Examination for Housebound Status or Permanent Need for Regular Aid and Attendance

OMB Control No. 2900-0721

Respondent Burden: 30 minutes

Expiration Date: 5-31-2018

EXAMINATION FOR HOUSEBOUND STATUS OR PERMANENT

NEED FOR REGULAR AID AND ATTENDANCE

1. FIRST NAME - MIDDLE NAME - LAST NAME OF VETERAN 2. FIRST NAME - MIDDLE NAME - LAST NAME OF CLAIMANT

3. RELATIONSHIP OF CLAIMANT

TO VETERAN

4A. VETERAN'S SOCIAL SECURITY NUMBER 4B. CLAIMANT'S SOCIAL SECURITY NUMBER

8B. DATE ADMITTED

NOTE: EXAMINER PLEASE READ CAREFULLY

The purpose of this examination is to record manifestations and findings pertinent to the question of whether the claimant is housebound (confined to the home or

immediate premises) or in need of the regular aid and attendance of another person.

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 of

coordination 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 and

presentable.

Findings should be recorded to show whether the claimant is blind or bedridden.

14. NUTRITION 15. GAIT

16. BLOOD PRESSURE 17. PULSE RATE 18. RESPIRATORY RATE 19. WHAT DISABILITIES RESTRICT THE LISTED ACTIVITIES/FUNCTIONS?

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)

YES NO

22. IS CLAIMANT ABLE TO PREPARE OWN MEALS? (If "Yes," provide explanation)

YES NO

23. DOES THE CLAIMANT NEED ASSISTANCE IN BATHING AND TENDING TO OTHER HYGIENE NEEDS?

(If "Yes," provide explanation)

YES NO

26. DOES THE CLAIMANT REQUIRE MEDICATION MANAGEMENT? (If "Yes," provide explanation)

YES NO

27. DOES THE CLAIMANT HAVE THE ABILITY TO MANAGE HIS/HER OWN FINANCIAL AFFAIRS? (If "No," provide explanation)

YES NO

VA FORM

MAY 2015

21-2680

SUPERSEDES VA FORM 21-2680, JUN 2008,

WHICH WILL NOT BE USED.