Form 21-0960j-4 - Urinary Tract (Including Bladder And Urethra) Conditions (Excluding Male Reproductive System) Disability Benefits Questionnaire Page 3
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4PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
SECTION VII - OTHER BLADDER/URETHRAL CONDITIONS
7. DOES THE VETERAN NOW HAVE OR HAS THE VETERAN EVER HAD A BLADDER OR URETHRAL FISTULA, STRICTURE, NEUROGENIC BLADDER, BLADDER
INJURY OR OTHER BLADDER SURGERY?
(If "Yes," complete Items 7A thru 7E):
YES
NO
A. DOES THE VETERAN HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO A BLADDER OR URETHRAL FISTULA?
YES
NO
(If "Yes," check all that apply):
(urine leakage, obstructed voiding)
Voiding dysfunction
Requirement for catheter drainage
(cystitis or urethritis)
Infection
Impaired kidney function
(NOTE: If veteran has impaired kidney function, also complete VA Form 21-0960J-1, Kidney Conditions (Nephrology) Disability Benefits Questionnaire)
Other, describe:
B. HAS THE VETERAN HAD SURGERY FOR A BLADDER OR URETHRAL FISTULA?
YES
NO
(If "Yes," indicate surgical treatment):
None
(If checked, provide date of treatment and name of treatment facility:
)
Resection or closure of fistula
(If checked, provide date of treatment and name of treatment facility:
)
Urinary diversion
(If checked, provide date of treatment and name of treatment facility:
)
Partial bladder resection
(If checked, provide date of treatment and name of treatment facility:
)
Other, describe:
C. DOES THE VETERAN HAVE A NEUROGENIC OR A SEVERELY DYSFUNCTIONAL BLADDER?
(If "Yes," describe):
YES
NO
D. DOES THE VETERAN HAVE A BLADDER INJURY?
(If "Yes," describe):
YES
NO
E. HAS THE VETERAN HAD OTHER BLADDER SURGERY?
(If "Yes," describe):
YES
NO
SECTION VIII - TUMORS AND NEOPLASMS
8. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DIAGNOSIS?
(If "Yes," complete Items 8A through 8D)
YES
NO
A. IS THE NEOPLASM
BENIGN
MALIGNANT
B. HAS THE VETERAN COMPLETED TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT NEOPLASM OR
METASTASES?
YES
NO; WATCHFUL WAITING
(If "Yes," indicate type of treatment the veteran is currently undergoing or has completed (check all that apply)):
Treatment completed; currently in watchful waiting status
(If checked, describe:
and provide date(s) of surgery:
Surgery
(If checked, provide date of most recent treatment:
and provide date of completion of treatment or anticipated date of
Radiation therapy
completion:
)
(If checked, provide date of most recent treatment:
and provide date of completion of treatment or
Antineoplastic chemotherapy
anticipated date of completion:
)
(If checked, describe procedure:
and provide date of most recent
Other therapeutic procedure
procedure:
)
(If checked, describe treatment:
and provide date
Other therapeutic treatment
of completion of treatment or anticipated date of completion:
)
(including metastases)
C. DOES THE VETERAN CURRENTLY HAVE ANY RESIDUAL CONDITIONS OR COMPLICATIONS DUE TO THE NEOPLASM
OR ITS
TREATMENT, OTHER THAN THOSE ALREADY DOCUMENTED ON THIS QUESTIONNAIRE?
(If "Yes," list residual conditions and complications (brief summary)):
YES
NO
D. IF THERE ARE ADDITIONAL BENIGN OR MALIGNANT NEOPLASMS OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DIAGNOSIS,
DESCRIBE USING THE ABOVE FORMAT:
Page 3
VA FORM 21-0960J-4, SEP 2016
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