(Mt Carat 2986721 Esnionbec’ Ohaaiat WD department of Veterans Affairs ONT WRITE NTs SPACE EXAMINATION FOR HOUSEBOUND STATUS OR PERMANENT NEED FOR REGULAR AID AND ATTENDANCE ‘SECTION: VETERAN'S DENTIFIGATIONT PNOTE: You can cher complete oe for eae orby hand. Pesepein the informaton eure i ak, pally and lel oelp proces ie oom 7. VETERANENEFOARY NAVE Fir Mie al as 2, S00AL SECURITY NUMBER, [3 VAFLE NUMBER fat DATE OF BRTH anUDD TAT Meath Day You VETERANS SERVICE NOMSER (apie) GENDER, EMALE DOFEMALE 7. TELEPHONE NUMBER cin dra Cat) {PREFERRED EMAIL ADDRESS (aod ‘PREFERRED WAING RODRESS (Nbr and sre or ara ote P.O. Box. Gy Satz IP Cole a Cosas) out Number oy SwoPromce ‘couney 2 CodePota Case - ‘SECTION IT CLAIM INFORMATION. 10: GLAMANTS NAME (rt, il nial, La 1. CLAIMANTS SOCIAL SECURITY NUMBER "RELATIONSHIP OF CCADIANT TO VETERAN 18 BENEFT YOU ARE APPLYING FOR (Gm Os) [Speci Monthly Compensation (SMC) - Veterans and survivin ng spouses or parents who are eligible to receive VA compensation duc toa service telated disability or death and require ad and attendance of another person o perform persona fnetons required in everday living och bathing, feeding, dressing, attending tothe wants of nature, adjusting prosthetic devices, o protecting oneself from the havars of the dally vironment may be eligible for Special Monthly Compensation. Veta o a deceased Veterans surviving spouse may sie be slg for ‘Special Monthly Compensation based on being houscbound (substantially confined tothe iwnedite premises becuse of permanent Gsbiliy) Fora Veter, the disability causing the need for aid and atendance or housebound status mis be related to service. These beets ae oad ‘addition to monthly compensation. They ae not paid without eligibility to compensation, [Special Monthly Pension (SMP) - Veterans and survivors who _atendance of another person in order o perform personal fact ‘wants of nature, adjusting prosthetic devices, ‘confined to hisher immediate premises bec increased monthly amount pai to Veteran ar ligible for Veteran's Pension andlor Survivors benefits and require the ai and ins required in everyday living, such as bathing, feeding, dressing. attending tothe ‘or protecting himvber fom the hazards of hisher daily environment, rare housebound (sbstetally use of permanent disability), may be eligible for Special Monthly Pension (SMP). This benefits an ‘or survivor who is eligible for Veterns Pension or Survivors befits, ‘SECTION i INFORMATION OF EXAMINATION rae) "4 OATE OF EXAMNATION "5 HOME ADDRESS TOTS CANT ROSPTALEED? 16S DATE ROME TEE WANE AND AODRESS OF HOGPTAL | TI YES BNO crte*cmpe tems 18a 150 ERT —py-2680 TBRSTING STOGK OF VA FOR BT 2000 MAY 20, ‘War BEUSED, Page +PATIENTVETERAN'S SOCIAL SECURITY NO, NOTE: EXAMINER PLEASE READ CAREFULLY is pupos of is examination io eos manitations nd dings prion to he question of {fo dress and undress to fed him/herself to attend tthe wan of nature: or keep hither onina Feilecthow well he/she ambltes, where he'ahe goes and wht blo to do during ypeal 17. COUPLETE BINGNOSIS (gn nr oat lof anions dc ren 7 ash ‘corded to show whether the claimant is blind or bediddan Whether he clamant sks housebound he winter the claimant is housebound (confined to the home of immediate premises) orn need ofthe repular aid and atendagce of anater person. The report should be im these data for be VR dein Takers to determing he exe fst sas or nj produces Piya or menial ngeoetta on of cordon ot acheter he a. cy sea ad presale. Pndng shoal fra end altendanes beefs, the report should ers 765: WEIGHT 780, HEIGHT ‘eTUAL as. ESTMATED: Las, reer none: Fs, NUTRITION er fe BLOOD PRESSURE [22 PUISERATE [25 RESPIRATORY RATE 2, WHAT DSABEITIES RESTRICT THE USTED AGTITTESTUNGTINST 2. THE GLAMANT IS CONANED TO BED, NOIGATE THE NUMBER OF HOURS BED From 9 Plo 9 A From 9AM 9 Pat Ba 1S THE CLAMANT ABLE TO FEED RMUFERSELF? ("ojo pana) faves Gyno {7S GIARANT ABLE TO PREPARE OWN MEALS (Wa on open Bs BRO 25, DOES THE GAMANT NEED ASSISTANGE W BATHING AND TENDING TO OTHER HYGIENE NEEDST 7 aves Bxo "Tar po plan) "ER, 18 THE GLANANT LEGALLY GUNG? (7p clay 725 CORRECTED VOT EE Bes Bro RIGHTEYE, 130, DOES THE GLAMANT REQUIRE NURSING HOME GARE? 77sec SAT faves No 1 DOES THE GLAWANT REGUIRE MEDICATION WANAGEMENT? G7" pron aT aves no DIRECT SOMEONE T0100 S07 (Ns pre xmpler and tomato peonner oat Byes Bro [5% Br YOUR JUDGIENT, DOES THE VETERAN AIWANT HAVE TE MENTAL CAPRCTTY TO TANASE HS GA HERE INERT PRVUIENTS, ORS HE GH OTE ABLE TO SEH 21-2680 Page 2PATIENTVETERAVS SOCIAL SECURITY NO, {8 POSTURE AND GENERAL APPEARANCE nacho Do pa onal peel 36, DESCRIBE RESTRICTIONS OF EACH UPPER EXTREMITY WITH PARTICULAR REFERENCE TO GR, FNE HOVENENTS, AND ABILITY To EEO WUNERGELFTO BUTTON CLOTHING, SHAVE AND ATTEND TO THE NEEDS OF NATURE (Hinks of per on eo ed 25, DESCRIBE RESTRICTIONS OF EXCH LOWER EXTREMITY WH PARTIOULAR REFERENCE TO THE EXTENT OF LNITATION GF NOTION, ATROAGY NO fonactoneton HER WERPERENGE.F ROKATED, COMMENT SNCPCALT NUON SONS SUNY UO MECN SON Senn ‘5. DESGRBE RESTRICTION OF THE SPINE, TRUNK AND NEG Br, SET FORTH ALL OTHER PATHOLOGY NGLUDNG THE LOSS OF BOWEL OR BLADDER CONTROL OR THE EFFECTS OF ADVINGING AGE SIGH AG DEENESS .088 OF MEMORY OR POOR GALANCE, THAT AFFECTS CLAMANTS ABILITY TO PERFORM SELF-CARE. ANBULATE GA TRAVEL SovoNS Tie Pocsoeee aE HOME, ORF HOSPITALIZED, BEYOND THE WARD OR GLINCAL AREA. DESCRIBE WHERE THE CLAMANT GOSS AND WHAT RE OR Sn ooee OURS aePAL Dar ‘DESCRIBE HOW OFTEN PER DAY OR WEEK AND UNDER WHAT CIRCUMSTANCES THE GLAMIANT 18 ABLE TO LEAVE THE HOME GA RmNEDATE PREINSES "ARE RDS GUGHAS CANES, RAGES, CRUTGTES, OR WHE ASSISTANCE OF ANOTHER PERTON REGUIRED FOR [GOGMOTION? Tm ech ed TOS ‘Genero ae tt or beled i em ado coves “1, gee Cat ot pees tmz on Lovo Sabir Ch 1moce seemons FFs OX PRRTEORAE OF ARNG SCOR — 5 SRRTORE AG TLE SF SNS CAT TEESE Fa WaE RS ADDRESS OF MEDEA ROUT i TELEPRRE WOGER OF MEDEA FRGTTY tends rn Cody PRIVACY ACT NOTICE: The VA will pt dsl infomation sled on Ws fro Tee hago fde se {alles of mosey or 3 th ulmiiseaton of VA progr Sad deter oF VA ‘efi, wefan of ioebty ao was and perenael adnate) sy ented ke VA yee ee se =a ‘esata! Rehan Records - Va, an punished othe Foden Regine Wee ‘Secty Numer (SSN) acount inoation manditony, Applicants xe seca oy benef or refsing to provide i other SSN ans te to sigma omer evan nd nosey dtmine moxie 2) -Tnfermatin that you ferns may be uid in computer aching programs with aes fede r Rac eee See iy Yo ‘civ VAP as Wel st cae ay aunt one tan Sas ina Sari i de Dopaine erie VA bene by vie of yur patspaton in ay Deel progr sind ke Dense oe GESTONBENT BURDEN: We nee is infomation t determine your ligitliy for sd and atennc or housebound benefit, Tle 38, United Stes Co an {9),115(1X@) 1310) and (41313), 122,15410\6) ad 108 0) and oa Sis Code 1821 ad e rt 1 ak this infra We eimai Jou ll ned unrest Aooes [Bautien eitrtons, find he intation, and complet frm, VA ann Cons x spent atan es oa eed a eae 30 ‘eli OM cond ures sins suse eleassase ine! memantine aig OD ntl pete ane aoe Gi oe goad PRAbain date. youn al 00.87 Nw get aon see ee ee oe ON te ‘VAFORU T2600 SEP 018 Pages