Va Form 21-0960k-2 - Gynecological Conditions Disability Benefits Questionnaire
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6OMB Approved No. 2900-0778
Respondent Burden: 30 minutes
GYNECOLOGICAL CONDITIONS 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
1A. DOES THE VETERAN NOW HAVE OR HAS SHE EVER HAD A GYNECOLOGICAL CONDITION?
(If "Yes," complete Item 1B)
YES
NO
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO GYNECOLOGICAL CONDITION(S):
DIAGNOSIS # 1 -
ICD CODE -
DATE OF DIAGNOSIS -
DIAGNOSIS # 2 -
ICD CODE -
DATE OF DIAGNOSIS -
DIAGNOSIS # 3 -
ICD CODE -
DATE OF DIAGNOSIS -
1C. IF THERE ARE ADDITIONAL GYNECOLOGICAL DIAGNOSES, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including cause, onset and course)
2. DESCRIBE THE HISTORY
OF EACH OF THE VETERAN'S GYNECOLOGICAL CONDITION(S):
SECTION III - SYMPTOMS
3. DOES THE VETERAN CURRENTLY HAVE SYMPTOMS RELATED TO A GYNECOLOGICAL CONDITION, INCLUDING ANY DISEASES, INJURIES OR ADHESIONS
OF THE FEMALE REPRODUCTIVE ORGANS?
YES
NO
(If yes, indicate current symptoms including frequency and severity of pain, if any - check all that apply):
Intermittent pain
Constant pain
Mild pain
Moderate pain
Severe pain
Pelvic pressure
Irregular menstruation
Frequent or continuous menstrual disturbances
Other signs and/or symptoms, describe and indicate condition(s) causing them:
SECTION IV - TREATMENT
4A. HAS THE VETERAN HAD TREATMENT FOR SYMPTOMS/FINDINGS FOR ANY DISEASES, INJURIES AND/OR ADHESIONS OF THE REPRODUCTIVE ORGANS?
YES
NO
(If yes, specify condition(s), organ(s) affected and treatment):
Date(s) of treatment:
4B. DOES THE VETERAN CURRENTLY REQUIRE TREATMENT OR MEDICATIONS FOR SYMPTOMS RELATED TO REPRODUCTIVE TRACT CONDITIONS?
YES
NO
(If yes, list current treatment/medications and the reproductive organ conditions being treated):
VA FORM
SUPERSEDES VA FORM 21-0960K-2, FEB 2011,
21-0960K-2
Page 1
OCT 2012
WHICH WILL NOT BE USED.
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