Fillable Va Form 21-0960g-6 - Peritoneal Adhesions Disability Benefits Questionnaire printable pdf download

OMB Control No. 2900-0778

Respondent Burden: 15 minutes

PERITONEAL ADHESIONS 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 BEEN DIAGNOSED WITH A PERITONEAL ADHESION?

(If "Yes," complete Item 1B)

YES

1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO PERITONEAL ADHESIONS:

Diagnosis # 1 -

ICD code -

Date of diagnosis -

Diagnosis # 2 -

ICD code -

Date of diagnosis -

Diagnosis # 3 -

ICD code -

Date of diagnosis -

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO PERITONEAL ADHESIONS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY

(including cause, onset and course)

(brief summary)

2A. DESCRIBE THE HISTORY

OF THE VETERAN'S PERITONEAL ADHESIONS

2B. DOES THE VETERAN HAVE A HISTORY OF OPERATIVE, TRAUMATIC OR INFECTIOUS (INTRAABDOMINAL) PROCESS?

YES

(check all that apply)

IF YES, INDICATE ORGAN(S) AFFECTED

STOMACH

GALL BLADDER

LIVER

SMALL INTESTINES

LARGE INTESTINES

OTHER:

2C. HAS THE VETERAN HAD SEVERE PERITONITIS, RUPTURED APPENDIX, PERFORATED ULCER OR OPERATION WITH DRAINAGE?

YES

2D. DOES THE VETERAN HAVE A CURRENT DIAGNOSIS OF PERITONEAL ADHESIONS?

YES

(check all that apply)

IF YES, INDICATE ORGAN(S) AFFECTED

STOMACH

GALL BLADDER

LIVER

SMALL INTESTINES

LARGE INTESTINES

OTHER:

2E. DOES THE VETERAN HAVE ANY SIGNS AND/OR SYMPTOMS DUE TO PERITONEAL ADHESIONS?

(check all that apply)

YES

IF YES, INDICATE SIGNS AND SYMPTOMS:

(on X-ray)

NAUSEA

DELAYED MOTILITY OF BARIUM MEAL

PARTIAL OR COMPLETE BOWEL OBSTRUCTION

VOMITING

REFLEX DISTURBANCES

ABDOMINAL DISTENTION

(perhaps alternating with diarrhea)

PAIN

CONSTIPATION

2F. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING CONTINUOUS MEDICATION FOR THE DIAGNOSED CONDITION?

YES

LIST MEDICATIONS:

SECTION III - SEVERITY OF MANIFESTATIONS OF PERITONEAL ADHESIONS

NOTE - Indicate level of severity of signs and/or symptoms, if present: (Check all that apply in each level)

3A. LEVEL IV

DEFINITE PARTIAL

FREQUENT EPISODES OF SEVERE

FREQUENT EPISODES

SEVERE

OBSTRUCTION SHOWN BY X-RAY

COLIC DISTENSION

OF SEVERE NAUSEA

OF SEVERE VOMITING

PROLONGED EPISODES OF SEVERE COLIC DISTENSION

PROLONGED EPISODES OF SEVERE NAUSEA

PROLONGED EPISODES OF SEVERE VOMITING

3B. LEVEL III

LESS FREQUENT

PARTIAL OBSTRUCTION MANIFESTED BY

LESS PROLONGED

MODERATELY SEVERE

EPISODES OF PAIN

DELAYED MOTILITY OF BARIUM MEAL

EPISODES OF PAIN

3C. LEVEL II

PULLING PAIN ON ATTEMPTING

OCCASIONAL

OCCASIONAL EPISODES

ABDOMINAL

MODERATE

WORK OR AGGRAVATED BY

EPISODES

OF CONSTIPATION

DISTENSION

MOVEMENTS OF THE BODY

OF COLIC PAIN

OF NAUSEA

(Perhaps alternating with diarrhea)

3D. LEVEL I

MILD, DESCRIBE:

VA FORM

SUPERSEDES VA FORM 21-0960G-6, FEB 2011,

21-0960G-6

Page 1

OCT 2012

WHICH WILL NOT BE USED.

Va Form 21-0960g-6 - Peritoneal Adhesions Disability Benefits Questionnaire

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