Va Form 21-0960j-2 - Male Reproductive Organ Conditions Disability Benefits Questionnaire Page 3
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SECTION IV - URINARY TRACT/KIDNEY INFECTION
(check all that apply) (Continued):
4B. INDICATE ALL TREATMENT MODALITIES USED FOR RECURRENT URINARY TRACT OR KIDNEY INFECTIONS
Hospitalization
If checked, indicate frequency of hospitalization:
1 or 2 per year
>2 per year
Drainage
If checked, indicate dates when drainage performed over past 12 months:
Continuous intensive management
If checked, indicate types of treatment and medications used over past 12 months:
Intermittent intensive management
If checked, indicate types of treatment and medications used over past 12 months:
Other, describe:
SECTION V - ERECTILE DYSFUNCTION
5A. DOES THE VETERAN HAVE ERECTILE DYSFUNCTION?
(If yes, complete Items 5B and 5C)
YES
NO
(If yes, provide etiology of erectile dysfunction):
(at least a 50% probability)
5B. IF THE VETERAN HAS ERECTILE DYSFUNCTION, IS IT AS LIKELY AS NOT
ATTRIBUTABLE TO ONE OF THE DIAGNOSES IN
SECTION I, INCLUDING RESIDUALS OF TREATMENT FOR THIS DIAGNOSIS?
YES
NO
(If yes, specify the diagnosis to which the erectile dysfunction is as likely as not attributable):
5C. IF THE VETERAN HAS ERECTILE DYSFUNCTION, IS HE ABLE TO ACHIEVE AN ERECTION SUFFICIENT FOR PENETRATION AND EJACULATION
(without medication)?
YES
NO
(with medication)
IF NO, IS THE VETERAN ABLE TO ACHIEVE AN ERECTION SUFFICIENT FOR PENETRATION AND EJACULATION
?
YES
NO
SECTION VI - RETROGRADE EJACULATION
6A. DOES THE VETERAN HAVE RETROGRADE EJACULATION?
(If yes, complete Item 6B and provide etiology of retrograde ejaculation)
YES
NO
(If yes, provide etiology of retrograde ejaculation):
(at least a 50% probability)
6B. IF THE VETERAN HAS RETROGRADE EJACULATION, IS IT AS LIKELY AS NOT
ATTRIBUTABLE TO ONE OF THE DIAGNOSES IN
SECTION I, INCLUDING RESIDUALS OF TREATMENT FOR THIS DIAGNOSIS?
YES
NO
(If yes, specify the diagnosis to which the erectile dysfunction is as likely as not attributable):
SECTION VII - MALE REPRODUCTIVE ORGAN INFECTIONS
7. DOES THE VETERAN HAVE A HISTORY OF CHRONIC EPIDIDYMITIS, EPIDIDYMO-ORCHITIS OR PROSTATITIS?
YES
NO
(If yes, indicate all treatment modalities used for chronic epididymitis, epididymo-orchitis or prostatitis (check all that apply)):
No treatment
Long-term drug therapy
If checked, list medications used and indicate dates for courses of treatment over the past 12 months:
Hospitalization
If checked, indicate frequency of hospitalization:
1 or 2 per year
>2 per year
Continuous intensive management
If checked, indicate types of treatment and medications used over past 12 months:
Intermittent intensive management
If checked, indicate types of treatment and medications used over past 12 months:
Other, describe:
Page 3
VA FORM 21-0960J-2, OCT 2012
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