Va Form 21-0960g-1 - Esophageal Conditions (Including Gastroesophageal Reflux Disease (Gerd), Hiatal Hernia And Other Esophageal Disorders) Disability Benefits Questionnaire Page 3

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SECTION IV - ESOPHAGEAL STRICTURE, SPASM AND DIVERTICULA
4. DOES THE VETERAN HAVE AN ESOPHAGEAL STRICTURE, SPASM OF ESOPHAGUS (CARDIOSPASM OR ACHALASIA), OR AN ACQUIRED DIVERTICULUM OF
THE ESOPHAGUS?
YES
NO
If Yes, indicate severity of condition:
ASYMPTOMATIC
NOT AMENABLE TO DILATION
MILD If checked, describe:
MODERATE If checked, describe:
SEVERE, PERMITTING PASSAGE OF LIQUIDS ONLY
If checked, describe:
SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, SIGNS AND/OR SYMPTOMS
5A. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS? IF YES, DESCRIBE
(brief summary)
:
5B. DOES THE VETERAN HAVE ANY SCARS (SURGICAL OR OTHERWISE) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS
LISTED IN SECTION I, DIAGNOSIS?
YES
NO
IF YES, ARE ANY OF THE SCARS PAINFUL AND/OR UNSTABLE, OR IS THE TOTAL AREA OF ALL RELATED SCARS GREATER THAN OR EQUAL TO 39 SQUARE CM
(6 square inches)
?
YES
NO
(If "Yes," ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)
SECTION VI - DIAGNOSTIC TESTING
Note: If testing has been performed and reflects veteran's current condition, no further testing is required for this examination report.
6A. HAVE DIAGNOSTIC IMAGING STUDIES OR OTHER DIAGNOSTIC PROCEDURES BEEN PERFORMED?
YES
NO
If Yes, check all that apply:
UPPER ENDOSCOPY
Date:
Results:
UPPER GI RADIOGRAPHIC STUDIES
Date:
Results:
ESOPHAGRAM (barium swallow)
Date:
Results:
MRI
Date:
Results:
CT
Date:
Results:
BIOPSY, SPECIFY SITE:
Date:
Results:
OTHER, SPECIFY:
Date:
Results:
6B. HAS LABORATORY TESTING BEEN PERFORMED?
YES
NO
If Yes, check all that apply:
CBC
Date of testing:
Hemoglobin:
Hematocrit:
White blood cell count:
Platelets:
HELICOBACTER PYLORI
Date of test:
Results:
OTHER, SPECIFY:
Date of test:
Results:
Page 3
VA FORM 21-0960G-1, OCT 2012

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