VA Form 21-0960e-2

1 endocrine Diseases Disability Benefits Questionnaire Released January 2022 Updated on April 16, 2020 ~v20_1 Page 1 of 7 endocrine DISEASES (Other than Thyroid, Parathyroid or Diabetes Mellitus) DISABILITY BENEFITS QUESTIONNAIRENAME OF PATIENT/VETERANPATIENT/VETERAN'S SOCIAL SECURITY NUMBERNote - The Veteran is applying to the 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 may obtain additional medical information, including an examination, if necessary, to complete VA's review of the veteran's application.

2 VA reserves the right to confirm the authenticity of ALL questionnaires completed by providers. It is intended that this questionnaire will be completed by the Veteran's - 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. Are you completing this Disability Benefits Questionnaire at the request of:Veteran/ClaimantOther: please describeAre you a VA Healthcare provider?Is the Veteran regularly seen as a patient in your clinic? YesNoYesNoWas the Veteran examined in person?

3 YesNoIf no, how was the examination conducted?Please identify the evidence reviewed ( service treatment records, VA treatment records, private treatment records) and the date range. Evidence reviewed:EVIDENCE REVIEWNo records were reviewedRecords reviewedEndocrine Diseases Disability Benefits Questionnaire Released January 2022 Updated on April 16, 2020 ~v20_1 Page 2 of 7 OTHER DIAGNOSIS #1:ICD code - Date of diagnosis - ICD code - Date of diagnosis - OTHER (Specify):OTHER DIAGNOSIS #2:NEOPLASM, BENIGN, ANY SPECIFIED PART OF THE endocrine SYSTEMICD code - Date of diagnosis - NEOPLASM, MALIGNANT, ANY SPECIFIED PART OF THE endocrine SYSTEMICD code - Date of diagnosis - ACTIVE MALIGNANCYUNDERGOING SURGICAL, X-RAY, ANTINEOPLASTIC CHEMOTHERAPY OR OTHER THERAPEUTIC PROCEDUREIN REMISSION1C.

4 IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO endocrine CONDITION(S), LIST USING ABOVE FORMAT:ICD code -Date of diagnosis -ICD code - ICD code -Date of diagnosis - Date of diagnosis - HYPERALDOSTERONISMPHEOCHROMOCYTOMAHYPOGO NADISMBENIGNMALIGNANTACTIVEIN REMISSIONBENIGNMALIGNANTACTIVEIN REMISSIONICD code - Date of diagnosis -ICD code -Date of diagnosis - HYPOPITUITARISMHYPERPITUITARISM (prolactin secreting pituitary dysfunction)BENIGNMALIGNANTIN REMISSIONACTIVE1A. DOES THE VETERAN HAVE OR HAS HE OR SHE EVER HAD AN endocrine CONDITION? (This is the condition the veteran is claiming or for which an exam has been requested)1B.

5 SELECT THE VETERAN'S CONDITION (Check all that apply)SECTION I - DIAGNOSISDate of diagnosis -ICD code - Date of diagnosis - ICD code - Date of diagnosis - ICD code - YESNO(If "Yes," complete Item 1B)ICD code - Date of diagnosis -Date of diagnosis - ICD code -CUSHING'S SYNDROMEACROMEGALYDIABETES INSIPIDUSADDISON'S DISEASE (adrenocortical insufficiency)POLYGLANDULAR SYNDROME (multiple endocrine neoplasia, auto-immune polyglandular syndrome)1D. PLEASE SELECT THE BODY SYSTEMS AFFECTED BY THE DIAGNOSES LISTED IN SECTION SYMPTOMS, (complete appropriate musculoskeletal DBQ)RESPIRATORY SYMPTOMS, (complete appropriate respiratory DBQ)GENITOURINARY SYMPTOMS, (complete appropriate genitourinary DBQ)MENTAL AND PSYCHOLOGICAL SYMPTOMS, (complete appropriate psychological DBQ)SKIN SYMPTOMS, (complete appropriate dermatological DBQ)REPRODUCTIVE SYMPTOMS, (complete appropriate gynecological or male reproductive organ DBQ)EYE INVOLVEMENT, (complete appropriate ophthalmological DBQ)

6 NEUROLOGICAL SYMPTOMS, (complete appropriate neurological DBQ)GASTROINTESTINAL SYMPTOMS, (complete appropriate gastrointestinal DBQ)CARDIOVASCULAR SYMPTOMS, (complete appropriate cardiovascular DBQ)DENTAL AND ORAL CONDITIONS, (complete appropriate dental and oral DBQ) endocrine Diseases Disability Benefits Questionnaire Released January 2022 Updated on April 16, 2020 ~v20_1 Page 3 of 7 SECTION III - CUSHING'S SYNDROME 2D. HAS THE VETERAN HAD ANY OTHER TYPE OF TREATMENT FOR AN endocrine CONDITION?YESNO(If "Yes," specify the condition and type of treatment):(Date of treatment):If no, please select the symptoms below.

7 Proximal upper extremity muscle wasting that results in inability to climb stairsHypertensionAs active, progressive diseaseAreas of osteoporosisProximal lower extremity muscle wasting that results in inability to climb stairsProximal upper extremity muscle wasting that results in inability to raise armsProximal upper extremity muscle wasting that results in inability to rise from a deep chair without assistanceProximal upper extremity muscle wasting that results in inability to rise from squatting positionStriaeProximal lower extremity muscle wasting that results in inability to raise armsProximal lower extremity muscle wasting that

8 Results in inability to rise from a deep chair without assistanceProximal lower extremity muscle wasting that results in inability to rise from squatting positionVascular fragilityGlucose intoleranceObesityMoon faceOther, please specify:If yes, evaluate residuals with the appropriate DBQ (refer to and select appropriate checkbox from section 1D).3A. CUSHING'S SYNDROME SECTION II - MEDICAL HISTORY2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S endocrine CONDITION (brief summary):2B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF AN endocrine CONDITION?

9 YESNO(If "Yes," specify the condition and list only those medications required for the Veteran's endocrine condition):2C. HAS THE VETERAN HAD SURGERY FOR AN endocrine CONDITION?YESNO(If "Yes," specify the condition and type of surgery):(Date of surgery):(Date of initial diagnosis:)Has it been more than 6 months since the initial diagnosis?YESNOE ndocrine Diseases Disability Benefits Questionnaire Released January 2022 Updated on April 16, 2020 ~v20_1 Page 4 of 7 NOTE: An Addisonian crisis consists of the rapid onset of peripheral vascular collapse (with acute hypotension and shock), with findings that may include anorexia; nausea; vomiting; dehydration; profound weakness; pain in the abdomen; legs and back; fever; apathy and depressed mentation with possible progression to coma, renal shutdown and death.

10 For VA purposes, an Addisonian "episode" is a less acute and less severe event than an Addisonian crisis and may consist of anorexia, nausea, vomiting, diarrhea, dehydration, weakness, malaise, orthostatic hypotension or hypoglycemia, but not peripheral vascular VI - ADDISON'S DISEASE (ADRENOCORTICAL INSUFFICIENCY)6A. DOES THE VETERAN CURRENTLY HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO ADDISON'S DISEASE?YESNOCORTICOSTEROID THERAPY REQUIRED FOR CONTROLWEAKNESS AND FATIGABILITY(If "Yes," check all that apply)SECTION VII - OTHER endocrine CONDITIONS7B.