Va Form 21-0960g-4 - Intestinal Surgery (Bowel Resection, Colostomy, Ileostomy) Disability Benefits Questionnaire
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3OMB Approved No. 2900-0778
Respondent Burden: 15 minutes
INTESTINAL SURGERY (BOWEL RESECTION, COLOSTOMY, ILEOSTOMY)
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 INFORMATION
BEFORE COMPLETING 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
1A. HAS THE VETERAN HAD INTESTINAL SURGERY?
(If "Yes," complete Item 1B)
YES
NO
(check all that apply)
1B. SELECT THE VETERAN'S CONDITION
RESECTION OF THE SMALL INTESTINE
ICD code:
Date of diagnosis:
Reason for surgery:
RESECTION OF THE LARGE INTESTINE
ICD code:
Date of diagnosis:
Reason for surgery:
ICD code:
Date of diagnosis:
Reason for surgery:
PERITONEAL ADHESIONS ATTRIBUTABLE TO
RESECTION OF THE LARGE OR SMALL
INTESTINE. IF CHECKED, ALSO COMPLETE VA
FORM 21-0960G-6, PERITONEAL ADHESIONS
DISABILITY BENEFITS QUESTIONNAIRE
PERSISTENT FISTULA
ICD code:
Date of diagnosis:
Reason for surgery:
OTHER INTESTINAL SURGERY, SPECIFY DIAGNOSES BELOW, PROVIDING ONLY DIAGNOSES THAT PERTAIN TO INTESTINAL SURGERY:
OTHER DIAGNOSIS #1:
ICD code:
Date of diagnosis:
Reason for surgery:
OTHER DIAGNOSIS #2:
ICD code:
Date of diagnosis:
Reason for surgery:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO INTESTINAL SURGERY, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
(brief summary)
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S INTESTINAL SURGERY
:
2B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF THE VETERAN'S INTESTINAL CONDITION(S)?
(If "Yes," list only those medications required for the intestinal conditions)
YES
NO
SECTION III - SIGNS AND SYMPTOMS
3A. DOES THE VETERAN HAVE ANY SIGNS OR SYMPTOMS ATTRIBUTABLE TO ANY INTESTINAL SURGERY?
(If "Yes," check all that apply)
YES
NO
Slight symptoms attributable to resection of large intestine. If checked, describe:
Moderate symptoms attributable to resection of large intestine. If checked, describe:
:
Severe symptoms, objectively supported by examination findings, attributable to resection of large intestine. If checked,describe
:
Abdominal pain and/or colic pain. If checked, describe
Diarrhea. If checked, describe:
Alternating diarrhea and constipation. If checked, describe:
Abdominal distension. If checked, describe:
Anemia. If checked, provide hemoglobin/hematocrit in Section 9, Diagnostic Testing.
Nausea. If checked, describe:
Vomiting. If checked, describe:
Pulling pain on attempting work or aggravated by movements of the body. If checked, describe:
,
Other
describe:
VA FORM
SUPERSEDES VA FORM 21-0960G-4, FEB 2011,
21-0960G-4
Page 1
OCT 2012
WHICH WILL NOT BE USED.
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