Form 21-0960j-4 - Urinary Tract (Including Bladder And Urethra) Conditions (Excluding Male Reproductive System) Disability Benefits Questionnaire
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4OMB Approved No. 2900-0781
Respondent Burden: 15 Minutes
Expiration Date: 09/30/2019
URINARY TRACT (INCLUDING BLADDER AND URETHRA) CONDITIONS
(EXCLUDING MALE REPRODUCTIVE SYSTEM) 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 THIS FORM.
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 A CONDITION OF THE BLADDER OR URETHRA OF THE URINARY
(This is the condition the veteran is claiming or for which an exam has been requested)
TRACT?
(If "Yes," complete Item 1B)
YES
NO
NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed above. 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 appropriate date determined through record review or reported history.
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO URINARY TRACT CONDITIONS OF THE BLADDER OR URETHRA:
Diagnosis # 1 -
ICD code -
Date of diagnosis -
Diagnosis # 2 -
ICD code -
Date of diagnosis -
Diagnosis # 3 -
ICD code -
Date of diagnosis -
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO URINARY TRACT CONDITIONS OF THE BLADDER OR URETHRA, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL RECORD REVIEW
2. INDICATE MEDICAL RECORDS REVIEWED IN PREPARATION OF THIS REPORT:
C-FILE (VA ONLY)
OTHER, DESCRIBE:
SECTION III - MEDICAL HISTORY
(including onset and course)
(brief summary):
3A. DESCRIBE THE HISTORY
OF THE VETERAN'S URINARY TRACT CONDITION
3B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF THE VETERAN'S URINARY TRACT CONDITION?
(If "Yes," list only those medications required for the veteran's urinary tract condition):
YES
NO
SECTION IV - VOIDING DYSFUNCTION
4. DOES THE VETERAN HAVE A VOIDING DYSFUNCTION?
(If "Yes," complete Items 4A thru 4E):
YES
NO
(i.e., relationship of voiding dysfunction to any condition in Section I, Diagnosis):
A. ETIOLOGY OF VOIDING DYSFUNCTION
B. DOES THE VOIDING DYSFUNCTION CAUSE URINE LEAKAGE?
YES
NO
(If "Yes," indicate severity)
Does not require the wearing of absorbent material
Requires absorbent material which must be changed less than 2 times per day
Requires absorbent material which must be changed 2 to 4 times per day
Requires absorbent material which must be changed more than 4 times per day
Other, describe:
C. DOES THE VOIDING DYSFUNCTION REQUIRE THE USE OF AN APPLIANCE?
(If "Yes," describe the appliance):
YES
NO
D. DOES THE VOIDING DYSFUNCTION CAUSE INCREASED URINARY FREQUENCY?
YES
NO
(If "Yes," check all that apply):
Daytime voiding interval between 2 and 3 hours
Daytime voiding interval between 1 and 2 hours
Daytime voiding interval less than 1 hour
Nighttime awakening to void 2 times
Nighttime awakening to void 3 to 4 times
Nighttime awakening to void 5 or more times
21-0960J-4
SUPERSEDES VA FORM 21-0960J-4, OCT 2012,
Page 1
VA FORM
WHICH WILL NOT BE USED.
SEP 2016
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