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

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SECTION III - TREATMENT
3. HAS THE VETERAN COMPLETED ANY TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING ANY TREATMENT FOR ANY HEMATOLOGIC OR
LYMPHATIC CONDITION, INCLUDING LEUKEMIA?
YES
NO; WATCHFUL WAITING
(Check all that apply):
IF YES, INDICATE TYPE OF TREATMENT THE VETERAN IS CURRENTLY UNDERGOING OR HAS COMPLETED
Treatment completed; currently in watchful waiting status
Bone marrow transplant, if checked provide:
Date of hospital admission and location:
Date of hospital discharge after transplant:
Surgery, if checked describe:
Date(s) of surgery:
Radiation therapy, if checked provide:
Date of most recent treatment:
Date of completion of treatment or anticipated date of completion:
Antineoplastic chemotherapy, if checked provide:
Date of most recent treatment:
Date of completion of treatment or anticipated date of completion:
Other therapeutic procedure
If checked, describe procedure:
Date of most recent procedure:
Other therapeutic treatment
If checked, describe treatment:
Date of completion of treatment or anticipated date of completion:
(Primary, secondary, idiopathic and immune)
SECTION IV - ANEMIA AND THROMBOCYTOPENIA
4A. DOES THE VETERAN HAVE ANEMIA OR THROMBOCYTOPENIA, INCLUDING THAT CAUSED BY TREATMENT FOR A HEMATOLOGIC OR LYMPHATIC
CONDITION?
YES
NO
IF YES, COMPLETE THE FOLLOWING:
4B. DOES THE VETERAN HAVE ANEMIA?
YES
NO
IF YES, IS THE ANEMIA CAUSED BY TREATMENT FOR ANOTHER HEMATOLOGIC OR LYMPHATIC CONDITION?
YES
NO
IF YES, PROVIDE THE NAME OF THE OTHER HEMATOLOGIC OR LYMPHATIC CONDITION CAUSING THE SECONDARY ANEMIA:
4C. DOES THE VETERAN HAVE THROMBOCYTOPENIA?
YES
NO
IF YES, IS THE THROMBOCYTOPENIA CAUSED BY TREATMENT FOR ANOTHER HEMATOLOGIC OR LYMPHATIC CONDITION?
YES
NO
IF YES, PROVIDE THE NAME OF THE OTHER HEMATOLOGIC OR LYMPHATIC CONDITION CAUSING THE SECONDARY THROMBOCYTOPENIA:
IF YES, CHECK ALL THAT APPLY:
Stable platelet count of 100,000 or more
Stable platelet count between 70,000 and 100,000
Platelet count between 20,000 and 70,000
Platelet count of less than 20,000
With active bleeding
Other, describe:
4D. DOES THE VETERAN HAVE ANY COMPLICATIONS OR RESIDUALS OF TREATMENT REQUIRING TRANSFUSION OF PLATELETS OR RED BLOOD CELLS?
YES
NO
IF YES, INDICATE FREQUENCY OF TRANSFUSIONS IN THE PAST 12 MONTHS:
None
At least once per year but less than once every 3 months
At least once every 3 months
At least once every 6 weeks
Page 2
VA FORM 21-0960B-2, OCT 2012

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