Va Form 21-0960g-8 - Infectious Intestinal Disorders, Including Bacterial And Parasitic Infections Disability Benefits Questionnaire Page 2

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION IV - SYMPTOM EPISODES, ATTACKS AND EXACERBATIONS

4. DOES THE VETERAN HAVE EPISODES OF BOWEL DISTURBANCE WITH ABDOMINAL DISTRESS, OR EXACERBATIONS OR ATTACKS OF THE

INTESTINAL CONDITION?

YES

(check all that apply)

IF YES, INDICATE SEVERITY AND FREQUENCY

EPISODES OF BOWEL DISTURBANCE WITH ABDOMINAL DISTRESS. IF CHECKED, INDICATE FREQUENCY:

Occasional episodes

More or less constant abdominal distress

Frequent episodes

EPISODES OF EXACERBATIONS AND/OR ATTACKS OF THE INTESTINAL CONDITION

IF CHECKED, DESCRIBE TYPICAL EXACERBATION OR ATTACK:

INDICATE NUMBER OF EXACERBATIONS AND/OR ATTACKS IN PAST 12 MONTHS:

7 or more

SECTION V - WEIGHT LOSS

5. DOES THE VETERAN HAVE WEIGHT LOSS ATTRIBUTABLE TO AN INFECTIOUS INTESTINAL CONDITION?

YES

IF YES, PROVIDE VETERAN'S BASELINE WEIGHT:

AND CURRENT WEIGHT:

(NOTE: For VA purposes, baseline weight is the average weight for 2-year period preceding onset of disease)

SECTION VI - MALNUTRITION, COMPLICATIONS AND OTHER GENERAL HEALTH EFFECTS

6. DOES THE VETERAN HAVE MALNUTRITION, SERIOUS COMPLICATIONS OR OTHER GENERAL HEALTH EFFECTS ATTRIBUTABLE TO THE INTESTINAL

CONDITION?

YES

(check all that apply)

IF YES, INDICATE SEVERITY

Health only fair during remissions

Resulting in general debility

Serious complication such as liver abscess (Describe)

Malnutrition. If checked, is malnutrition marked?

Yes

Other (Describe):

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

(surgical or otherwise)

7A. DOES THE VETERAN HAVE ANY SCARS

RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN

THE DIAGNOSIS SECTION?

YES

(6 square inches

IF YES, ARE ANY OF THE SCARS PAINFUL OR UNSTABLE; HAVE A TOTAL AREA EQUAL TO OR GREATER THAN 39 SQUARE CM

) 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

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.

7B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY

CONDITIONS LISTED IN THE DIAGNOSIS SECTION?

(brief summary)

YES

NO IF YES, DESCRIBE

SECTION VIII - DIAGNOSTIC TESTING

NOTE: If imaging studies, diagnostic procedures or laboratory testing have been performed and reflect the veteran's current condition, provide most recent results; no

further studies or testing are required for this examination.

8A. HAS LABORATORY TESTING BEEN PERFORMED?

YES

IF YES, CHECK ALL THAT APPLY:

(if anemia due to any intestinal condition is suspected or present)

CBC

Date of test:

Hemoglobin:

Hematocrit:

White blood cell count:

Platelets:

Other, specify: