Veteran's Name:

Veterans SSN:

VA Claim Number:

Diagnosis:

(Physician's Initials)

The veteran has been diagnosed with Diabetes Mellitus, Type II (adult onset).

Evaluation: Please check only one applicable statement

The veteran's diabetes mellitus is manageable by restricted diet ONLY.

The veteran's diabetes mellitus requires insulin and restricted diet, or oral hypoglycemic agent and restricted diet.

The veteran's diabetes mellitus requires insulin, restricted diet, AND regulation of activities.

(Please describe regulation of activities in the Remarks section below).

The veteran's diabetes mellitus requires insulin, restricted diet, and regulation of activities, with episodes of ketoacidosis or hypoglycemic reactions requiring one or two hospitalization per year or twice a month visits to a diabetic care provider.

Complications:

The veteran currently has NO complication that are directly due to diabetes mellitus.

The veteran has the following complication that are directly due to diabetes mellitus, or is likely to be caused in part and/or aggravated by the diabetes mellitus.

Visual

Cardiovascular

Neurological

Renal

Other:

Remarks:

PHYSICIAN'S SIGNTURE

DATE

PHYSICIAN'S PRINTED NAME

PHYSICIAN'S ADDRESS & PHONE #

Please return completed, SIGNED form to: