Va Form 21-0960c-5 - Central Nervous System And Neuromuscular Diseases Disability Benefits Questionnaire Page 4
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9SECTION III - CONDITIONS, SIGNS AND SYMPTOMS (Continued)
3E. DOES THE VETERAN HAVE ANY BOWEL FUNCTIONAL IMPAIRMENT?
YES
NO
IF YES, CHECK ALL THAT APPLY:
Slight impairment of sphincter control, without leakage
Constant slight impairment of sphincter control, or occasional moderate leakage
Occasional involuntary bowel movements, necessitating wearing of a pad
Extensive leakage and fairly frequent involuntary bowel movements
Total loss of bowel sphincter control
Chronic constipation
(describe)
Other bowel impairment
:
3F. DOES THE VETERAN HAVE VOIDING DYSFUNCTION CAUSING URINE LEAKAGE?
YES
NO
IF YES, CHECK ONE:
Does not require/does not use absorbent material
Requires absorbent material that is changed less than 2 times per day
Requires absorbent material that is changed 2 to 4 times per day
Requires absorbent material that is changed more than 4 times per day
3G. DOES THE VETERAN HAVE VOIDING DYSFUNCTION CAUSING SIGNS AND/OR SYMPTOMS OF URINARY FREQUENCY?
YES
NO
IF YES, CHECK ALL THAT APPLY:
Daytime voiding interval between 2 and 3 hours
Nighttime awakening to void 2 times
Daytime voiding interval between 1 and 2 hours
Nighttime awakening to void 3 to 4 times
Daytime voiding interval less than 1 hour
Nighttime awakening to void 5 or more times
3H. DOES THE VETERAN HAVE VOIDING DYSFUNCTION CAUSING FINDINGS, SIGNS AND/OR SYMPTOMS OF OBSTRUCTED VOIDING?
YES
NO
IF YES, CHECK ALL SIGNS AND SYMPTOMS THAT APPLY:
(If checked, is hesitancy marked?)
Hesitancy
Yes
No
(If checked, is stream markedly slow or weak?)
Slow or weak stream
Yes
No
(If checked, is force of stream markedly decreased?)
Decreased force of stream
Yes
No
Stricture disease requiring dilatation 1 to 2 times per year
Stricture disease requiring periodic dilatation every 2 to 3 months
Recurrent urinary tract infections secondary to obstruction
Uroflowmetry peak flow rate less than 10 cc/sec
Post void residuals greater than 150 cc
Urinary retention requiring intermittent or continuous catheterization
3I. DOES THE VETERAN HAVE VOIDING DYSFUNCTION REQUIRING THE USE OF AN APPLIANCE?
YES
NO
IF YES, DESCRIBE:
3J. DOES THE VETERAN HAVE A HISTORY OF RECURRENT SYMPTOMATIC URINARY TRACT INFECTIONS?
YES
NO
IF YES, CHECK ALL TREATMENTS THAT APPLY:
No treatment
Long-term drug therapy
(If checked, list medications used for urinary tract infection and indicate dates for courses of treatment over the past 12 months)
Hospitalization
(If checked, indicate frequency of hospitalization)
1 or 2 per year
More than 2 per year
Drainage
IF CHECKED, INDICATE DATES WHEN DRAINAGE PERFORMED OVER PAST 12 MONTHS:
(Description of management/treatment including dates of treatment)
Other management/treatment not listed above
:
Page 4
VA FORM 21-0960C-5, OCT 2012
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