Va Form 21-0960g-1 - Esophageal Conditions (Including Gastroesophageal Reflux Disease (Gerd), Hiatal Hernia And Other Esophageal Disorders) Disability Benefits Questionnaire

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OMB Control No. 2900-0778
Respondent Burden: 15 minutes
ESOPHAGEAL CONDITIONS (Including gastroesophageal reflux disease (GERD),
hiatal hernia and other esophageal disorders) 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 THIS 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
NOTE: The diagnosis of gastroesophageal reflux disease (GERD) can be made clinically by evidence of relief of typical symptoms of reflux, epigastric discomfort and/or burning, by treatment
with proton pump inhibitors, histamine 2 receptor antagonists and/or antacids. If upper endoscopy was indicated or performed, the findings of erythema, ulcers and/or strictures are consistent
with the diagnosis of GERD.
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH AN ESOPHAGEAL CONDITION?
(If "Yes," complete Item 1B)
YES
NO
(Check all that apply)
1B. DIAGNOSIS
GERD
ICD CODE:
DATE OF DIAGNOSIS:
HIATAL HERNIA
ICD CODE:
DATE OF DIAGNOSIS:
ESOPHAGEAL STRICTURE
ICD CODE:
DATE OF DIAGNOSIS:
ESOPHAGEAL SPASM
ICD CODE:
DATE OF DIAGNOSIS:
ESOPHAGEAL DIVERTICULUM
ICD CODE:
DATE OF DIAGNOSIS:
OTHER ESOPHAGEAL CONDITION(S), specify:
(such as eosinophilic esophagitis, Barrett's
esophagitis, etc.)
OTHER DIAGNOSIS #1:
ICD CODE:
DATE OF DIAGNOSIS:
OTHER DIAGNOSIS #2:
ICD CODE:
DATE OF DIAGNOSIS:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO ESOPHAGEAL DISORDERS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
(brief summary)
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S ESOPHAGEAL CONDITIONS
:
2B. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING CONTINUOUS MEDICATION FOR THE DIAGNOSED CONDITION?
(If, "Yes," list only those medications used for the diagnosed condition):
YES
NO
SECTION III - SIGNS AND SYMPTOMS
(including
)
3. DOES THE VETERAN HAVE ANY OF THE FOLLOWING SIGNS OR SYMPTOMS DUE TO ANY ESOPHAGEAL CONDITIONS
GERD
?
YES
NO
(If "Yes," check all that apply)
PERSISTENTLY RECURRENT EPIGASTRIC DISTRESS
If checked, indicate frequency of symptom recurrence per year:
1
2
3
4 or more
If checked, indicate average duration of episodes of symptoms:
Less than 1 day
1-9 days
10 days or more
INFREQUENT EPISODES OF EPIGASTRIC DISTRESS
If checked, indicate frequency of symptom recurrence per year:
1
2
3
4 or more
If checked, indicate average duration of episodes of symptoms:
Less than 1 day
1-9 days
10 days or more
DYSPHAGIA
If checked, indicate frequency of symptom recurrence per year:
1
2
3
4 or more
If checked, indicate average duration of episodes of symptoms:
Less than 1 day
1-9 days
10 days or more
PYROSIS (Heartburn)
If checked, indicate frequency of symptom recurrence per year:
1
2
3
4 or more
If checked, indicate average duration of episodes of symptoms:
Less than 1 day
1-9 days
10 days or more
Page 1
21-0960G-1
SUPERSEDES VA FORM 21-0960G-1, FEB 2011,
VA FORM
WHICH WILL NOT BE USED.
OCT 2012

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