Va Form 21-0960a-2 - Artery And Vein Conditions (Vascular Diseases Including Varicose Veins) Disability Benefits Questionnaire Page 2
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5SECTION IV - PERIPHERAL VASCULAR DISEASE, ANEURYSM OF ANY LARGE ARTERY (OTHER THAN AORTA) ARTERIOSCLEROSIS
OBLITERANS OR THROMBO-ANGIITIS OBLITERANS (BUERGER'S DISEASE)
(OTHER THAN AORTA)
4A. HAS THE VETERAN EVER BEEN DIAGNOSED WITH PERIPHERAL VASCULAR DISEASE, ANEURYSM OF ANY LARGE ARTERY
(BUERGER'S DISEASE)? (Check all that apply):
ARTERIOSCLEROSIS OBLITERANS OR THROMBO-ANGIITIS OBLITERANS
Peripheral vascular disease
Aneurysm of any large artery (other than aorta)
Arteriosclerosis obliterans
Thrombo-angiitis obliterans (Buerger's Disease)
None of the above
(If any of the above conditions are checked, answer questions 4B - 4D)
4B. HAS THE VETERAN UNDERGONE SURGERY FOR ANY OF THESE LISTED CONDITIONS?
(If "Yes," list type of surgery):
Date of surgery:
)
YES
NO
(OTHER THAN SURGERY)
4C. HAS THE VETERAN UNDERGONE ANY PROCEDURE
FOR REVASCULARIZATION?
(If "Yes," list type of procedure):
Date of procedure:
)
YES
NO
Check all that apply)
4D. INDICATE SEVERITY OF CURRENT SIGNS AND SYMPTOMS AND INDICATE EXTREMITY AFFECTED: (
Right
Left
Both
Claudication on walking more than 100 yards
Claudication on walking between 25 and 100 yards on a level grade at 2 miles per hour
Right
Left
Both
Claudication on walking less than 25 yards on a level grade at 2 miles per hour
Right
Left
Both
Persistent coldness of the extremity
Right
Left
Both
Diminished peripheral pulses
Right
Left
Both
Ischemic limb pain at rest
Right
Left
Both
(thin skin, absence of hair, dystrophic nails)
Trophic changes
Right
Left
Both
1 or more deep ischemic ulcers
Right
Left
Both
SECTION V - AORTIC ANEURYSM
5A. HAS THE VETERAN EVER BEEN DIAGNOSED WITH AN AORTIC ANEURYSM?
(If "Yes," complete Item 5B)
YES
NO
5B. HAS THE VETERAN HAD A SURGICAL PROCEDURE FOR AN AORTIC ANEURYSM?
(If "Yes," indicate type of surgery):
Date of surgery:
)
YES
NO
5C. DOES THE VETERAN CURRENTLY HAVE AN AORTIC ANEURYSM?
(If "Yes," indicate severity):
YES
NO
YES
NO
5 centimeters or larger in diameter
Symptomatic
YES
NO
Precludes exertion
YES
NO
5D. DOES THE VETERAN HAVE ANY POST-SURGICAL RESIDUALS DUE TO TREATMENT FOR AORTIC ANEURYSM?
YES
NO
(If "Yes," describe):
(If there are symptoms or post-surgical residuals, ALSO complete appropriate Questionnaire according to body system affected)
SECTION VI - ANEURYSM OF A SMALL ARTERY
6A. HAS THE VETERAN BEEN DIAGNOSED WITH AN ANEURYSM OF A SMALL ARTERY?
(If "Yes," complete Item 6B)
YES
NO
6B. HAS THE VETERAN HAD A SURGICAL PROCEDURE FOR AN ANEURYSM OF A SMALL ARTERY?
YES
NO
(If "Yes," list type of surgery):
Date of surgery:
6C. DOES THE VETERAN CURRENTLY HAVE AN ANEURYSM OF A SMALL ARTERY?
(If "Yes," is the condition symptomatic?)
YES
NO
(If "Yes," describe):
YES
NO
(Also complete appropriate Questionnaire according to body system affected)
6D. DOES THE VETERAN HAVE ANY POST-SURGICAL RESIDUALS DUE TO TREATMENT FOR AN ANEURYSM OF A SMALL ARTERY?
(If "Yes," describe):
YES
NO
(If there are symptoms or post-surgical residuals, ALSO complete appropriate Questionnaire according to body system affected)
SECTION VII - RAYNAUD'S SYNDROME
7A. DOES THE VETERAN HAVE RAYNAUD'S SYNDROME?
(If "Yes," complete Item 7B)
YES
NO
Page 2
VA FORM 21-0960A-2, OCT 2012
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