Va Form 21-0960j-2 - Male Reproductive Organ Conditions Disability Benefits Questionnaire Page 2
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6SECTION III - VOIDING DYSFUNCTION
3A. DOES THE VETERAN HAVE A VOIDING DYSFUNCTION?
(If yes, complete Items 3B thru 3E)
YES
NO
(If yes, provide etiology of voiding dysfunction):
3B. DOES THE VOIDING DYSFUNCTION CAUSE URINE LEAKAGE?
YES
NO
(check one):
Indicate severity
Does not require the wearing of absorbent material
Requires absorbent material which must be changed less than 2 times per day
Requires absorbent material which must be changed 2 to 4 times per day
Requires absorbent material which must be changed more than 4 times per day
Other, describe:
3C. DOES THE VOIDING DYSFUNCTION REQUIRE THE USE OF AN APPLIANCE?
YES
NO
(If yes, describe the appliance):
3D. DOES THE VOIDING DYSFUNCTION CAUSE INCREASED URINARY FREQUENCY?
YES
NO
(If yes, check all that apply):
Daytime voiding interval between 2 and 3 hours
Nighttime awakening to void 2 times
Daytime voiding interval between 1 and 2 hours
Nighttime awakening to void 3 to 4 times
Daytime voiding interval less than 1 hour
Nighttime awakening to void 5 or more times
3E. DOES THE VOIDING DYSFUNCTION CAUSE SIGNS OR SYMPTOMS OF OBSTRUCTED VOIDING?
YES
NO
(If yes, check all that apply):
Hesitancy
If checked, is hesitancy marked?
YES
NO
Slow or weak stream
If checked, is stream markedly slow or weak?
YES
NO
Decreased force of stream
If checked, is force of stream markedly decreased?
YES
NO
Stricture disease requiring dilatation 1 to 2 times per year
Stricture disease requiring periodic dilatation every 2 to 3 months
Recurrent urinary tract infections secondary to obstruction
Uroflowmetry peak flow rate less than 10 cc/sec
Post void residuals greater than 150 cc
Urinary retention requiring intermittent catheterization
Urinary retention requiring continuous catheterization
Other, describe:
SECTION IV - URINARY TRACT/KIDNEY INFECTION
4A. DOES THE VETERAN HAVE A HISTORY OF RECURRENT SYMPTOMATIC URINARY TRACT OR KIDNEY INFECTIONS?
(If yes, complete Item 4B)
YES
NO
(If yes, provide etiology of recurrent urinary tract or kidney infections):
(check all that apply):
4B. INDICATE ALL TREATMENT MODALITIES USED FOR RECURRENT URINARY TRACT OR KIDNEY INFECTIONS
No treatment
Long-term drug therapy
If checked, list medications used and indicate dates for courses of treatment over the past 12 months:
Page 2
VA FORM 21-0960J-2, OCT 2012
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