Va Form 21-0960i-6 - Tuberculosis Disability Benefits Questionnaire Page 3
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4SECTION VI - DIAGNOSTIC TESTING
NOTE: If test results are in the medical record and reflect the Veteran's current respiratory condition, repeat testing is not required.
6A. HAVE IMAGING STUDIES OR PROCEDURES BEEN PERFORMED?
YES
NO
IF YES, CHECK ALL THAT APPLY:
Chest x-ray
Date:
Results:
(MRI)
Magnetic resonance imaging
Date:
Results:
(CT)
Computerized axial tomography
Date:
Results:
(HRCT)
High resolution computed tomography to evaluate interstitial lung disease such as asbestosis
Date:
Results:
Other, specify:
Date:
Results:
(PFT)
6B. HAS PULMONARY FUNCTION TESTING
BEEN PERFORMED?
YES
NO
IF YES, DO PFT RESULTS REPORTED BELOW REFLECT THE VETERAN'S CURRENT PULMONARY FUNCTION?
YES
NO
6C. PULMONARY FUNCTION TESTING IS NOT REQUIRED IN ALL INSTANCES. IF PFTs HAVE NOT BEEN COMPLETED, PROVIDE REASON:
Veteran requires outpatient oxygen therapy
Veteran has had 1 or more episodes of acute respiratory failure
Veteran has been diagnosed with cor pulmonale, right ventricular hypertrophy or pulmonary hypertension
Veteran has had exercise capacity testing and results are 20 ml/kg/min or less
Other, describe:
6D. PFT RESULTS
Date:
Pre-bronchodilator:
Post-bronchodilator, if indicated:
FEV-1:
% predicted
FEV-1:
% predicted
FVC :
% predicted
FVC :
% predicted
FEV-1/FVC:
%
FEV-1/FVC:
%
DLCO:
% predicted
DLCO:
% predicted
6E. WHICH TEST RESULT MOST ACCURATELY REFLECTS THE VETERAN'S CURRENT PULMONARY FUNCTION?
FEV-1
FEV-1/FVC
FVC
DLCO
6F. IF POST-BRONCHODILATOR TESTING HAS NOT BEEN COMPLETED, PROVIDE REASON:
Pre-bronchodilator results are normal
Post-bronchodilator testing not indicated for veteran's condition
Post-bronchodilator testing not indicated in veteran's particular case
If checked, provide reason:
Other, describe:
(DLCO)
6G. IF DIFFUSION CAPACITY OF THE LUNG FOR CARBON MONOXIDE BY THE SINGLE BREATH METHOD
TESTING HAS NOT BEEN COMPLETED,
PROVIDE REASON:
Not indicated for Veteran's condition
Not indicated in Veteran's particular case
Not valid for Veteran's particular case
Other, describe:
6H. DOES THE VETERAN HAVE MULTIPLE RESPIRATORY CONDITIONS?
YES
NO
IF YES, LIST CONDITIONS AND INDICATE WHICH CONDITION IS PREDOMINANTLY RESPONSIBLE FOR THE LIMITATION IN PULMONARY FUNCTION, IF ANY
LIMITATION IS PRESENT:
6I. HAS EXERCISE CAPACITY TESTING BEEN PERFORMED?
YES
NO
IF YES, COMPLETE THE FOLLOWING:
Maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation)
Maximum oxygen consumption of 15-20 ml/kg/min (with cardiac or respiratory limit)
Page 3
VA FORM 21-0960I-6, OCT 2012
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