Va Form 21-0960b-2 - Hematologic And Lymphatic Conditions, Including Leukemia Disability Benefits Questionnaire Page 3

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SECTION V - FINDINGS, SIGNS AND SYMPTOMS

5. DOES THE VETERAN CURRENTLY HAVE ANY FINDINGS, SIGNS AND SYMPTOMS DUE TO A HEMATOLOGIC OR LYMPHATIC DISORDER

OR TO TREATMENT FOR A HEMATOLOGIC OR LYMPHATIC DISORDER?

YES

IF YES, CHECK ALL THAT APPLY:

Weakness

If checked, describe:

Easy fatigability

If checked, describe:

Light-headedness

If checked, describe:

Shortness of breath

If checked, describe:

Headaches

If checked, describe:

Dyspnea on mild exertion

If checked, describe:

Dyspnea at rest

If checked, describe:

Tachycardia

If checked, describe:

Syncope

If checked, describe:

Cardiomegaly

High output congestive heart failure

Other, describe:

SECTION VI - RECURRING INFECTIONS

6. DOES THE VETERAN CURRENTLY HAVE RECURRING INFECTIONS ATTRIBUTABLE TO ANY CONDITIONS, COMPLICATIONS OR RESIDUALS OF TREATMENT

FOR A HEMATOLOGIC OR LYMPHATIC DISORDER?

YES

IF YES, INDICATE FREQUENCY OF INFECTIONS OVER 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

SECTION VII - POLYCYTHEMIA VERA

7. DOES THE VETERAN HAVE POLYCYTHEMIA VERA?

YES

IF YES, CHECK ALL THAT APPLY:

Stable with or without continuous medication

Requiring phlebotomy

Requiring myelosuppressant treatment

Other, describe:

NOTE: If there are complications due to polycythemia vera such as hypertension, gout, stroke or thrombotic disease, ALSO complete appropriate Questionnaire for

each condition.

SECTION VIII - SICKLE CELL ANEMIA

8. DOES THE VETERAN HAVE SICKLE CELL ANEMIA?

YES

IF YES, CHECK ALL THAT APPLY:

Asymptomatic

In remission

With identifiable organ impairment

Following repeated hemolytic sickling crises with continuing impairment of health

Painful crises several times a year

Repeated painful crises, occurring in skin, joints, bones or any major organs

With anemia, thrombosis and infarction