Va Form 21-0960g-3 - Intestinal Conditions (Other Than Surgical Or Infectious) (Including Irritable Bowel Syndrome, Crohn'S Disease, Ulcerative Colitis, And Diverticulitis) Disability Benefits Questionnaire
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4OMB Control No. 2900-0778
Respondent Burden: 15 minutes
INTESTINAL CONDITIONS (OTHER THAN SURGICAL OR INFECTIOUS)
(INCLUDING IRRITABLE BOWEL SYNDROME, CROHN'S DISEASE, ULCERATIVE COLITIS,
AND DIVERTICULITIS) 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
(other than surgical or infectious)
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH AN INTESTINAL CONDITION
?
(If "Yes," complete Item 1B)
YES
NO
(Check all that apply)
1B. SELECT THE VETERAN'S CONDITION
IRRITABLE BOWEL SYNDROME
ICD code:
Date of diagnosis:
SPASTIC COLITIS
ICD code:
Date of diagnosis:
MUCOUS COLITIS
ICD code:
Date of diagnosis:
CHRONIC DIARRHEA
ICD code:
Date of diagnosis:
ULCERATIVE COLITIS
ICD code:
Date of diagnosis:
CROHN'S DISEASE
ICD code:
Date of diagnosis:
CHRONIC ENTERITIS
ICD code:
Date of diagnosis:
CHRONIC ENTEROCOLITIS
ICD code:
Date of diagnosis:
CELIAC DISEASE
ICD code:
Date of diagnosis:
DIVERTICULITIS
ICD code:
Date of diagnosis:
INTESTINAL NEOPLASM
ICD code:
Date of diagnosis:
PERITONEAL ADHESIONS ATTRIBUTABLE TO DIVERTICULITIS.
ICD code:
Date of diagnosis:
IF CHECKED, ALSO COMPLETE VA Form 21-0960G-6, Peritoneal
Adhesions Disability Benefits Questionnaire
OTHER NON-SURGICAL OR NON-INFECTIOUS INTESTINAL CONDITIONS:
OTHER DIAGNOSIS #1:
ICD code:
Date of diagnosis:
OTHER DIAGNOSIS #2:
ICD code:
Date of diagnosis:
(other than surgical or infectious)
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO INTESTINAL CONDITIONS
, LIST USING THE FORMAT IN ITEM 1B
SECTION II - MEDICAL HISTORY
(including onset and course)
(Brief summary)
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S INTESTINAL CONDITION
2B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF THE VETERAN'S INTESTINAL CONDITION?
YES
NO
IF YES, LIST ONLY THOSE MEDICATIONS REQUIRED FOR THE INTESTINAL CONDITION
2C. HAS THE VETERAN HAD SURGICAL TREATMENT FOR AN INTESTINAL CONDITION?
YES
NO
IF YES, ALSO COMPLETE VA FORM 21-0960G-4, INTESTINAL SURGERY (BOWEL RESECTION, COLOSTOMY, ILEOSTOMY) DISABILITY BENEFITS
QUESTIONNAIRE
VA FORM
21-0960G-3
Page 1
SUPERSEDES VA FORM 21-0960G-3, FEB 2011,
OCT 2012
WHICH WILL NOT BE USED.
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