OMB Approved No. 2900-0776
Respondent Burden: 30 minutes
ARTERY AND VEIN CONDITIONS (VASCULAR DISEASES INCLUDING VARICOSE
VEINS) 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 OR SHE EVER HAD A VASCULAR DISEASE (ARTERIAL OR VENOUS)?
(If "Yes," complete Item 1B)
YES
NO
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO VASCULAR CONDITION(S):
ICD CODE -
DATE OF DIAGNOSIS -
DIAGNOSIS # 1 -
DIAGNOSIS # 2 -
ICD CODE -
DATE OF DIAGNOSIS -
DIAGNOSIS # 3 -
ICD CODE -
DATE OF DIAGNOSIS -
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO VASCULAR DISEASES, LIST USING ABOVE FORMAT
SECTION II - MEDICAL HISTORY
(Provide a brief summary)
2A. DESCRIBE THE CAUSE/ONSET OF THE VETERAN'S CURRENT VASCULAR CONDITION(S)
(Check all that apply and then complete the corresponding Section(s) III-VIII)
2B. TYPE OF VASCULAR DISEASE CONDITION
Section III: Varicose veins and/or post-phlebitic syndrome
(other than aorta)
Section IV: Peripheral vascular disease, aneurysm of any large artery
,
(Buerger's Disease)
arteriosclerosis obliterans or thrombo-angitis obliterans
Section V: Aortic aneurysm
Section VI: Aneurysm of a small artery
Section VII: Raynaud's syndrome
(AV)
Section VIII: Arteriovenous
fistula, angioneurotic edema or erythromelalgia
Regardless of checked condition, complete Section IX
SECTION III - VARICOSE VEINS AND/OR POST- PHLEBITIC SYNDROME
3A. DOES THE VETERAN HAVE VARICOSE VEINS OR POST-PHLEBITIC SYNDROME OF ANY ETIOLOGY?
(If "Yes," complete Items 3B and 3C)
YES
NO
3B. CHECK ALL SYMPTOMS THAT APPLY AND INDICATE EXTREMITY AFFECTED:
Asymptomatic palpable varicose veins
Right
Left
Both
Asymptomatic visible varicose veins
Right
Left
Both
Aching and fatigue in leg after prolonged standing or walking
Right
Left
Both
Symptoms relieved by elevation of extremity
Right
Left
Both
Symptoms relieved by compression hosiery
Right
Left
Both
3C. CHECK ALL FINDINGS AND/OR SIGNS THAT APPLY AND INDICATE EXTREMITY AFFECTED:
Incipient stasis pigmentation or eczema
Right
Left
Both
Persistent stasis pigmentation or eczema
Right
Left
Both
Intermittent ulceration
Right
Left
Both
Intermittent edema of extremity
Right
Left
Both
Persistent edema that is incompletely
Right
Left
Both
relieved by elevation of extremity
Persistent edema
Right
Left
Both
Persistent subcutaneous induration
Right
Left
Both
Massive board-like edema
Right
Left
Both
Constant pain at rest
Right
Left
Both
21-0960A-2
SUPERSEDES VA FORM 21-0960A-2, JAN 2011,
VA FORM
Page 1
OCT 2012
WHICH WILL NOT BE USED.