Va Form 21-0960h-1 - Hernias (Including Abdominal, Inguinal And Femoral Hernias) Disability Benefits Questionnaire Page 2
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SECTION IV - HERNIA CONDITIONS
2. FEMORAL 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):
Right:
Left:
Irremediable, provide reason:
(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
3. VENTRAL HERNIA
(check all that apply):
A. SURGICAL STATUS
(If "Yes," indicate date and type of surgery):
Surgery performed
Date and type of surgery:
No previous surgery but hernia appears operable and remediable
Irremediable, provide reason:
Inoperable, provide reason:
(If checked, indicate status of postoperative recurrent hernia):
Recurrent hernia following surgical repair
(If checked, indicate side):
Recurrent hernia appears operable and remediable
Irremediable, provide reason:
Inoperable, provide reason:
(check all that apply):
B. EXAM
No hernia detected
Healed postoperative ventral hernia repair
Healed postoperative wounds with weakening of abdominal wall
Small ventral hernia
Large ventral hernia
Massive, persistent, severe diastasis of recti muscles
Extensive diffuse destruction or weakening of muscular and fascial support of abdominal wall so as to be inoperable
Other, describe:
(Is there an indication for a supporting belt?)
C. INDICATION FOR SUPPORT
(If "Yes," can the hernia be supported by truss or belt?):
YES
NO
Yes, can be well supported by truss or belt
Not well supported by truss or belt
N/A, no truss or belt tried or used
Page 2
VA FORM 21-0960H-1, OCT 2012
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