Avitaminosis, beriberi (thiamine deficiency), pellagra (niacin deficiency) and other nutritional deficiency conditions claimed for VA disability are documented on this 6-page questionnaire. The clinician records the history and any continuous medication, then checks the findings VA rates: nonspecific symptoms, stomatitis, achlorhydria, diarrhea, symmetrical dermatitis and mental symptoms for pellagra or avitaminosis, and neuropathy, cardiomegaly or heart failure for active beriberi.
The Veteran's treating or examining clinician completes the form and signs the Section VIII examiner's certification. The Veteran fills in no part of it.
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Nutritional Deficiencies Disability Benefits Questionnaire
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Item 3A covers pellagra and avitaminosis: a confirmed diagnosis, nonspecific symptoms such as decreased appetite, weight loss, abdominal discomfort, weakness, poor concentration and irritability, plus stomatitis, achlorhydria, diarrhea, symmetrical dermatitis, mental symptoms and impaired bodily vigor, with the most severe findings listed separately.
It is listed as a finding of active beriberi in item 3B, together with congestive heart failure and anasarca. Mental health and nerve residuals from the deficiency also need the matching questionnaires, such as Mental Disorders or Peripheral Nerves.