Va Form 21-0960j-2 - Male Reproductive Organ Conditions Disability Benefits Questionnaire
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6OMB Control No. 2900-0779
Respondent Burden: 15 minutes
MALE REPRODUCTIVE ORGAN CONDITIONS
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 EVER BEEN DIAGNOSED WITH ANY CONDITIONS OF THE MALE REPRODUCTIVE SYSTEM?
(If "Yes," complete Item 1B)
YES
NO
(check all that apply)
1B. INDICATE DIAGNOSES:
Erectile dysfunction
ICD code:
Date of diagnosis:
(e.g., Peyronie's)
Penis, deformity
ICD code:
Date of diagnosis:
Testis, atrophy, one or both
ICD code:
Date of diagnosis:
Testis, removal, one or both
ICD code:
Date of diagnosis:
Epididymitis, chronic
ICD code:
Date of diagnosis:
Epididymo-orchitis, chronic
ICD code:
Date of diagnosis:
Prostate injury
ICD code:
Date of diagnosis:
(BPH)
Prostate hypertrophy
ICD code:
Date of diagnosis:
Prostatitis, chronic
ICD code:
Date of diagnosis:
(as addressed in items 3–6)
ICD code:
Date of diagnosis:
Prostate surgical residuals
Neoplasms of the male reproductive system
ICD code:
Date of diagnosis:
(specify
Other male reproductive system condition
diagnosis, providing only diagnoses that pertain to the
male reproductive system)
Other diagnosis #1:
ICD code:
Date of diagnosis:
Other diagnosis #2:
ICD code:
Date of diagnosis:
1C. IF THERE ARE ANY ADDITIONAL DIAGNOSES THAT PERTAIN TO THE MALE REPRODUCTIVE ORGAN CONDITIONS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
(brief summary):
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S MALE REPRODUCTIVE ORGAN CONDITION(S)
2B. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING CONTINUOUS MEDICATION FOR THE DIAGNOSED CONDITION?
YES
NO
List medications taken for the male reproductive organ condition:
2C. HAS THE VETERAN HAD AN ORCHIECTOMY?
YES
NO
Indicate testicle removed:
Right
Left
Both
Indicate reason for removal:
Undescended
Congenitally underdeveloped
Other, provide reason for removal:
VA FORM
SUPERSEDES VA FORM 21-0960J-2, DEC 2010,
21-0960J-2
Page 1
OCT 2012
WHICH WILL NOT BE USED.
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