Form 21-2680 Exam. for Housebound Status or Permanent Need For Regular Aid and Attend.

28 POSTURE AND GENERAL APPEARANCE (Attach a separate sheet of paper if additional space is needed) ( 1 FIRST NAME MIDDLE NAME LAST NAME OF VETERAN ) ( 11A AGE) ( 15 GAIT) ( 16 BLOOD PRESSURE) ( 17 PULSE RATE) ( 24 A IS THE CLAIMANT LEGALLY BLIND? (If "Yes " provide explanation)) ( 26 DOES CLAIMANT REQUIRE MEDICATION MANAGEMENT? (If "Yes " provide explanation)) ( 27 DOES THE CLAIMANT HAVE THE ABILITY TO MANAGE HIS/HER OWN FINANCIAL AFFAIRS? (If "No " provide explanation)) ( 28 POSTURE AND GENERAL APPEARANCE (Attach a separate sheet of paper if additional space is needed)) ( 29 DESCRIBE RESTRICTIONS OF EACH UPPER EXTREMITY WITH PARTICULAR REFERENCE TO GRIP FINE MOVEMENTS AND ABILITY TO FEED HIM/HERSELF TO BUTTON CLOTHING SHAVE AND ATTEND TO THE NEEDS OF NATURE (Attach a separate sheet of paper if additional space is needed)) ( 3 RELATIONSHIP OF CLAIMANT TO VETERAN) ( 30 DESCRIBE RESTRICTIONS OF EACH LOWER EXTREMITY WITH PARTICULAR REFERENCE TO THE EXTENT OF LIMITATION OF MOTION ATROPHY AND ( 31 DESCRIBE RESTRICTION OF THE SPINE TRUNK AND NECK) ( 32 SET FORTH ALL OTHER PATHOLOGY INCLUDING THE LOSS OF BOWEL OR BLADDER CONTROL OR THE EFFECTS OF ADVANCING AGE SUCH AS DIZZINESS LOSS OF MEMORY OR POOR BALANCE THAT AFFECTS CLAIMANT'S ABILITY TO PERFORM SELF CARE AMBULATE OR TRAVEL BEYOND THE PREMISES OF THE HOME OR IF HOSPITALIZED BEYOND THE WARD OR CLINICAL AREA DESCRIBE WHERE THE CLAIMANT GOES AND WHAT HE OR SHE DOES DURING A TYPICAL DAY ) ( 33 DESCRIBE HOW OFTEN PER DAY OR WEEK AND UNDER WHAT CIRCUMSTANCES THE CLAIMANT IS ABLE TO LEAVE THE HOME OR IMMEDIATE PREMISES) ( 35 A PRINTED NAME OF EXAMINING PHYSICIAN ) ( 35B SIGNATURE OF EXAMINING PHYSICIAN This is a protected field ) ( 35C DATE SIGNED Enter 2 digit month 2 digit day and 4 digit year ) ( 36 A NAME AND ADDRESS OF MEDICAL FACILITY) ( 36B TELEPHONE NUMBER OF MEDICAL FACILITY (Include Area Code)) (10 COMPLETE DIAGNOSIS (Diagnosis needs to equate to the level of assistance described in questions 20 through 34)) (11B SEX) (14 NUTRITION) (18 RESPIRATORY RATE) (19 WHAT DISABILITIES RESTRICT THE LISTED ACTIVITIES/FUNCTIONS?) (2 FIRST NAME MIDDLE NAME LAST NAME OF CLAIMANT (If other than veteran)) (20 IF THE CLAIMANT IS CONFINED TO BED INDICATE THE NUMBER OF HOURS IN BED From 9 AM To 9 PM) (20 IF THE CLAIMANT IS CONFINED TO BED INDICATE THE NUMBER OF HOURS IN BED From 9 PM To 9 AM) (21 IS THE CLAIMANT ABLE TO FEED HIM/HERSELF? (If "No " provide explanation)) (22 IS CLAIMANT ABLE TO PREPARE OWN MEALS? (If "Yes " provide explanation)) (23 DOES THE CLAIMANT NEED ASSISTANCE IN BATHING AND TENDING TO OTHER HYGIENE NEEDS? (If "Yes " provide explanation)) (25 DOES THE CLAIMANT REQUIRE NURSING HOME CARE? (If "Yes " provide explanation)) (35B TITLE OF EXAMINING PHYSICIAN ) (4 A VETERAN'S SOCIAL SECURITY NUMBER Enter 9 digit social security number ) (4B CLAIMANT'S SOCIAL SECURITY NUMBER Enter 9 digit social security number ) (5 CLAIM NUMBER) (6 DATE OF EXAMINATION Enter 2 digit month 2 digit day and 4 digit year ) (7 HOME ADDRESS) (8B DATE ADMITTED Enter 2 digit month 2 digit day and 4 digit year ) (9 NAME AND ADDRESS OF HOSPITAL) (ACTUAL POUNDS) (ESTIMATED POUNDS) (FEET) (If "Yes " complete Items 8B and 9) (If "YES " give distance)(Checkapplicable box or specify distance) (INCHES) (LEFT EYE) (OTHER (Specify distance)) (RIGHT EYE) 1 FIRST NAME MIDDLE NAME LAST NAME OF VETERAN 1 MILE 10 COMPLETE DIAGNOSIS (Diagnosis needs to equate to the level of assistance described in questions 20 through 34) 11A AGE 11B SEX 12 WEIGHT 13 HEIGHT 14 NUTRITION 15 GAIT 16 BLOOD PRESSURE 17 PULSE RATE 18 RESPIRATORY RATE 19 WHAT DISABILITIES RESTRICT THE LISTED ACTIVITIES/FUNCTIONS? 2 FIRST NAME MIDDLE NAME LAST NAME OF CLAIMANT(If other than veteran) 20 IF THE CLAIMANT IS CONFINED TO BED INDICATE THE NUMBER OF HOURS IN BED 21 IS THE CLAIMANT ABLE TO FEED HIM/HERSELF? (If "No " provide explanation) 22 IS CLAIMANT ABLE TO PREPARE OWN MEALS? (If "Yes " provide explanation) 23 DOES THE CLAIMANT NEED ASSISTANCE IN BATHING AND TENDING TO OTHER HYGIENE NEEDS? (If "Yes " provide explanation) 24A IS THE CLAIMANT LEGALLY BLIND? (If "Yes " provide explanation) 24B CORRECTED VISION 25 DOES THE CLAIMANT REQUIRE NURSING HOME CARE? (If "Yes " provide explanation) 26 DOES CLAIMANT REQUIRE MEDICATION MANAGEMENT? (If "Yes " provide explanation) 27 DOES THE CLAIMANT HAVE THE ABILITY TO MANAGE HIS/HER OWN FINANCIAL AFFAIRS? (If "No " provide explanation) 29 DESCRIBE RESTRICTIONS OF EACH UPPER EXTREMITY WITH PARTICULAR REFERENCE TO GRIP FINE MOVEMENTS AND ABILITY TO FEED HIM/HERSELF 3 RELATIONSHIP OF CLAIMANT 30 DESCRIBE RESTRICTIONS OF EACH LOWER EXTREMITY WITH PARTICULAR REFERENCE TO THE EXTENT OF LIMITATION OF MOTION ATROPHY AND 31 DESCRIBE RESTRICTION OF THE SPINE TRUNK AND NECK 32 SET FORTH ALL OTHER PATHOLOGY INCLUDING THE LOSS OF BOWEL OR BLADDER CONTROL OR THE EFFECTS OF ADVANCING AGE SUCH AS DIZZINESS 33 DESCRIBE HOW OFTEN PER DAY OR WEEK AND UNDER WHAT CIRCUMSTANCES THE CLAIMANT IS ABLE TO LEAVE THE HOME OR IMMEDIATE PREMISES 34 ARE AIDS SUCH AS CANES BRACES CRUTCHES OR THE ASSISTANCE OF ANOTHER PERSON REQUIRED FOR LOCOMOTION? (If so specify and describe 35A PRINTED NAME OF EXAMINING PHYSICIAN 35B SIGNATURE AND TITLE OF EXAMINING PHYSICIAN 35C DATE SIGNED 36A NAME AND ADDRESS OF MEDICAL FACILITY 36B TELEPHONE NUMBER OF MEDICAL FACILITY(Include Area Code) 4A VETERAN'S SOCIAL SECURITY NUMBER 4B CLAIMANT'S SOCIAL SECURITY NUMBER 5 CLAIM NUMBER 5701(c) (1) The 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 ineffect prior to January 1 1975 and still in effect The requested information is considered relevant and necessary to determine maximum benefits provided under thelaw The responses you submit are considered confidential (38 U S C 5701) Information that you furnish may be utilized in computer matching programs with otherFederal or state agencies for the purpose of determining your eligibility to receive VA benefits as well as to collect any amount owed to the United States by virtue ofyour participation in any benefit program administered by the Department of Veterans Affairs 6 DATE OF EXAMINATION 7 HOME ADDRESS 8A IS CLAIMANT HOSPITALIZED? 8B DATE ADMITTED 9 NAME AND ADDRESS OF HOSPITAL A TYPICAL DAY ACTUAL: LBS ESTIMATED: LBS and (e) 1115 (1)(e) 1311(c) and (d) 1315 (h) 1122 1541 (d) (e) and 1502(b) and (c) allows us to ask for this information We estimate that you will need an average of30 minutes to review the instructions find the information and complete this form VA cannot conduct or sponsor a collection of information unless a valid OMBcontrol 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 locatedon the OMB Internet page at www whitehouse gov/omb/library/OMBINV VA EPA html#VA If desired you can call 1 800 827 1000 to get information on where tosend comments or suggestions about this form CONTRACTURESOR OTHER INTERFERENCE IF INDICATED COMMENT SPECIFICALLY ON WEIGHT BEARING BALANCE AND PROPULSION OF EACH LOWER CONTRACTURESOR OTHER INTERFERENCE IF INDICATED COMMENT SPECIFICALLY ON WEIGHT BEARING BALANCE AND PROPULSION OF EACH LOWER) Department of Veterans Affairs effectiveness in terms of distance that can be traveled as in Item 32 above) EXAMINATION FOR HOUSEBOUND STATUS OR PERMANENTNEED FOR REGULAR AID AND ATTENDANCE EXTREMITY Findings should be recorded to show whether the claimant is blind or bedridden From 9 PM To 9 AM: From 9 AM To 9 PM: INCHES: FEET: JUN 200821 2680WHICH WILL NOT BE USED LEFT EYE LOSS OF MEMORY OR POOR BALANCE THAT AFFECTS CLAIMANT'S ABILITY TO PERFORM SELF CARE AMBULATE OR TRAVEL BEYOND THE PREMISES OF NOTE: EXAMINER PLEASE READ CAREFULLYThe purpose of this examination is to record manifestations and findings pertinent to the question of whether the claimant is housebound (confined to the home orimmediate premises) or in need of the regular aid and attendance of another person NOYES NOYES NOYES NOYES OMB Control No 2900 0721Respondent Burden: 30 minutes OTHER(Specify distance) Pension Education and Vocational Rehabilitation Records VA and published in the Federal Register Your obligation to respond is required to obtain or retainbenefits Giving us your Social Security Number (SSN) account information is mandatory Applicants are required to provide their SSN under Title 38 U S C U S C PRIVACY ACT NOTICE:The VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of1974 or Title 38 Code of Federal Regulations 1 576 for routine uses (i e civil or criminal law enforcement congressional communications epidemiological or researchstudies 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 anddelivery of VA benefits verification of identity and status and personnel administration) as identified in the VA system of records 58VA21/22/28 Compensation RESPONDENT BURDEN:We need this information to determine your eligibility for aid and attendance or housebound benefits Title 38 United States Code 1521 (d) RIGHT EYE THE HOME OR IF HOSPITALIZED BEYOND THE WARD OR CLINICAL AREA DESCRIBE WHERE THE CLAIMANT GOES AND WHAT HE OR SHE DOES DURING The report should be in sufficient detail for the VA decision makers to determine the extent that disease or injury produces physical or mental impairment that loss ofcoordination or enfeeblement affects the ability: to dress and undress; to feed him/herself; to attend to the wants of nature; or keep him/herself ordinarily clean andpresentable TO BUTTON CLOTHING SHAVE AND ATTEND TO THE NEEDS OF NATURE (Attach a separate sheet of paper if additional space is needed) TO VETERAN VA FORM 21 2680 JUN 2008 VA FORMSUPERSEDES VA FORM 21 2680 OCT 1992 Whether the claimant seeks housebound or aid and attendance benefits the report should reflect how well he/she ambulates where he/she goes and what he/she is ableto do during a typical day YESNO1 BLOCK5 or 6 BLOCKS