Va Form 21-0960k-2 - Gynecological Conditions Disability Benefits Questionnaire Page 3
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SECTION VIII - CONDITIONS OF THE UTERUS
8E. HAS THE VETERAN BEEN DIAGNOSED WITH ANY OTHER DISEASES, INJURIES, ADHESIONS OR OTHER CONDITIONS OF THE UTERUS?
YES
NO
(If yes, describe):
SECTION IX - CONDITIONS OF THE FALLOPIAN TUBES
(to include pelvic
9. HAS THE VETERAN BEEN DIAGNOSED WITH ANY DISEASES, INJURIES, ADHESIONS OR OTHER CONDITIONS OF THE FALLOPIAN TUBES
inflammatory disease)?
YES
NO
(If yes, describe):
SECTION X - CONDITIONS OF THE OVARIES
10A. HAS THE VETERAN UNDERGONE MENOPAUSE?
(If yes, indicate):
YES
NO
Natural menopause
Premature menopause
Surgical menopause
Chemical-induced menopause
Radiation-induced menopause
10B. HAS THE VETERAN UNDERGONE PARTIAL OR COMPLETE OOPHORECTOMY?
YES
NO
(If yes, check all that apply):
Partial removal of an ovary
Right
Left
Both
Complete removal of an ovary
Right
Left
Both
(If yes, provide date(s) of surgery, facility(ies) where performed and reason for surgery)
:
10C. DOES THE VETERAN HAVE EVIDENCE OF COMPLETE ATROPHY OF 1 OR BOTH OVARIES?
(If yes, etiology):
YES
NO
UNKNOWN
(If yes, indicate severity)
:
Partial atrophy of 1 or both ovaries
Complete atrophy of 1 ovary
(excluding natural menopause)
Complete atrophy of both ovaries
10D. HAS THE VETERAN BEEN DIAGNOSED WITH ANY OTHER DISEASES, INJURIES, ADHESIONS AND/OR OTHER CONDITIONS OF THE OVARIES?
YES
NO
(If yes, describe)
:
SECTION XI - INCONTINENCE
11. DOES THE VETERAN HAVE URINARY INCONTINENCE/LEAKAGE?
(If yes, condition causing it):
YES
NO
(If yes, is the urinary incontinence/leakage due to a gynecologic condition?):
YES
NO
(If yes, check all that apply)
:
Does not require/does not use absorbent material
Stress incontinence
Requires absorbent material that is changed less than 2 times per day
Requires absorbent material that is changed 2 to 4 times per day
Requires absorbent material that is changed more than 4 times per day
Requiring the use of an appliance
If checked, describe appliance:
Page 3
VA FORM 21-0960K-2, OCT 2012
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