Va Form 21-0960k-2 - Gynecological Conditions Disability Benefits Questionnaire Page 4
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6SECTION XII - FISTULAE
12A. DOES THE VETERAN HAVE A RECTOVAGINAL FISTULA?
(If yes, cause):
YES
NO
(If yes, does the veteran have vaginal-fecal leakage?):
YES
NO
(If yes, indicate frequency (check all that apply)):
Less than once a week
1-3 times per week
4 or more times per week
Daily or more often
Requires wearing of pad or absorbent material
12B. DOES THE VETERAN HAVE AN URETHROVAGINAL FISTULA?
(If yes, cause):
YES
NO
(If yes, does the veteran have urine leakage?):
YES
NO
(If yes, check all that apply)
:
Does not require/does not use absorbent material
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
Requires the use of an appliance
If checked, describe appliance:
SECTION XIII - ENDOMETRIOSIS
NOTE - A diagnosis of endometriosis must be substantiated by laparoscopy.
13. HAS THE VETERAN BEEN DIAGNOSED WITH ENDOMETRIOSIS?
YES
NO
(If yes, does the veteran currently have any findings, signs or symptoms due to endometriosis?)
YES
NO
(If yes, check all that apply)
:
Pelvic pain
Heavy or irregular bleeding requiring continuous treatment for control
Heavy or irregular bleeding not controlled by treatment
Lesions involving bowel or bladder confirmed by laparoscopy
Bowel or bladder symptoms from endometriosis
Anemia caused by endometriosis
Other, describe:
SECTION XIV - COMPLICATIONS AND RESIDUALS OF PREGNANCY OR OTHER GYNECOLOGIC PROCEDURES
14A. HAS THE VETERAN HAD ANY SURGICAL COMPLICATIONS OF PREGNANCY?
YES
NO
(If yes, check all that apply):
Relaxation of perineum
Rectocele
Cystocele
Other, describe:
14B. HAS THE VETERAN HAD ANY OTHER COMPLICATIONS RESULTING FROM OBSTETRICAL OR GYNECOLOGIC CONDITIONS OR PROCEDURES?
YES
NO
(If yes, describe)
:
NOTE - If obstetrical or gynecologic complications impact other body systems, also complete the additional appropriate Questionnaire(s)
Page 4
VA FORM 21-0960K-2, OCT 2012
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