Va Form 21-0960a-4 - Heart Conditions (Including Ischemic And Non-Ischemic Heart Disease, Arrhythmias, Valvular Disease And Cardiac Surgery) Disability Benefits Questionnaire Page 2
Download a blank fillable Va Form 21-0960a-4 - Heart Conditions (Including Ischemic And Non-Ischemic Heart Disease, Arrhythmias, Valvular Disease And Cardiac Surgery) 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 21-0960a-4 - Heart Conditions (Including Ischemic And Non-Ischemic Heart Disease, Arrhythmias, Valvular Disease And Cardiac Surgery) 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
1
2
3
4
5
6
7(Continued)
SECTION II - MEDICAL HISTORY
2C. PROVIDE THE ETIOLOGY, IF KNOWN, OF EACH OF THE VETERAN'S HEART CONDITIONS, INCLUDING THE RELATIONSHIP/CAUSALITY TO OTHER HEART
CONDITIONS, PARTICULARLY THE RELATIONSHIP/CAUSALITY TO THE VETERAN'S IHD CONDITIONS, IF ANY:
Heart condition #1 (provide etiology):
Heart condition #2 (provide etiology):
2D. IF THERE ARE ADDITIONAL HEART CONDITIONS, PROVIDE ETIOLOGY AND LIST USING THE ABOVE FORMAT:
2E. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF THE VETERAN'S HEART CONDITION?
YES
NO
(If, "Yes," list medications required for the veteran's heart condition (include name of medication and heart condition it is used for, such as atenolol for myocardial
infarction or atrial fibrillation):
SECTION III - MYOCARDIAL INFARCTION (MI)
3A. HAS THE VETERAN HAD A MYOCARDIAL INFARCTION (MI)?
(If, "Yes," complete the following):
YES
NO
MI #1: Date and treatment facility:
MI #2: Date and treatment facility:
3B. IF THE VETERAN HAS HAD ADDITIONAL MIs, LIST USING ABOVE FORMAT:
SECTION IV - CONGESTIVE HEART FAILURE (CHF)
4A. HAS THE VETERAN HAD CONGESTIVE HEART FAILURE (CHF)?
(If "Yes," complete Item 4B)
YES
NO
4B. DOES THE VETERAN HAVE CHRONIC CHF?
YES
NO
4C. HAS THE VETERAN HAD ANY EPISODES OF ACUTE CHF IN THE PAST YEAR?
YES
NO
(If, "Yes," specify the number of episodes of acute CHF the veteran has had in the past year):
Provide date of most recent episode of acute CHF:
0
1
More than 1
4D. WAS THE VETERAN ADMITTED FOR TREATMENT OF ACUTE CHF?
(If, "Yes," indicate name of treatment facility):
YES
NO
SECTION V - ARRHYTHMIA
5A. HAS THE VETERAN HAD A CARDIAC ARRHYTHMIA?
(If "Yes," complete Item 5B)
YES
NO
(Check all that apply):
5B. SELECT TYPE OF ARRHYTHMIA
Atrial fibrillation
(If checked, indicate frequency):
Constant
Intermittent (paroxysmal)
(If "Intermittent," indicate number of episodes in the past 12 months):
0
1 - 4
More than 4
(Indicate how these episodes were documented.) (Check all that apply):
EKG
Holter
Other, specify:
Atrial flutter
(If checked, indicate frequency):
Constant
Intermittent (paroxysmal)
(If "Intermittent," indicate number of episodes in the past 12 months):
0
1 - 4
More than 4
(Indicate how these episodes were documented.) (Check all that apply):
EKG
Holter
Other, specify:
Supraventricular tachycardia
(If checked, indicate frequency):
Constant
Intermittent (paroxysmal)
(If "Intermittent," indicate number of episodes in the past 12 months):
0
1 - 4
More than 4
(Indicate how these episodes were documented.) (Check all that apply):
EKG
Holter
Other, specify:
Page 2
VA FORM 21-0960A-4, OCT 2012
ADVERTISEMENT
0 votes
Related Articles
Related forms
Va Form 21-0960j-4 - Urinary Tract (including Bladder And Urethra) Conditions (excluding Male Reproductive System) Disability Benefits Questionnaire
Legal
Va Form 21-0960n-1 - Ear Conditions (including Vestibular And Infectious Conditions) 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
Legal
Va Form 21-0960g-1 - Esophageal Conditions (including Gastroesophageal Reflux Disease (gerd), Hiatal Hernia And Other Esophageal Disorders) Disability Benefits Questionnaire
Legal
Form 21-0960j-4 - Urinary Tract (including Bladder And Urethra) Conditions (excluding Male Reproductive System) Disability Benefits Questionnaire
Legal
Va Form 21-0960g-8 - Infectious Intestinal Disorders, Including Bacterial And Parasitic Infections Disability Benefits Questionnaire
Legal
Related Categories
Parent category: Legal