Va Form 21-0960g-4 - Intestinal Surgery (Bowel Resection, Colostomy, Ileostomy) Disability Benefits Questionnaire Page 3

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SECTION IX - DIAGNOSTIC TESTING

NOTE: If imaging studies, diagnostic procedures or laboratory testing have been performed and reflect the veteran's current condition, no further studies or testing are

required for this examination.

9A. HAS LABORATORY TESTING BEEN PERFORMED?

(If "Yes, check all that apply)

YES

(if anemia due to any intestinal condition is suspected or present)

CBC

Date of test:

Hemoglobin:

Hematocrit:

White blood cell count:

Platelets:

Other

Date of test:

Results:

9B. HAVE IMAGING STUDIES OR DIAGNOSTIC PROCEDURES BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?

(If "Yes," provide type of test or procedure, date and results (brief summary):

YES

9C. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?

(If "Yes," provide type of test or procedure, date and results (brief summary):

YES

SECTION X - FUNCTIONAL IMPACT

10. DO ANY OF THE VETERAN'S INTESTINAL SURGERY RESIDUALS IMPACT HIS OR HER ABILITY TO WORK?

YES

(If "Yes," describe the impact of each of the veteran's surgery residuals including any ongoing symptoms of original cause of surgery that may

be hard to distinguish from post-surgical residuals, providing one or more examples)

SECTION XI - REMARKS

(If any)

11. REMARKS

SECTION XII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.

12A. PHYSICIAN'S SIGNATURE

12B. PHYSICIAN'S PRINTED NAME

12C. DATE SIGNED

12D. PHYSICIAN'S PHONE AND FAX NUMBER

12E. PHYSICIAN'S MEDICAL LICENSE NUMBER

12F. PHYSICIAN'S ADDRESS

NOTE - VA may obtain additional medical information, including additional examinations if necessary to complete VA's review of the veteran's application.

IMPORTANT - Physician please fax the completed form to

(VA Regional Office FAX No.)

NOTE - A list of VA Regional Office FAX Numbers can be found at

or obtained by calling 1-800-827-1000.

PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38, Code of

Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection of money owed to the

United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits, verification of identity and status, and

personnel administration) as identified in the VA system of records, 58VA21/22/28, Compensation, Pension, Education and Vocational Rehabilitation and Employment Records - VA,

published in the Federal Register. Your obligation to respond is voluntary. VA uses your SSN to identify your claim file. Providing your SSN will help ensure that your records are properly

associated with your claim file. Giving us your SSN account information is voluntary. Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an

individual benefits for refusing to provide his or her SSN unless the disclosure of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The

requested information is considered relevant and necessary to determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701).

Information submitted is subject to verification through computer matching programs with other agencies.

RESPONDENT BURDEN: We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this information. We estimate

that you will need an average of 15 minutes to review the instructions, find the information, and complete a form. VA cannot conduct or sponsor a collection of information unless a valid

OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control numbers can be located on the OMB

Internet Page at . If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.

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VA FORM 21-0960G-4, OCT 2012