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 Page 2

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SECTION III - SIGNS AND SYMPTOMS
3. DOES THE VETERAN HAVE ANY SIGNS OR SYMPTOMS ATTRIBUTABLE TO ANY NON-SURGICAL NON-INFECTIOUS INTESTINAL CONDITION(S)?
(If "Yes," check all that apply)
YES
NO
(If checked, describe)
DIARRHEA
(If checked, describe)
ALTERNATING DIARRHEA AND CONSTIPATION
(If checked, describe)
ABDOMINAL DISTENSION
(If checked, provide hemoglobin/hematocrit in Section IX, Diagnostic Testing)
ANEMIA
(If checked, describe)
NAUSEA
(If checked, describe)
VOMITING
(If checked, describe)
OTHER
SECTION IV - SYMPTOM EPISODES, ATTACKS AND EXACERBATIONS
4. DOES THE VETERAN HAVE EPISODES OF BOWEL DISTURBANCE WITH ABDOMINAL DISTRESS, OR EXACERBATIONS OR ATTACKS OF THE INTESTINAL
CONDITION?
YES
NO
(Check all that apply)
IF YES, INDICATE SEVERITY AND FREQUENCY
Episodes of bowel disturbance with abdominal distress
If checked, indicate frequency
Occasional episodes
Frequent episodes
More or less constant abdominal distress
Episodes of exacerbations and/or attacks of the intestinal condition. If checked, describe typical exacerbation or attack
Indicate number of exacerbations and/or attacks in past 12 months
1
2
3
4
5
6
7 or more
SECTION V - WEIGHT LOSS
(other than surgical or infectious condition)?
5. DOES THE VETERAN HAVE WEIGHT LOSS ATTRIBUTABLE TO AN INTESTINAL CONDITION
YES
NO
If "Yes," provide veteran's baseline weight:
and current weight:
(For VA purposes, baseline weight is the average weight for 2-year period preceding onset of disease)
SECTION VI - MALNUTRITION, COMPLICATIONS AND OTHER GENERAL HEALTH EFFECTS
6. DOES THE VETERAN HAVE MALNUTRITION, SERIOUS COMPLICATIONS OR OTHER GENERAL HEALTH EFFECTS ATTRIBUTABLE TO THE INTESTINAL
CONDITION?
(If "Yes," indicate findings) (Check all that apply)
YES
NO
Health only fair during remissions
General debility
(Describe)
Serious complication such as liver abscess
YES
NO
Malnutrition. If checked, is malnutrition marked?
(Describe)
Other
NOTE: Complete additional Disability Benefits Questionnaire(s) for complications noted, as deemed appropriate (schedule with appropriate provider).
VA FORM 21-0960G-3, OCT 2012
Page 2

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