Va Form 21-0960a-4 - Heart Conditions (Including Ischemic And Non-Ischemic Heart Disease, Arrhythmias, Valvular Disease And Cardiac Surgery) Disability Benefits Questionnaire
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7OMB Approved No. 2900-0776
Respondent Burden: 30 minutes
HEART CONDITIONS (INCLUDING ISCHEMIC AND NON-ISCHEMIC HEART DISEASE,
ARRHYTHMIAS, VALVULAR DISEASE AND CARDIAC SURGERY)
DISABILITY BENEFITS QUESTIONNAIRE
NOTE: For coronary artery disease, myocardial infarction, or hypertensive disease, complete VA Form 21-0960A-1, Ischemic Heart Disease 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. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH A HEART CONDITION?
(If "Yes," complete Item 1B)
YES
NO
(Check all that apply):
1B. SELECT THE VETERAN'S HEART CONDITION(S)
Acute, subacute, or old myocardial infarction
ICD Code:
Date of diagnosis:
Atherosclerotic cardiovascular disease
ICD Code:
Date of diagnosis:
Coronary artery disease
ICD Code:
Date of diagnosis:
Stable angina
ICD Code:
Date of diagnosis:
Unstable angina
ICD Code:
Date of diagnosis:
Coronary spasm, including Prinzmetal's angina
ICD Code:
Date of diagnosis:
Congestive heart failure
ICD Code:
Date of diagnosis:
Supraventricular arrhythmia
ICD Code:
Date of diagnosis:
Ventricular arrhythmia
ICD Code:
Date of diagnosis:
Heart block
ICD Code:
Date of diagnosis:
Valvular heart disease
ICD Code:
Date of diagnosis:
Heart valve replacement
ICD Code:
Date of diagnosis:
Cardiomyopathy
ICD Code:
Date of diagnosis:
Hypertensive heart disease
ICD Code:
Date of diagnosis:
Heart transplant
ICD Code:
Date of diagnosis:
Implanted cardiac pacemaker
ICD Code:
Date of diagnosis:
Implanted automatic implantable cardioverter defibrillator (AICD)
ICD Code:
Date of diagnosis:
Infectious heart conditions (including active valvular infection, rheumatic heart
disease, endocarditis, pericarditis or syphilitic heart disease)
ICD Code:
Date of diagnosis:
Pericardial adhesions
ICD Code:
Date of diagnosis:
Other heart condition, specify below
Diagnosis #1:
ICD Code:
Date of diagnosis:
Diagnosis #2:
ICD Code:
Date of diagnosis:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO HEART CONDITIONS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
(brief summary):
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S HEART CONDITION(S)
2B. DO ANY OF THE VETERAN'S HEART CONDITIONS QUALIFY WITHIN THE GENERALLY ACCEPTED MEDICAL DEFINITION OF ISCHEMIC HEART DISEASE (IHD)?
(If "Yes," list the conditions that qualify):
YES
NO
SUPERSEDES VA FORM 21-0960A-4, JAN 2011,
VA FORM
21-0960A-4
Page 1
OCT 2012
WHICH WILL NOT BE USED.
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