Va Form 21-0960i-6 - Tuberculosis Disability Benefits Questionnaire Page 2
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SECTION III - PULMONARY TUBERCULOSIS
3B. DOES THE VETERAN HAVE ANY RESIDUAL FINDINGS, SIGNS AND/OR SYMPTOMS DUE TO PULMONARY TB?
YES
NO
IF YES, INDICATE RESIDUALS:
Emphysema
Dyspnea on exertion
Requires oxygen therapy
Episodes of acute respiratory failure
Moderately advanced lesions
(diagnosed at any time while the disease process was active)
Far advanced lesions
Pulmonary hypertension
Right ventricular hypertrophy
(right heart failure)
Cor pulmonale
Impairment of health
If checked, describe:
Other, describe:
3C. HAS THE VETERAN HAD THORACOPLASTY DUE TO TB?
YES
NO
Date of procedure:
IF YES, HAS THE VETERAN HAD RESECTION OF ANY RIBS INCIDENT TO THORACOPLASTY?
YES
NO
IF YES, INDICATE NUMBER OF RIBS INVOLVED:
1
2
3 or 4
5 or 6
More than 6
SECTION IV - NON-PULMONARY TB
4A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH NON-PULMONARY TUBERCULOSIS?
YES
NO
IF YES, CHECK ALL NON-PULMONARY TB CONDITIONS THAT APPLY:
Tuberculous pleurisy
Tuberculous peritonitis
Tuberculosis meningitis
Skeletal TB
Genitourinary TB
Gastrointestinal TB
Tuberculous lymphadenitis
Cutaneous TB
Ocular TB
Other, describe:
4B. FOR ALL CHECKED CONDITIONS, INDICATE WHETHER THE CONDITION IS ACTIVE OR INACTIVE; IF INACTIVE, PROVIDE DATE CONDITION
BECAME INACTIVE:
4C. DOES THE VETERAN HAVE ANY RESIDUALS FROM ANY OF THE NON-PULMONARY TB CONDITIONS?
YES
NO
IF YES, DESCRIBE:
ALSO COMPLETE APPROPRIATE QUESTIONNAIRES FOR THE SPECIFIC RESIDUAL CONDITIONS.
SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
(surgical or otherwise)
5A. DOES THE VETERAN HAVE ANY SCARS
RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
SECTION 1, DIAGNOSIS?
YES
NO
IF YES, ARE ANY OF THE SCARS PAINFUL AND/OR UNSTABLE, OR IS THE TOTAL AREA OF ALL RELATED SCARS GREATER THAN OR EQUAL TO 39 SQUARE CM
(6 square inches)
?
YES
NO
IF YES, ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT DISABILITY BENEFITS QUESTIONNAIRE.
5B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS?
YES
NO
(brief summary):
IF YES, DESCRIBE
Page 2
VA FORM 21-0960I-6, OCT 2012
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