Va Form 21-0960g-1 - Esophageal Conditions (Including Gastroesophageal Reflux Disease (Gerd), Hiatal Hernia And Other Esophageal Disorders) Disability Benefits Questionnaire Page 2

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PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION III - SIGNS AND SYMPTOMS (Continued)
REFLUX
If checked, indicate frequency of symptom recurrence per year:
1
2
3
4 or more
If checked, indicate average duration of episodes of symptoms:
Less than 1 day
1-9 days
10 days or more
REGURGITATION
If checked, indicate frequency of symptom recurrence per year:
1
2
3
4 or more
If checked, indicate average duration of episodes of symptoms:
Less than 1 day
1-9 days
10 days or more
SUBSTERNAL ARM OR SHOULDER PAIN
If checked, indicate frequency of symptom recurrence per year:
1
2
3
4 or more
If checked, indicate average duration of episodes of symptoms:
Less than 1 day
1-9 days
10 days or more
SLEEP DISTURBANCE CAUSE BY ESOPHAGEAL REFLUX
If checked, indicate frequency of symptom recurrence per year:
1
2
3
4 or more
If checked, indicate average duration of episodes of symptoms:
Less than 1 day
1-9 days
10 days or more
ANEMIA
If checked, provide hemoglobin/hematocrit in diagnostic testing section.
WEIGHT LOSS
If checked, provide baseline weight:
and current weight:
(For VA purposes, baseline weight is the average weight for 2-year period preceding onset of disease)
NAUSEA
If checked, indicate severity:
Mild
Transient
Recurrent
Periodic
If checked, indicate frequency of episodes of nausea per year:
1
2
3
4 or more
If checked, indicate average duration of episodes of nausea:
Less than 1 day
1-9 days
10 days or more
VOMITING
If checked, indicate severity:
Mild
Transient
Recurrent
Periodic
If checked, indicate frequency of episodes of vomiting per year:
1
2
3
4 or more
If checked, indicate average duration of episodes of vomiting:
Less than 1 day
1-9 days
10 days or more
HEMATEMESIS
If checked, indicate severity:
Mild
Transient
Recurrent
Periodic
If checked, indicate frequency of episodes of vomiting per year:
1
2
3
4 or more
If checked, indicate average duration of episodes of vomiting:
Less than 1 day
1-9 days
10 days or more
MELENA
If checked, indicate severity:
Mild
Transient
Recurrent
Periodic
If checked, indicate frequency of episodes of vomiting per year:
1
2
3
4 or more
If checked, indicate average duration of episodes of vomiting:
Less than 1 day
1-9 days
10 days or more
VA FORM 21-0960G-1, SEP 2016
Page 2

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