Va Form 21-0960g-8 - Infectious Intestinal Disorders, Including Bacterial And Parasitic Infections Disability Benefits Questionnaire

Download a blank fillable Va Form 21-0960g-8 - Infectious Intestinal Disorders, Including Bacterial And Parasitic Infections Disability Benefits Questionnaire in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Va Form 21-0960g-8 - Infectious Intestinal Disorders, Including Bacterial And Parasitic Infections Disability Benefits Questionnaire with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

OMB Approved No. 2900-0778

Respondent Burden: 15 Minutes

Expiration Date: 09/30/2019

INFECTIOUS INTESTINAL DISORDERS, INCLUDING BACTERIAL AND

PARASITIC INFECTIONS DISABILITY BENEFITS QUESTIONNAIRE

IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE PROCESS OF

COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION BEFORE COMPLETING FORM.

(First, Middle Initial, Last)

NAME OF PATIENT/VETERAN

PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

NOTE TO PHYSICIAN - Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information you provide on this questionnaire

as part of their evaluation in processing the veteran's claim. VA reserves the right to confirm the authenticity of ALL DBQs completed by private health care providers.

SECTION I - DIAGNOSIS

1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH AN INFECTIOUS INTESTINAL CONDITION?

(If "Yes," complete Item 1B)

YES

NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed below. If there is no diagnosis, if the diagnosis is different from a previous diagnosis

for this condition, or if there is a diagnosis of a complication due to the claimed condition, explain your findings and reasons in the Remarks section. Date of diagnosis can be the date of the

evaluation if the clinician is making the initial diagnosis, or an approximate date is determined through record review or reported history.

(check all that apply)

1B. SELECT THE VETERAN'S CONDITION

BACILLARY DYSENTERY

ICD code:

Date of diagnosis:

(intestinal fluke)

INTESTINAL DISTOMIASIS

ICD code:

Date of diagnosis:

PARASITIC INFECTION OF THE INTESTINES

ICD code:

Date of diagnosis:

AMEBIASIS

ICD code:

Date of diagnosis:

NOTE: If the veteran has a lung abscess due to amebiasis, ALSO complete VA Form 21-0960L-1, Respiratory Conditions Disability Benefits Questionnaire.

OTHER INFECTIOUS INTESTINAL CONDITION

OTHER DIAGNOSIS #1:

ICD code:

Date of diagnosis:

OTHER DIAGNOSIS #2:

ICD code:

Date of diagnosis:

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO INFECTIOUS INTESTINAL CONDITIONS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY

(including onset, course, and past treatment)

(brief summary)

2A. DESCRIBE THE HISTORY

OF THE VETERAN'S INFECTIOUS INTESTINAL CONDITIONS

2B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF THE VETERAN'S INTESTINAL CONDITIONS?

YES

IF YES, LIST ONLY THOSE MEDICATIONS REQUIRED FOR THE INTESTINAL CONDITIONS:

2C. HAS THE VETERAN HAD SURGICAL TREATMENT FOR AN INTESTINAL CONDITION?

YES

(If "Yes," ALSO complete VA Form 21-0960G-4, Intestinal Surgery (Bowel Resection, Colostomy, Ileostomy) Disability Benefits Questionnaire)

SECTION III - SIGNS AND SYMPTOMS

3. DOES THE VETERAN HAVE ANY SIGNS OR SYMPTOMS ATTRIBUTABLE TO ANY INFECTIOUS INTESTINAL CONDITIONS?

YES

IF YES, CHECK ALL THAT APPLY

(If checked, describe)

MILD SYMPTOMS ATTRIBUTABLE TO DISTOMIASIS, INTESTINAL OR HEPATIC

(If checked, describe)

MODERATE SYMPTOMS ATTRIBUTABLE TO DISTOMIASIS, INTESTINAL OR HEPATIC

(If checked, describe)

SEVERE SYMPTOMS ATTRIBUTABLE TO DISTOMIASIS, INTESTINAL OR HEPATIC

(If checked, describe)

MILD GASTROINTESTINAL DISTURBANCES

If checked, describe

LOWER ABDOMINAL CRAMPS.

(If checked, describe)

GASEOUS DISTENTION

(If checked, describe)

CHRONIC CONSTIPATION INTERRUPTED BY DIARRHEA

ANEMIA (If checked, provide hemoglobin/hematocrit in Section 8, Diagnostic Testing)

(If checked, describe)

NAUSEA

(If checked, describe)

VOMITING

(describe)

OTHER,

NOTE - Complete the appropriate Disability Benefits Questionnaire(s) when the infectious disease affects other organs such as the liver, lung, kidney, etc. (schedule with

appropriate provider).

VA FORM

21-0960G-8

SUPERSEDES VA FORM 21-0960G-8, OCT 2012,

Page 1

SEP 2016

WHICH WILL NOT BE USED.