Va Form 21-0960k-2 - Gynecological Conditions Disability Benefits Questionnaire Page 5
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6SECTION XV - TUMORS AND NEOPLASMS
15A. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DIAGNOSIS?
(If "Yes," also complete Items 15B through 15E)
YES
NO
15B. IS THE NEOPLASM
BENIGN
MALIGNANT
15C. HAS THE VETERAN COMPLETED TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT NEOPLASM
OR METASTASES?
YES
NO, WATCHFUL WAITING
(If "Yes," indicate type of treatment the veteran is currently undergoing or has completed) (Check all that apply):
Treatment completed; currently in watchful waiting status
Surgery
If checked, describe:
Date(s) of surgery:
Radiation therapy
Date of most recent treatment:
Date of completion of treatment or anticipated date of completion:
Antineoplastic chemotherapy
Date of most recent treatment:
Date of completion of treatment or anticipated date of completion:
Other therapeutic procedure
If checked, describe procedure:
Date of most recent procedure:
Other therapeutic treatment
If checked, describe treatment:
Date of completion of treatment or anticipated date of completion:
15D. DOES THE VETERAN CURRENTLY HAVE ANY RESIDUAL CONDITIONS OR COMPLICATIONS DUE TO THE NEOPLASM (INCLUDING METASTASES) OR ITS
TREATMENT, OTHER THAN THOSE ALREADY DOCUMENTED IN ITEM 15C?
(If "Yes," list residual conditions and complications - brief summary):
YES
NO
15E. IF THERE ARE ADDITIONAL BENIGN OR MALIGNANT NEOPLASMS OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DESCRIBE
USING THE FORMAT IN ITEM 15C:
SECTION XVI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
(surgical or otherwise)
16A. DOES THE VETERAN HAVE ANY SCARS
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)?)
(If "Yes," also complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)
YES
NO
16B. DOES THE VETERAN HAVE ANY OTHER PERTINENT FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN SECTION I, DIAGNOSIS?
(If yes, describe - brief summary):
YES
NO
SECTION XVII - DIAGNOSTIC TESTING
NOTE - If laboratory test results are in the medical record and reflect the veteran's current condition, repeat testing is not required.
17A. HAS THE VETERAN HAD LAPAROSCOPY?
(If yes, provide date(s), facility where performed, and results):
YES
NO
17B. HAS THE VETERAN BEEN DIAGNOSED WITH ANEMIA?
(If yes, provide most recent test results):
YES
NO
Hgb:
Hct:
Date of test:
17C. HAS THE VETERAN HAD ANY OTHER DIAGNOSTIC TESTING AND IF SO, ARE THERE SIGNIFICANT FINDINGS AND/OR RESULTS?
(If yes, provide type of test or procedure, date and results (brief summary)):
YES
NO
Page 5
VA FORM 21-0960K-2, OCT 2012
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