STATEMENT IN SUPPORT OF CLAIM

SECTION I: VETERAN'S IDENTIFICATION INFORMATION

Social Security Number

VA File Number

DATE OF BIRTH (MM-DD-YYYY)

Veterans Service Number

Telephone Phone Number

Email Address

PREFERRED MAILING ADDRESS (Number and street or rural route, P. O. Box, City, State, ZIP Code and Country)

No. & Street

Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

SECTION II: CLAIM INFORMATION

Claimants Social Security Number

CLAIMANT'S HOME ADDRESS
No. & Street

Apt./Unit Number

City

State/Province

Country

ZIP Code/Postal Code

SECTION III: INFORMATION OF EXAMINATION

DATE OF EXAMINATION (MM-DD-YYYY)

Name Of Hospital

Address Of Hospital

PATIENT/VETERAN'S SOCIAL SECURITY NO

COMPLETE DIAGNOSIS (Diagnosis needs to equate to the level of assistance described in questions 25 through 39)

AGE

Weight ACTUAL LBS.

Weight ESTIMATED LBS.

Height

NUTRITION

GAIT

BLOOD PRESSURE

PULSE RATE

RESPIRATORY RATE

IF THE CLAIMANT IS CONFINED TO BED, INDICATE THE NUMBER OF HOURS IN BED
From 9 PM to 9 AM:

From 9 AM to 9 PM:

Claimants Social Security Number

DESCRIBE POSTURE AND GENERAL APPEARANCE (Attach a separate sheet of paper if additional space is needed)

DESCRIBE RESTRICTIONS OF EACH UPPER EXTREMITY WITH PARTICULAR REFERANCE 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

DESCRIBE RESTRICTIONS OF EACH LOWER EXTREMITY WITH PARTICULAR REFERANCE TO THE EXTENT OF LIMITATION OF MOTION, ATROPHY, AND CONTRACTURES OR OTHER INTERFERENCE. IF INDICATED, COMMENT SPECIFICALLY ON WEIGHT BEARING, BALANCE AND PROPULSION OF EACH LOWER EXTREEMITY

DESCRIBE RESTRICTION OF SPINE, TRUNK AND NECK

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

DESCRIBE HOW OFTEN PER DAY OR WEEK AND UNDER WHAT CIRCUMSTANCES THE CLAIMANT IS ABLE TO LEAVE THE HOME OR IMMEDIATE PREMISES

SECTION IV: CERTIFICATION AND SIGNATURE
PRINTED NAME OF PHYSICIAN

SIGNATURE AND TITLE OF EXAMINING PHYSICIAN
Clear

DATE SIGNED (MM-DD-YYYY)

NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER

Name Of Medical Facility

Telephone Phone Number

Address Of Medical Facility