Va Form 21-0960h-2 - Rectum And Anus Conditions (Including Hemorrhoids) Disability Benefits Questionnaire
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3OMB Approved No. 2900-0778
Respondent Burden: 15 minutes
RECTUM AND ANUS CONDITIONS (INCLUDING HEMORRHOIDS)
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 HAD ANY CONDITION OF THE RECTUM OR ANUS?
(If "Yes," complete Item 1B)
YES
NO
(check all that apply):
1B. SELECT THE VETERAN'S CONDITION
Internal or external hemorrhoids
ICD code:
Date of diagnoses:
Anal/perianal fistula
ICD code:
Date of diagnoses:
Rectal stricture
ICD code:
Date of diagnoses:
Impairment of rectal sphincter control
ICD code:
Date of diagnoses:
Rectal prolapse
ICD code:
Date of diagnoses:
Pruritus ani
ICD code:
Date of diagnoses:
Other, specify below:
Other diagnoses #1:
ICD code:
Date of diagnoses:
Other diagnoses #2:
ICD code:
Date of diagnoses:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO RECTUM OR ANUS CONDITIONS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
(brief summary):
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S RECTUM OR ANUS CONDITIONS
2B. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING CONTINUOUS MEDICATION FOR THE DIAGNOSED CONDITIONS?
YES
NO
IF YES, LIST ONLY THOSE MEDICATIONS USED FOR THE DIAGNOSED CONDITIONS:
SECTION III - SIGNS AND SYMPTOMS
3. DOES THE VETERAN HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO ANY OF THE DIAGNOSES IN SECTION 1, DIAGNOSIS?
YES
NO
IF YES, SPECIFY THE CONDITIONS BELOW AND COMPLETE THE APPROPRIATE SECTIONS.
INTERNAL OR EXTERNAL HEMORRHOIDS
(check all that apply):
IF CHECKED, INDICATE SEVERITY
Mild or moderate
If checked, describe:
Large or thrombotic, irreducible, with excessive redundant tissue, evidencing frequent recurrences
With persistent bleeding
With secondary anemia
If checked, provide hemoglobin/hematocrit in Section VI, Diagnostic Testing
With fissures
Other, describe:
ANAL/PERIANAL FISTULA
(check all that apply):
IF CHECKED, INDICATE SEVERITY
Slight impairment of sphincter control, without leakage
If checked, describe:
Leakage necessitates wearing of pad
Constant slight leakage
Occasional moderate leakage
Occasional involuntary bowel movements
21-0960H-2
VA FORM
SUPERSEDES VA FORM 21-0960H-2, FEB 2011,
Page 1
OCT 2012
WHICH WILL NOT BE USED.
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