Form 21-0960j-4 - Urinary Tract (Including Bladder And Urethra) Conditions (Excluding Male Reproductive System) Disability Benefits Questionnaire Page 2
Download a blank fillable Form 21-0960j-4 - Urinary Tract (Including Bladder And Urethra) Conditions (Excluding Male Reproductive System) 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 Form 21-0960j-4 - Urinary Tract (Including Bladder And Urethra) Conditions (Excluding Male Reproductive System) 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.
ADVERTISEMENT
1
2
3
4PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
(Continued)
SECTION IV - VOIDING DYSFUNCTION
E. DOES THE VOIDING DYSFUNCTION CAUSE SIGNS OR SYMPTOMS OF OBSTRUCTED VOIDING?
(If "Yes," check all that apply):
YES
NO
(If checked, is hesitancy marked?):
Hesitancy
Yes
No
(If checked, is stream markedly slow or weak?):
Slow or weak stream
Yes
No
(If checked, is force of stream markedly decreased?):
Decreased force of stream
Yes
No
(If checked, indicate frequency of periodic dilation):
Stricture disease requiring dilatation
1 to 2 times per year
Every 2 to 3 months
Other, specify:
Recurrent urinary tract infections secondary to obstruction
Uroflowmetry peak flow rate less than 10 cc/sec
Post void residuals greater than 150 cc
Urinary retention requiring intermittent catheterization
Urinary retention requiring continuous catheterization
Other, describe:
SECTION V - UROLITHIASIS
(cysto or urethrolithiasis)
5. DOES THE VETERAN HAVE A HISTORY OF URETHRAL OR BLADDER CALCULI
?
(If "Yes," complete Items 5A thru 5C):
YES
NO
(check all that apply):
A. INDICATE LOCATION OF CALCULI
Urethra
Bladder
B. HAS THE VETERAN HAD TREATMENT FOR RECURRENT STONE FORMATION IN THE URETHRA OR BLADDER?
(If "Yes," indicate treatment (check all that apply)):
YES
NO
(If checked, specify diet:
and dates of use:
)
Diet therapy
(If checked, list medication:
and dates of use:
)
Drug therapy
(If checked, indicate average number of times per year invasive or non-invasive procedures were required):
Invasive or non-invasive procedures
0 to 1 per year
2 per year
> 2 per year
Provide name of facility and dates of most recent invasive or noninvasive procedure:
C. DOES THE VETERAN HAVE SIGNS OR SYMPTOMS DUE TO URETHROLITHIASIS?
(If "Yes," indicate type/severity (check all that apply)):
YES
NO
Bladder pain
Dysuria
Hematuria
Voiding dysfunction
Requirement for catheter drainage
Sudden painful interruption of urinary stream
Other, describe:
SECTION VI - BLADDER OR URETHRAL INFECTION
6. DOES THE VETERAN HAVE A HISTORY OF RECURRENT SYMPTOMATIC BLADDER OR URETHRAL INFECTIONS?
(If "Yes," complete Items 6A & 6B)
YES
NO
(i.e., relationship of recurrent symptomatic bladder or urethral infections to any condition in Section I, Diagnosis):
A. PROVIDE ETIOLOGY
B. IF THE VETERAN HAS HAD RECURRENT SYMPTOMATIC URETHRAL OR BLADDER INFECTIONS, INDICATE ALL TREATMENT MODALITIES THAT APPLY:
No treatment
(If checked, list medications used and indicate dates for courses of treatment over the past 12 months):
Long-term drug therapy
(If checked, indicate frequency of hospitalization):
Hospitalization
1 or 2 per year
> 2 per year
(If checked, indicate dates when drainage performed over past 12 months):
Drainage
(If checked, indicate types of treatment and medications used over past 12 months):
Continuous intensive management
(If checked, indicate types of treatment and medications used over past 12 months):
Intermittent intensive management
Other, describe:
Page 2
VA FORM 21-0960J-4, SEP 2016
ADVERTISEMENT
0 votes
Related Articles
Related forms
Va Form 21-0960j-4 - Urinary Tract (including Bladder And Urethra) Conditions (excluding Male Reproductive System) Disability Benefits Questionnaire
Legal
Form Sp-41 - Application For Vehicle License Plates And/or Placard For Persons With A Disability - New Jersey
Legal
Va Form 21-0960g-7 - Stomach And Duodenal Conditions (not Including Gerd Or Esophageal Disorders) Disability Benefits Questionnaire
Legal
Related Categories
Parent category: Legal