Va Form 21-0960a-1 - Ischemic Heart Disease (Ihd) Disability Benefits Questionnaire

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OMB Approved No. 2900-0749
Respondent Burden: 15 minutes
Expiration Date: 06/30/2020
ISCHEMIC HEART DISEASE (IHD) 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 ON
REVERSE BEFORE COMPLETING 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 use the information you provide
on this questionnaire to process the Veteran's claim. VA reserves the right to confirm the authenticity of ALL DBQ's completed by private health care providers.
SECTION I - DIAGNOSIS
NOTE: IHD includes, but is not limited to, acute, sub-acute and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease
(including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina. IHD does not include hypertension or peripheral manifestations
of arteriosclerosis such as peripheral vascular disease or stroke, or any other condition that does not qualify within the generally accepted medical definition of
ischemic heart disease.
IHD encompasses any atherosclerotic heart disease resulting in clinically significant ischemia or requiring coronary revascularization.
(IHD)
1A. DOES THE VETERAN HAVE ISCHEMIC HEART DISEASE
?
YES
NO
NOTE: Provide only diagnoses that pertain to IHD
1B. DIAGNOSIS # 1 -
ICD CODE -
DATE OF DIAGNOSIS -
1C. DIAGNOSIS # 2 -
ICD CODE -
DATE OF DIAGNOSIS -
1D. DIAGNOSIS # 3 -
ICD CODE -
DATE OF DIAGNOSIS -
1E. IF ADDITIONAL DIAGNOSES THAT PERTAIN TO IHD, LIST USING ABOVE FORMAT
SECTION II - MEDICAL HISTORY
2A. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING CONTINUOUS MEDICATION FOR THE DIAGNOSED CONDITION?
YES
NO
2B. LIST MEDICATIONS PRESCRIBED FOR IHD-RELATED CONDITIONS:
(Check all that apply and provide treatment facility and treatment date)
2C. IS THERE A HISTORY OF:
(Check)
(Check)
CONDITION
YES
NO
TREATMENT FACILITY
DATE OF TREATMENT
PERCUTANEOUS CORONARY INTERVENTION
(PCI)
MYOCARDIAL INFARCTION
CORONARY BYPASS SURGERY
HEART TRANSPLANT
(If "Yes," is it as likely as not that the veteran's
heart transplant is due to IHD?)
YES
NO
IMPLANTED CARDIAC PACEMAKER
(If "Yes," is it as likely as not that the veteran's
pacemaker is due to IHD?)
YES
NO
IMPLANTED AUTOMATIC IMPLANTABLE
(If
CARDIOVERTER DEFIBRILLATOR (AICD)
"Yes," is it as likely as not that the veteran's
AICD is due to IHD?)
YES
NO
SECTION III - CONGESTIVE HEART FAILURE (CHF)
3A. DOES THE VETERAN HAVE CHF?
YES
NO
3B. IS THE VETERAN'S CHF CHRONIC?
YES
NO
VA FORM
SUPERSEDES VA FORM 21-0960A-1, JAN 2014,
21-0960A-1
Page 1
JUN 2017
WHICH WILL NOT BE USED.

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