VA Form 21-0960C-8 Headaches (Including Migraine Headaches) Disability Benefits Questionnaire

VA Form 21-0960C-8 or the "Headaches (including Migraine Headaches) Disability Benefits Questionnaire" is a form issued by the U.S. Department of Veterans Affairs.

Download a PDF version of the VA Form 21-0960C-8 down below or find it on the U.S. Department of Veterans Affairs Forms website.

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OMB Control No. 2900-0778
Respondent Burden: 15 Minutes
Expiration Date: 09/30/2019
HEADACHES (INCLUDING MIGRAINE HEADACHES)
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.
(First, Middle Initial, Last)
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 HEADACHE CONDITION?
(If "Yes," complete Item 1B)
YES
NO
NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed below. 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 approximate date is determined through record review or
reported history.
(check all that apply):
1B. SELECT THE VETERAN'S CONDITION
Migraine including migraine variants
ICD Code:
Date of Diagnosis:
Tension
ICD Code:
Date of Diagnosis:
Cluster
ICD Code:
Date of Diagnosis:
(specify type of headache):
Other
ICD Code:
Date of Diagnosis:
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 A HEADACHE CONDITION, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
(brief summary):
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S HEADACHE CONDITIONS
2B. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING MEDICATION FOR THE DIAGNOSED CONDITION?
(list only those medications used for the diagnosed condition):
YES
NO
IF YES, DESCRIBE TREATMENT
SECTION III - SYMPTOMS
3A. DOES THE VETERAN EXPERIENCE HEADACHE PAIN?
YES
NO
(If "Yes," check all that apply to headache pain):
Constant head pain
Pulsating or throbbing head pain
Pain localized to one side of the head
Pain on both sides of the head
Pain worsens with physical activity
Other, describe:
VA FORM
21-0960C-8
SUPERSEDES VA FORM 21-0960C-8, OCT 2012,
Page 1
SEP 2016
WHICH WILL NOT BE USED.
OMB Control No. 2900-0778
Respondent Burden: 15 Minutes
Expiration Date: 09/30/2019
HEADACHES (INCLUDING MIGRAINE HEADACHES)
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.
(First, Middle Initial, Last)
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 HEADACHE CONDITION?
(If "Yes," complete Item 1B)
YES
NO
NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed below. 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 approximate date is determined through record review or
reported history.
(check all that apply):
1B. SELECT THE VETERAN'S CONDITION
Migraine including migraine variants
ICD Code:
Date of Diagnosis:
Tension
ICD Code:
Date of Diagnosis:
Cluster
ICD Code:
Date of Diagnosis:
(specify type of headache):
Other
ICD Code:
Date of Diagnosis:
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 A HEADACHE CONDITION, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
(brief summary):
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S HEADACHE CONDITIONS
2B. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING MEDICATION FOR THE DIAGNOSED CONDITION?
(list only those medications used for the diagnosed condition):
YES
NO
IF YES, DESCRIBE TREATMENT
SECTION III - SYMPTOMS
3A. DOES THE VETERAN EXPERIENCE HEADACHE PAIN?
YES
NO
(If "Yes," check all that apply to headache pain):
Constant head pain
Pulsating or throbbing head pain
Pain localized to one side of the head
Pain on both sides of the head
Pain worsens with physical activity
Other, describe:
VA FORM
21-0960C-8
SUPERSEDES VA FORM 21-0960C-8, OCT 2012,
Page 1
SEP 2016
WHICH WILL NOT BE USED.
PATIENT/VETERAN'S SOCIAL SECURITY NO.
(Continued)
SECTION III - SYMPTOMS
(Including symptoms associated with an aura prior to
3B. DOES THE VETERAN EXPERIENCE NON-HEADACHE SYMPTOMS ASSOCIATED WITH HEADACHES?
headache pain)
YES
NO
(If "Yes," check all that apply):
Nausea
Vomiting
Sensitivity to light
Sensitivity to sound
(such as scotoma, flashes of light, tunnel vision)
Changes in vision
(such as feeling of pins and needles in extremities)
Sensory changes
Other, describe:
3C. INDICATE DURATION OF TYPICAL HEAD PAIN
Less than 1 day
1-2 days
More than 2 days
Other, describe:
3D. INDICATE LOCATION OF TYPICAL HEAD PAIN
Right side of head
Left side of head
Both sides of head
Other, describe:
SECTION IV - PROSTRATING ATTACKS OF HEADACHE PAIN
4A. MIGRANE - DOES THE VETERAN HAVE CHARACTERISTIC PROSTRATING ATTACKS OF MIGRAINE HEADACHE PAIN?
YES
NO
(If "Yes," indicate frequency, on average, of prostrating attacks over the last several months):
Less than once every 2 months
Once in 2 months
Once every month
More frequently than once per month
4B. DOES THE VETERAN HAVE VERY FREQUENT PROSTRATING AND PROLONGED ATTACKS OF MIGRAINE HEADACHE PAIN?
YES
NO
4C. NON-MIGRAINE - DOES THE VETERAN HAVE PROSTRATING ATTACKS OF NON-MIGRAINE HEADACHE PAIN?
YES
NO
(If "Yes," indicate frequency, on average, of prostrating attacks over the last several months):
Less than once every 2 months
Once in 2 months
Once every month
More frequently than once per month
4D. DOES THE VETERAN HAVE VERY FREQUENT PROSTRATING AND PROLONGED ATTACKS OF NON-MIGRAINE HEADACHE PAIN?
YES
NO
SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
(surgical or otherwise)
5A. DOES THE VETERAN HAVE ANY SCARS
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 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.)
(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 below. It is not necessary to also complete a Scars DBQ.
Page 2
VA FORM 21-0960C-8, SEP 2016
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS (Continued)
5B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN THE DIAGNOSIS SECTION?
YES
NO
(If "Yes," describe in a brief summary):
SECTION VI - DIAGNOSTIC TESTING
NOTE: Diagnostic testing is not requested for this examination report; if studies have already been completed, provide the most recent results below.
6. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES
NO
(brief summary):
IF YES, PROVIDE TYPE OF TEST OR PROCEDURE, DATE AND RESULTS
SECTION VII - FUNCTIONAL IMPACT
7. DOES THE VETERAN'S HEADACHE CONDITION IMPACT HIS OR HER ABILITY TO WORK?
(If "Yes," describe impact of the veteran's headache condition, providing one or more examples):
YES
NO
SECTION VIII - REMARKS
(If any)
8. REMARKS
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 AND FAX NUMBER
9E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER
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, 58VA21/22/28, 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 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.
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VA FORM 21-0960C-8, SEP 2016
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