Va Form 21-0960b-2 - Hematologic And Lymphatic Conditions, Including Leukemia Disability Benefits Questionnaire

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OMB Approved No. 2900-0779
Respondent Burden: 15 minutes
HEMATOLOGIC AND LYMPHATIC CONDITIONS, INCLUDING LEUKEMIA
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
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 consider the information you
provide on this questionnaire as part of their evaluation in processing the veteran's claim.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH A HEMATOLOGIC OR LYMPHATIC CONDITION?
YES
NO
(check all that apply):
IF YES, SELECT THE VETERAN'S CONDITION(S)
Acute lymphocytic leukemia (ALL)
ICD CODE:
DATE OF DIAGNOSIS:
Acute myelogenous leukemia (AML)
ICD CODE:
DATE OF DIAGNOSIS:
Chronic myelogenous leukemia (CML)
ICD CODE:
DATE OF DIAGNOSIS:
Chronic lymphocytic leukemia (CLL)
ICD CODE:
DATE OF DIAGNOSIS:
ICD CODE:
DATE OF DIAGNOSIS:
Hodgkin's disease
Non-Hodgkin's lymphoma
ICD CODE:
DATE OF DIAGNOSIS:
Multiple myeloma
ICD CODE:
DATE OF DIAGNOSIS:
Myelodysplastic syndrome
ICD CODE:
DATE OF DIAGNOSIS:
Plasmacytoma
ICD CODE:
DATE OF DIAGNOSIS:
(such as anemia of chronic disease, aplastic anemia, hemolytic
Anemia
anemia, iron or vitamin-deficient anemias, thalassemias,
myelophthisic anemia, etc.)
ICD CODE:
DATE OF DIAGNOSIS:
Thrombocytopenia
ICD CODE:
DATE OF DIAGNOSIS:
Polycythemia vera
ICD CODE:
DATE OF DIAGNOSIS:
Sickle cell anemia
ICD CODE:
DATE OF DIAGNOSIS:
Splenectomy
ICD CODE:
DATE OF DIAGNOSIS:
Hairy cell or other B-cell leukemia: if checked, complete VA Form 21-0960B-1, Hairy Cell and other B-Cell Leukemias Disability Benefits Questionnaire
Other, specify
Other diagnosis #1:
ICD CODE:
DATE OF DIAGNOSIS:
Other diagnosis #2:
ICD CODE:
DATE OF DIAGNOSIS:
Other diagnosis #3:
ICD CODE:
DATE OF DIAGNOSIS:
1B. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO HEMATOLOGIC OR LYMPHATIC CONDITION(S), LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
(Brief summary):
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S HEMATOLOGIC OR LYMPHATIC CONDITION
2B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF A HEMATOLOGIC OR LYMPHATIC CONDITION, INCLUDING ANEMIA OR THROMBOCYTOPENIA
CAUSED BY TREATMENT FOR A HEMATOLOGIC OR LYMPHATIC CONDITION?
YES
NO
IF YES, LIST ONLY THOSE MEDICATIONS REQUIRED FOR CONTROL OF THE VETERAN'S HEMATOLOGIC OR LYMPHATIC CONDITION, INCLUDING ANEMIA OR
THROMBOCYTOPENIA CAUSED BY TREATMENT FOR A HEMATOLOGIC OR LYMPHATIC CONDITION. PROVIDE THE NAME OF THE MEDICATION AND THE
CONDITION THE MEDICATION IS USED TO TREAT:
2C. INDICATE THE STATUS OF THE PRIMARY HEMATOLOGIC OR LYMPHATIC CONDITION:
ACTIVE
REMISSION
NOT APPLICABLE
VA FORM
21-0960B-2
SUPERSEDES VA FORM 21-0960B-2, DEC 2010,
Page 1
OCT 2012
WHICH WILL NOT BE USED.

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