Va Form 21-0960k-2 - Gynecological Conditions Disability Benefits Questionnaire Page 2
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SECTION IV - SYMPTOMS
4C. IF YES, INDICATE EFFECTIVENESS OF TREATMENT IN CONTROLLING SYMPTOMS:
Symptoms do not require continuous treatment for the following organ/condition:
Symptoms require continuous treatment for the following organ/condition:
Symptoms are not controlled by continuous treatment for the following organ/condition:
SECTION V - CONDITIONS OF THE VULVA
(to include vulvovaginitis)
5. HAS THE VETERAN BEEN DIAGNOSED WITH ANY DISEASES, INJURIES OR OTHER CONDITIONS OF THE VULVA
?
YES
NO
(If yes, describe)
:
SECTION VI - CONDITIONS OF THE VAGINA
6. HAS THE VETERAN BEEN DIAGNOSED WITH ANY DISEASES, INJURIES OR OTHER CONDITIONS OF THE VAGINA?
YES
NO
(If yes, describe)
:
SECTION VII - CONDITIONS OF THE CERVIX
7. HAS THE VETERAN BEEN DIAGNOSED WITH ANY DISEASES, INJURIES, ADHESIONS OR OTHER CONDITIONS OF THE CERVIX?
YES
NO
(If yes, describe)
:
SECTION VIII - CONDITIONS OF THE UTERUS
8A. HAS THE VETERAN BEEN DIAGNOSED WITH ANY DISEASES, INJURIES, ADHESIONS OR OTHER CONDITIONS OF THE UTERUS?
YES
NO
8B. HAS THE VETERAN HAD A HYSTERECTOMY?
YES
NO
(If yes, provide date(s) of surgery, facility(ies) where performed and cause):
8C. DOES THE VETERAN HAVE UTERINE PROLAPSE?
YES
NO
(If yes, indicate severity):
Incomplete
(through vagina and introitus)
Complete
(If yes, does the condition currently cause symptoms?)
YES
NO
(If yes, describe):
8D. DOES THE VETERAN HAVE UTERINE FIBROIDS, ENLARGEMENT OF THE UTERUS AND/OR DISPLACEMENT OF THE UTERUS?
YES
NO
(If yes, are there signs and symptoms?):
YES
NO
(If yes, check all that apply)
:
Adhesions
Marked displacement: If checked, indicate cause:
Marked enlargement: If checked, indicate cause:
Uterine fibroids
Irregular menstruation: If checked, indicate cause:
Frequent or continuous menstrual disturbances: If checked, indicate cause:
Other, describe and indicate cause:
Page 2
VA FORM 21-0960K-2, OCT 2012
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