Sections I to V: Identification, claim information, hospitalization, certification
The claimant enters the Veteran's name, SSN, VA file and service numbers and date of birth, then the claimant's details and relationship to the Veteran (self, spouse, parent or child). Item 13 selects Special Monthly Compensation or Special Monthly Pension. Item 14 asks whether the claimant is hospitalized, with admission date and hospital. The claimant signs item 15A, which is required. The examiner does not complete these sections.
Section VI: Examination Information (items 16 to 18)
Enter the examination date. The examiner note explains the purpose: record findings showing whether the claimant is housebound or needs the regular aid and attendance of another person, including whether they are blind or bedridden. Item 17 asks for complete diagnoses with the most significant symptoms for each, matched to the assistance described in items 26 to 37. Item 18 lists the disabilities considered permanent and totally disabling.
Items 19 to 25: Measurements, gait and restricting disabilities
Record age, weight (marking whether actual or estimated), height in feet and inches, nutrition, gait, blood pressure, pulse rate and respiratory rate. Item 25 asks which disabilities restrict the activities and functions listed in the rest of the form, which ties the diagnoses in item 17 to the functional findings that follow.
Items 26 to 30: Bed confinement, daily activities, vision, nursing care, competency
If the patient is confined to bed, give the hours in bed from 9 PM to 9 AM and from 9 AM to 9 PM. Item 27 lists activities needing assistance: bathing, hygiene, eating, dressing, ambulating within the home, transfers, toileting, medication management and additional activities such as housekeeping. Item 28 covers legal blindness and corrected vision in each eye, item 29 nursing home care, and item 30 the patient's capacity to manage benefit payments.
Items 31 to 37: Posture, extremities, spine, other pathology, leaving home, locomotion
Describe posture and general appearance, then restrictions of each upper extremity (grip, fine movements, feeding, buttoning, shaving, toileting) and each lower extremity (limitation of motion, atrophy, contractures, weight bearing, balance, propulsion). Item 34 covers spine, trunk and neck; item 35 other pathology such as bowel or bladder control and age-related dizziness, memory loss or poor balance. Item 36 asks how often and under what circumstances the patient leaves home; item 37 asks about canes, braces, crutches or another person, and walking distance.
Section VII: Examiner's Signature (items 38 to 41)
Print the examiner's name and title, sign item 40 and date it. The signature is marked required, and the form's penalty statement warns that willfully submitting a false statement or evidence of a material fact can bring a fine, imprisonment or both. The title should show one of the qualifying credentials: MD, DO, physician assistant or advanced practice registered nurse.
Section VIII: Examiner's Information (items 42 to 45)
Enter the examiner's National Provider Identifier, the name and full address of the medical facility, and the facility's telephone number, with an international number if applicable. These details let VA identify and contact the examiner about the findings, so they should belong to the place where the examination was performed.