Va Form 21-0960h-1 - Hernias (Including Abdominal, Inguinal And Femoral Hernias) Disability Benefits Questionnaire
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3OMB Approved No. 2900-0781
Respondent Burden: 15 minutes
HERNIAS (INCLUDING ABDOMINAL, INGUINAL AND FEMORAL HERNIAS)
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 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
(This is the condition the veteran is claiming or for which an
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER HAD ANY HERNIA CONDITIONS?
exam has been requested)
(If "Yes," complete Item 1B)
YES
NO
(Check all that apply):
1B. SELECT THE VETERAN'S CONDITION
(If checked, complete Section IV.1)
INGUINAL HERNIA
ICD code:
Date of diagnosis:
(If checked, complete Section IV.2)
FEMORAL HERNIA
ICD code:
Date of diagnosis:
(If checked, complete Section IV.3)
VENTRAL HERNIA
ICD code:
Date of diagnosis:
(Specify):
OTHER
OTHER DIAGNOSIS #1:
ICD code:
Date of diagnosis:
OTHER DIAGNOSIS #2:
ICD code:
Date of diagnosis:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO INGUINAL, FEMORAL OR VENTRAL HERNIAS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL RECORD REVIEW
2. INDICATE MEDICAL RECORDS REVIEWED IN PREPARATION OF THIS REPORT:
C-FILE (VA ONLY)
OTHER, DESCRIBE:
SECTION III - MEDICAL HISTORY
(including onset and course)
(brief summary):
3. DESCRIBE THE HISTORY
OF THE VETERAN'S HERNIA CONDITIONS
SECTION IV - HERNIA CONDITIONS
1. INGUINAL HERNIA
(check all that apply):
A. SURGICAL STATUS
(If "Yes," indicate side, date and type of surgery):
Surgery performed
Right:
Date and type of surgery:
Left:
Date and type of surgery:
(If checked, indicate side):
No previous surgery but hernia appears operable and remediable
Right:
Left:
(If checked, indicate side):
Irremediable, provide reason:
Right:
Left:
(If checked, indicate side):
Inoperable, provide reason:
Right:
Left:
(If checked, indicate status of postoperative recurrent hernia):
Recurrent hernia following surgical repair
(If checked, indicate side):
Recurrent hernia appears operable and remediable
Right:
Left:
(If checked, indicate side):
Irremediable, provide reason:
Right:
Left:
(If checked, indicate side):
Inoperable, provide reason:
Right:
Left:
B. EXAM
Right:
No hernia detected
No true hernia protrusion
Small hernia
Large hernia
Left:
No hernia detected
No true hernia protrusion
Small hernia
Large hernia
C. ABILITY TO BE REDUCED
Right:
Readily reducible
Not readily reducible
Left:
Readily reducible
Not readily reducible
(Is there an indication for a supporting belt?)
D. INDICATION FOR SUPPORT
(If "Yes," can the hernia be supported by truss or belt?):
YES
NO
(If checked, indicate side well supported):
Yes, can be well supported by truss or belt
Right:
Left:
(If checked, indicate side not well supported):
Not well supported by truss or belt
Right:
Left:
N/A, no truss or belt tried or used
VA FORM
SUPERSEDES VA FORM 21-0960H-1, MAR 2011,
Page 1
21-0960H-1
OCT 2012
WHICH WILL NOT BE USED.
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