Va Form 21-0960g-4 - Intestinal Surgery (Bowel Resection, Colostomy, Ileostomy) Disability Benefits Questionnaire Page 2

Download a blank fillable Va Form 21-0960g-4 - Intestinal Surgery (Bowel Resection, Colostomy, Ileostomy) Disability Benefits Questionnaire in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Va Form 21-0960g-4 - Intestinal Surgery (Bowel Resection, Colostomy, Ileostomy) Disability Benefits Questionnaire with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

SECTION IV - WEIGHT LOSS
4A. DOES THE VETERAN HAVE WEIGHT LOSS OR INABILITY TO GAIN WEIGHT ATTRIBUTABLE TO INTESTINAL SURGERY?
(If "Yes," complete Items 4B thru 4D)
YES
NO
(For VA purposes, baseline weight is the average weight for a 2-year period preceding
4B. PROVIDE VETERAN'S BASELINE WEIGHT AND CURRENT WEIGHT
onset of disease)
Baseline weight:
Current weight:
4C. HAS THE VETERAN'S WEIGHT LOSS BEEN SUSTAINED FOR 3 MONTHS OR LONGER?
YES
NO
4D. HAS THE VETERAN BEEN UNABLE TO REGAIN WEIGHT DESPITE APPROPRIATE THERAPY?
YES
NO
SECTION V - ABSORPTION AND NURTITION
5. DOES THE VETERAN HAVE ANY INTERFERENCE WITH ABSORPTION AND NUTRITION ATTRIBUTABLE TO RESECTION OF THE SMALL INTESTINE?
YES
NO
NOT APPLICABLE
IF YES, DOES THIS CAUSE IMPAIRMENT OF HEALTH OBJECTIVELY SUPPORTED BY EXAMINATION FINDINGS INCLUDING DEFINITE AND/OR MATERIAL
WEIGHT LOSS?
YES
NO
IF YES, IS IMPAIRMENT OF HEALTH SEVERE?
YES
NO
INDICATE SEVERITY OF INTERFERENCE WITH ABSORPTION AND NUTRITION:
Definite
Marked
SECTION VI - OSTOMY
6. DID THE VETERAN'S INTESTINAL CONDITION REQUIRE AN ILEOSTOMY OR COLOSTOMY?
YES
NO
IF YES, DESCRIBE:
SECTION VII - FISTULA
7. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER HAD A PERSISTENT INTESTINAL FISTULA ATTRIBUTABLE TO A SURGICAL INTESTINAL CONDITION?
YES
NO
IF YES, DOES THE VETERAN HAVE FECAL DISCHARGE ATTRIBUTABLE TO THIS?
YES
NO
(check all that apply):
IF YES, INDICATE THE SEVERITY AND FREQUENCY OF FECAL DISCHARGE
Slight
Copious
Infrequent
Frequent
Constant
,
Other
describe:
SECTION VIII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
(surgical or otherwise)
8A. DOES THE VETERAN HAVE ANY SCARS
RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
SECTION 1, 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
(6 square inches)?
CM
(If 'Yes." ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)
YES
NO
8B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN SECTION 1, DIAGNOSIS?
(If "Yes," describe (brief summary):
YES
NO
Page 2
VA FORM 21-0960G-4, OCT 2012

ADVERTISEMENT

00 votes

Related Articles

5 Things You Need To Know About The Gi Bill Benefits
Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids

Related forms

Va Form 21-0960g-5 - Hepatitis, Cirrhosis And Other Liver Conditions Disability Benefits Questionnaire Va Form 21-0960g-5 - Hepatitis, Cirrhosis And Other Liver Conditions Disability Benefits Questionnaire Legal
Va Form 21-0960b-2 - Hematologic And Lymphatic Conditions, Including Leukemia Disability Benefits Questionnaire Va Form 21-0960b-2 - Hematologic And Lymphatic Conditions, Including Leukemia Disability Benefits Questionnaire Legal
Va Form 21-0960c-5 - Central Nervous System And Neuromuscular Diseases Disability Benefits Questionnaire Va Form 21-0960c-5 - Central Nervous System And Neuromuscular Diseases Disability Benefits Questionnaire Legal
Va Form 21-0960h-2 - Rectum And Anus Conditions (including Hemorrhoids) Disability Benefits Questionnaire Va Form 21-0960h-2 - Rectum And Anus Conditions (including Hemorrhoids) Disability Benefits Questionnaire Legal
Va Form 21-0960i-1 - Persian Gulf And Afghanistan Infectious Diseases Disability Benefits Questionnaire Va Form 21-0960i-1 - Persian Gulf And Afghanistan Infectious Diseases Disability Benefits Questionnaire Legal
Va Form 21-0960g-3 - Intestinal Conditions (other Than Surgical Or Infectious) (including Irritable Bowel Syndrome, Crohn's Disease, Ulcerative Colitis, And Diverticulitis) Disability Benefits Questionnaire Va Form 21-0960g-3 - Intestinal Conditions (other Than Surgical Or Infectious) (including Irritable Bowel Syndrome, Crohn's Disease, Ulcerative Colitis, And Diverticulitis) Disability Benefits Questionnaire Legal
Va Form 21-0960g-8 - Infectious Intestinal Disorders, Including Bacterial And Parasitic Infections Disability Benefits Questionnaire Va Form 21-0960g-8 - Infectious Intestinal Disorders, Including Bacterial And Parasitic Infections Disability Benefits Questionnaire Legal
Va Form 21-0960g-8 - Infectious Intestinal Disorders, Including Bacterial And Parasitic Infections Disability Benefits Questionnaire Va Form 21-0960g-8 - Infectious Intestinal Disorders, Including Bacterial And Parasitic Infections Disability Benefits Questionnaire Legal
Va Form 21-0960a-4 - Heart Conditions (including Ischemic And Non-ischemic Heart Disease, Arrhythmias, Valvular Disease And Cardiac Surgery) Disability Benefits Questionnaire Va Form 21-0960a-4 - Heart Conditions (including Ischemic And Non-ischemic Heart Disease, Arrhythmias, Valvular Disease And Cardiac Surgery) Disability Benefits Questionnaire Legal
Va Form 21-0960g-1 - Esophageal Conditions (including Gastroesophageal Reflux Disease (gerd), Hiatal Hernia And Other Esophageal Disorders) Disability Benefits Questionnaire Va Form 21-0960g-1 - Esophageal Conditions (including Gastroesophageal Reflux Disease (gerd), Hiatal Hernia And Other Esophageal Disorders) Disability Benefits Questionnaire Legal

Related Categories

Parent category: Legal
Download
Go
Page of 3