If checked, indicate side):

Gluteal: at upper outer quadrant of buttocks (If checked, indicate side):

Greater trochanter: posterior to greater trochanteric prominence (If checked, indicate side):

Knee: medial joint line (If checked, indicate side):

Other, specify:

Right

Right

Right

Right

Right

Right

Right

Right

Right

Right

Left

Left

Left

Left

Left

Left

Left

Left

Left

Left

Both

Both

Both

Both

Both

Both

Both

Both

Both

Both

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 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 condition, repeat testing is not required.

6. ARE THERE ANY 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-7, OCT 2012

Page 2

SECTION VII - FUNCTIONAL IMPACT

7. DOES THE VETERAN'S FIBROMYALGIA IMPACT HIS OR HER ABILITY TO WORK?

YES

NO (If "Yes," describe impact of the veteran's fibromyalgia and provide 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

9B. PHYSICIAN'S PRINTED NAME

9C. DATE SIGNED

9D. PHYSICIAN'S PHONE NUMBER

9E. PHYSICIAN'S MEDICAL LICENSE NUMBER

9F. PHYSICIAN'S ADDRESS

NOTE - VA may obtain 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 15 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-7, OCT 2012

Page 3

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va form 21 0960c 7 writing process detailed (stage 1)

2. After the last section is completed, you have to put in the required specifics in B IS CONTINUOUS MEDICATION, YES, If Yes list only those medications, C IS THE VETERAN CURRENTLY, YES, If Yes describe, D ARE THE VETERANS FIBROMYALGIA, YES, NO If Yes describe, DOES THE VETERAN CURRENTLY HAVE, SECTION IV FINDINGS SIGNS AND, YES, NO If Yes complete items A thru C, WIDESPREAD MUSCULOSKELETAL PAIN, and STIFFNESS so that you can go further.

Part no. 2 of submitting va form 21 0960c 7

3. The following step is quite easy, B FREQUENCY OF FIBROMYALGIA, NO SYMPTOMS, EPISODIC WITH EXACERBATIONS, PRESENT MORE THAN ONETHIRD OF THE, CONSTANT OR NEARLY CONSTANT, OFTEN PRECIPITATED BY, OTHER describe, C TENDER POINTS trigger points FOR, None, All bilaterally, Low cervical region at anterior, Occiput at suboccipital muscle, Trapezius muscle midpoint of upper, Supraspinatus Muscle above medial, and Lateral epicondyle cm distal to - every one of these fields will have to be filled in here.

Stage no. 3 in completing va form 21 0960c 7

4. This next section requires some additional information. Ensure you complete all the necessary fields - ARE THERE ANY SIGNIFICANT, YES, NO If Yes provide type of test or, VA FORM C OCT , and Page - to proceed further in your process!

The best way to complete va form 21 0960c 7 portion 4

5. To finish your document, this particular section features some additional blanks. Filling in DOES THE VETERANS FIBROMYALGIA, YES, If Yes describe impact of the, REMARKS If any, and SECTION VIII REMARKS should conclude everything and you're going to be done in a snap!

Step # 5 of completing va form 21 0960c 7

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