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 3

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SECTION VII - TUMORS AND NEOPLASMS
7A. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DIAGNOSIS?
(If "Yes," complete questions 7B thru 7E)
YES
NO
7B. IS THE NEOPLASM?
BENIGN
MALIGNANT
7C. HAS THE VETERAN COMPLETED TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT NEOPLASM
OR METASTASES?
YES
NO, WATCHFUL WAITING
(Check all that apply)
IF YES, INDICATE TYPE OF TREATMENT THE VETERAN IS CURRENTLY UNDERGOING OR HAS COMPLETED
Treatment completed, currently in watchful waiting status
(If checked, describe)
Surgery
Date(s) of surgery:
Radiation therapy
Date of most recent treatment:
Date of completion of treatment or anticipated date of completion:
Antineoplastic chemotherapy
Date of most recent treatment:
Date of completion of treatment or anticipated date of completion:
(If checked, describe procedure)
Other therapeutic procedure
Date of most recent procedure:
(If checked, describe treatment
Other therapeutic treatment
)
Date of completion of treatment or anticipated date of completion
(including metastases)
7D. DOES THE VETERAN CURRENTLY HAVE ANY RESIDUAL CONDITIONS OR COMPLICATIONS DUE TO THE NEOPLASM
OR ITS
TREATMENT, OTHER THAN THOSE ALREADY DOCUMENTED IN ITEM 7C?
(Brief summary)
YES
NO
IF YES, LIST RESIDUAL CONDITIONS AND COMPLICATIONS
7E. IF THERE ARE ADDITIONAL BENIGN OR MALIGNANT NEOPLASMS OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN THE DIAGNOSIS SECTION,
DESCRIBE USING THE FORMAT IN ITEMS 7C AND 7D
SECTION VIII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
(surgical or otherwise)
8A. DOES THE VETERAN HAVE ANY SCARS
RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
SECTION I, 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.
8B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS?
YES
NO
(Brief summary)
IF YES, DESCRIBE
VA FORM 21-0960G-3, OCT 2012
Page 3

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