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Medical Statement for Consideration of Aid and Attendance
CAREGIVERS PLEASE READ CAREFULLY BEFORE COMPLETING FORMS
The claimant is applying for VA non service connected pension benefits for Aid and Attendance. It is imperative that the physician(s) consider the following circumstances when answering the questions on the VDVA form 10 and 21.2680. The claimant does not need to be helpless. They need only show that they are in need of aid and attendance of another person on a regular basis.
COMPLETE DIAGNOSIS: Specify ALL illnesses. If there are multiple physicians,obtain statements from each i.e. cardiologist,internist,oncologist,surgeon,etc.
Does the claimant require the aid of another person in order to perform personal functions required in everyday living,such as bathing,feeding,dressing,attending to the wants of nature,adjusting prosthetic devices or protecting himself/herself from the hazards of his/her daily environment.
IS THE CLAIMANT ABLE TO FEED HIM/HERSELF Can the claimant do all of the following without aid?
• Go to the market to purchase groceries
• Carry groceries in a cart and pay for service
• Handle the bags (1 or 2) back to their home
• Open food and prepare”using a stove,oven or microwave
• Physically eat food
• Clean up after the meal to maintain a healthy environment
DOES THE PATIENT REQUIRE CARE AND ASSISTANCE ON A REGULAR BASIS TO PROTECT HIM/HER FROM THE HAZARDS OF DAILY ENVIRONMENT?
In your opinion,are there other pertinent facts that would show the claimant’s need for aid and attendance of another person? Including but not limited to: inability to protect oneself from the hazards of the environment,properly dress oneself
(buttons, zippers, socks) poor balance, memory loss, confusion, psychiatric impairment, atrophy, contractor, prosthesis, etc.
IS THE CLAIMANT BEDRIDDEN? Do his/her disabilities require that he/she remain in bed apart from any prescribed course of convalescence or treatment?
IS THE CLAIMANT A PATIENT IN A NURSING HOME OR ASSISTED CARE CENTER,DUE TO MENTAL OR PHYSICAL INCAPACITY?
IS THE CLAIMANT BLIND? Or,so nearly blind as to have corrected visual acuity of 5/200 or less,in both eyes,or concentric contraction of the visual field to 5 degrees or less.
Section 12 of VDVA form 10 should state that the person has an incapacity which requires care or assistance on a regular basis to protect the claimant from the hazards or dangers incident to their daily environment.Revised December 2011