Va Form 21-0960a-1 - Ischemic Heart Disease (Ihd) Disability Benefits Questionnaire Page 2

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION III - CONGESTIVE HEART FAILURE (CHF) (Continued)

3C. IF THE VETERAN'S CHF IS NOT CHRONIC, HAS THE VETERAN HAD MORE THAN ONE EPISODE OF ACUTE CHF IN THE PAST YEAR?

YES

If "Yes," provide name of treatment facility:

Date of most recent episode of CHF:

SECTION IV - CARDIAC FUNCTIONAL ASSESSMENT

4A. HAS A DIAGNOSTIC EXERCISE TEST BEEN CONDUCTED?

YES

If "Yes," provide level of METS the veteran can perform as shown by diagnostic exercise testing:

Date of most recent test:

4B. IF EXERCISE METs TESTING WAS NOT COMPLETED BECAUSE IT IS NOT REQUIRED AS PART OF THE VETERAN'S TREATMENT PLAN, COMPLETE THE

FOLLOWING METs TEST BASED ON THE VETERAN'S RESPONSES:

(Check all symptoms that apply)

Lowest level of activity at which veteran reports symptoms

DYSPNEA

FATIGUE

ANGINA

DIZZINESS

SYNCOPE

This METs Level has been found to be consistent with activities such as:

(This METs level has been found to be consistent with activities such as

1-3 METs

(This METs level has been found to be consistent with

>7-10 METs

eating, dressing, taking a shower, slow walking (2 mph) for 1-2 blocks)

activities such as climbing stairs quickly, moderate bicycling, sawing

wood, jogging (6 mph)

(This METs level has been found to be consistent with activities such as

>3-5 METs

light yard work (weeding), mowing lawn (power mower), brisk walking (4 mph)

Veteran denies experiencing above symptoms with any level of physical

activity

(This METs level has been found to be consistent with activities such as

>5-7 METs

golfing (without cart), mowing lawn (push mower), heavy yard work (digging)

SECTION V - DIAGNOSTIC TESTING

NOTE: Determination of cardiac hypertrophy/dilatation is required; the suggested order of testing for cardiac hypertrophy/dilatation is EKG, then chest x-ray (PA and

lateral), then echocardiogram. Echocardiogram is only necessary if the other two tests are negative. A limited echocardiogram, if available, is appropriate to determine

if cardiac hypertrophy/dilatation is present by measuring only left ventricular dimension, wall thickness and ejection fraction.

5A. IS THERE EVIDENCE OF CARDIAC HYPERTROPHY OR DILATATION?

YES

(Provide most recent test only)

5B. DIAGNOSTIC TEST AND DATE GIVEN

EKG - Date of EKG:

CHEST X-RAY - Date of chest x-ray:

ECHOCARDIOGRAM - Date of echocardiogram:

OTHER STUDY (Specify):

(Date):

5C. LEFT VENTRICULAR EJECTION FRACTION (LVEF), IF KNOWN:

DATE OF TEST:

(If LVEF testing is not of record, but available medical information sufficiently reflects the severity of the veteran's cardiovascular condition, LVEF testing is not

required)

SECTION VI - FUNCTIONAL IMPACT AND REMARKS

6. DOES THE VETERAN'S IHD IMPACT THE VETERAN'S ABILITY TO WORK?

(If "Yes," describe impact, providing one or more examples)

YES

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VA FORM 21-0960A-1, JUN 2017