Form 21-0960j-4 - Urinary Tract (Including Bladder And Urethra) Conditions (Excluding Male Reproductive System) Disability Benefits Questionnaire Page 4

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PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

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

(surgical or otherwise)

9A. DOES THE VETERAN HAVE ANY SCARS

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

DIAGNOSIS SECTION?

YES

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

6 square inches); OR ARE LOCATED ON THE HEAD, FACE, OR NECK?

YES

IF "YES," ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT DISABILITY BENEFITS QUESTIONNAIRE (DBQ).

IF "NO," PROVIDE LOCATION AND MEASUREMENTS OF SCAR IN CENTIMETERS.

LOCATION:__________________________________ MEASUREMENTS: Length_____________ cm X width _____________ cm.

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. It is not necessary to also complete a Scars/Disfigurement DBQ.

9B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS?

(If "Yes," describe (brief summary)):

YES

SECTION X - DIAGNOSTIC TESTING

NOTE: If diagnostic test results are in the medical record and reflect the veteran's current urinary tract condition, repeat testing is not required.

10. HAS THE VETERAN HAD DIAGNOSTIC TESTING AND IF SO, ARE THERE SIGNIFICANT FINDINGS AND/OR RESULTS?

(If "Yes," provide type of test or procedure, date and results - brief summary):

YES

SECTION XI - FUNCTIONAL IMPACT

11. DOES THE VETERAN'S CONDITION(S) OF THE BLADDER OR URETHRA IMPACT HIS OR HER ABILITY TO WORK?

(If "Yes," describe the impact of each of the veteran's bladder or urethra condition(s), providing one or more examples):

YES

SECTION XII - REMARKS

(If any):

12. REMARKS

SECTION XIII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.

13A. PHYSICIAN'S SIGNATURE

13B. PHYSICIAN'S PRINTED NAME

13C. DATE SIGNED

13E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER 13F. PHYSICIAN'S ADDRESS

13D. PHYSICIAN'S PHONE/FAX NUMBERS

NOTE - VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.

IMPORTANT - Physician please fax the completed form to:

(VA Regional Office FAX No.)

NOTE - A list of VA Regional Office FAX Numbers can be found at

or obtained by calling 1-800-827-1000.

PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of

Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the

United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and

personnel administration) as identified in the VA system of records, 58/VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA,

published in the Federal Register. Your obligation to respond is voluntary. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly

associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an

individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The

requested information is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701).

Information submitted is subject to verification through computer matching programs with other agencies.

RESPONDENT BURDEN: We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this information. We estimate

that you will need an average of 15 minutes to review the instructions, find the information, and complete the form. VA cannot conduct or sponsor a collection of information unless a valid

OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB

Internet Page at If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

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VA FORM 21-0960J-4, SEP 2016