Va Form 21-0960g-1 - Esophageal Conditions (Including Gastroesophageal Reflux Disease (Gerd), Hiatal Hernia And Other Esophageal Disorders) Disability Benefits Questionnaire Page 3

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION IV - ESOPHAGEAL STRICTURE, SPASM AND DIVERTICULA

4. DOES THE VETERAN HAVE AN ESOPHAGEAL STRICTURE, SPASM OF ESOPHAGUS (CARDIOSPASM OR ACHALASIA), OR AN ACQUIRED DIVERTICULUM OF

THE ESOPHAGUS?

YES

If Yes, indicate severity of condition:

ASYMPTOMATIC

NOT AMENABLE TO DILATION

MILD If checked, describe:

MODERATE If checked, describe:

SEVERE, PERMITTING PASSAGE OF LIQUIDS ONLY

If checked, describe:

SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, SIGNS AND/OR SYMPTOMS

5A. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS? IF YES, DESCRIBE

(brief summary)

5B. DOES THE VETERAN HAVE ANY SCARS (SURGICAL OR OTHERWISE) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS

LISTED IN THE DIAGNOSIS SECTION?

YES

IF YES, ARE ANY OF THESE SCARS PAINFUL OR UNSTABLE; HAVE A TOTAL AREA EQUAL TO OR GREATER THAN 39 SQUARE CM (6 square inches); OR

ARE LOCATED ON THE HEAD, FACE OR NECK?

YES

IF YES, ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT DISABILITY BENEFITS QUESTIONNAIRE.

IF NO, PROVIDE LOCATION AND MEASURMENTS OF SCAR IN CENTIMETERS

LOCATION:

MEASUREMENTS: Length

cm X width

cm.

NOTE: An "unstable scar" is one where, for any reason, there is frequent loss of covering of the skin over the scar. If there are multiple scars, enter additional locations and measurements

in the Remarks section below. It is not necessary to also complete a Scars DBQ.

SECTION VI - DIAGNOSTIC TESTING

Note: If testing has been performed and reflects veteran's current condition, no further testing is required for this examination report.

6A. HAVE DIAGNOSTIC IMAGING STUDIES OR OTHER DIAGNOSTIC PROCEDURES BEEN PERFORMED?

YES

If Yes, check all that apply:

UPPER ENDOSCOPY

Date:

Results:

UPPER GI RADIOGRAPHIC STUDIES

Date:

Results: