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Get Disability Benefits Questionnaire Download

LEFT UPPER EXTREMITY C. RIGHT LOWER EXTREMITY VA FORM 21-0960F-1 OCT 2012 Page 2 D. LEFT LOWER EXTREMITY E. ANTERIOR TRUNK F. POSTERIOR TRUNK Page 3 SUMMARY OF SCAR FINDINGS FOR THE TRUNK AND EXTREMITIES A. ARE ANY OF THE SCARS OF THE TRUNK OR EXTREMITIES PAINFUL If yes specify the number of painful scars 5 or more DESCRIBE THE PAIN if there are multiple painful scars be sure to adequately identify which scars are painful DESCRIBE THE LOSS OF COV.

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