Aid and Attendance or Housebound Examination

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

Narrative: Once the existence of at least one permanent disability rated at 100% has been established, additional benefits may be payable if the veteran requires:

1. The regular assistance of another person in attending to the ordinary activities of daily living,
2. Assistance of another in protecting himself or herself from the ordinary hazards of his or her daily environment, and/or
3. If the veteran is restricted to his or her home or the immediate vicinity thereof, including the ward or immediate clinical area, if hospitalized.

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

1. Indicate whether or not the veteran requires an attendant in reporting for this exam, and if so, identify the nurse or attendant and the mode of travel employed.
2. Indicate whether or not the veteran is hospitalized, and if so, state where and the date of admission.
3. Indicate whether or not the veteran is permanently bedridden.
4. Indicate whether or not the veteran's best corrected vision is 5/200 or worse in both eyes
5. State whether the veteran is capable of managing benefit payments in his or her own best interests without restriction. (A physical disability which prevents the veteran from attending to financial matters in person is not a proper basis for a finding of incompetency unless he or she is, by reason of that disability, incapable of directing someone else in handling financial affairs.)
6. Capacity to protect oneself from the hazards/dangers of daily environment:

1. Describe briefly any pathological processes involving other body parts and systems, including the effects of advancing age, such as dizziness, loss of memory, poor balance affecting ability to ambulate, performing self- care, or travel beyond the premises of the home (or the ward or clinical area if hospitalized).
2. Describe where the veteran goes and what he or she does during a typical day.

C. Physical Examination (Objective Findings):

Comment on:

1. General appearance.
2. Height and weight (including maximum and minimum weight for past year).
3. Build and posture.
4. State of nutrition.
5. Gait.
6. Temperature, pulse, respiration.
7. Blood pressure.
8. Upper extremities (reporting each upper extremity separately):

1. Describe functional restrictions with reference to strength and coordination and ability for self-feeding, fastening clothing, bathing, shaving, and toileting.
2. If amputated, indicate level of amputation (or length of stump and state whether or not use of a prosthesis is feasible).

9. Lower extremities (reporting each lower extremity separately):

1. Describe functional restrictions with reference to extent of limitation of motion, muscle atrophy, contractures, weakness, lack of coordination, or other interference.
2. Indicate any deficits of weight bearing, balance and propulsion.
3. If amputated, indicate level of amputation (or length of stump and state whether use of a prosthesis is feasible).

10. Spine, trunk and neck:

a. Describe any limitation of motion or deformity of lumbar, thoracic, and cervical spine.

11. Note if deformity of thoracic spine interferes with breathing.
12. Ambulation:

1. Indicate whether the veteran is able to walk without the assistance of another person and give the maximum distance.
2. Indicate any mechanical aid used or recommended by the examiner for ambulation.
3. Indicate the frequency, and under what circumstances, the veteran is able to leave the home or immediate premises.

13. Except as to amputations and other anatomical losses, indicate if any restrictions noted in the examination are permanent.

D. Diagnostic and Clinical Tests:

1. No specific diagnostic testing required unless required to evaluate the veteran as required above.
2. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:

Date: