Va Form 21-0960a-4 - Heart Conditions (Including Ischemic And Non-Ischemic Heart Disease, Arrhythmias, Valvular Disease And Cardiac Surgery) Disability Benefits Questionnaire Page 3
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SECTION V - ARRHYTHMIA
(Check all that apply) (Continued)
5B. SELECT TYPE OF ARRHYTHMIA
Atrioventricular block
I degree
II degree
III degree
Ventricular arrhythmia (sustained)
(Indicate date of hospital admission for initial evaluation and medical treatment in Section IX, Procedures)
Other cardiac arrhythmia, specify:
(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:
SECTION VI - HEART VALVE CONDITIONS
6A. HAS THE VETERAN HAD A HEART VALVE CONDITION?
(If "Yes," complete Item 6B)
YES
NO
(Check all that apply):
6B. SELECT HEART VALVES AFFECTED
Mitral
Tricuspid
Aortic
Pulmonary
6C. DESCRIBE TYPE OF HEART VALVE CONDITION FOR EACH CHECKED VALVE:
SECTION VII - INFECTIOUS HEART CONDITIONS
7A. HAS THE VETERAN HAD ANY INFECTIOUS CARDIAC CONDITIONS, INCLUDING ACTIVE VALVULAR INFECTION (INCLUDING RHEUMATIC HEART DISEASE),
ENDOCARDITIS, PERICARDITIS OR SYPHILITIC HEART DISEASE?
(If "Yes," complete Item 7B)
YES
NO
7B. HAS THE VETERAN UNDERGONE OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR ANY ACTIVE INFECTION?
YES
NO
(If, "Yes," describe treatment and site of infection being treated):
7C. HAS TREATMENT FOR AN ACTIVE INFECTION BEEN COMPLETED?
YES
NO
(If, "Yes," provide date completed):
7D. HAS THE VETERAN HAD A SYPHILITIC AORTIC ANEURYSM?
(If "Yes," ALSO complete VA Form 21-0960A-2, Artery and Vein Conditions Disability Benefits Questionnaire)
YES
NO
SECTION VIII - PERICARDIAL ADHESIONS
8A. HAS THE VETERAN HAD PERICARDIAL ADHESIONS?
(If "Yes," complete Item 8B)
YES
NO
8B. SELECT ETIOLOGY OF PERICARDIAL ADHESIONS:
Pericarditis
Cardiac surgery/bypass
Other, describe:
SECTION IX - PROCEDURES
9A. HAS THE VETERAN HAD ANY NON-SURGICAL OR SURGICAL PROCEDURES FOR THE TREATMENT OF A HEART CONDITION?
(If "Yes," complete Item 9B)
YES
NO
(Check all that apply):
9B. INDICATE THE NON-SURGICAL OR SURGICAL PROCEDURES THE VETERAN HAS HAD FOR THE TREATMENT OF HEART CONDITIONS
Percutaneous coronary intervention (PCI) (angioplasty)
Indicate date of treatment or date of admission if admitted for treatment and name of treatment facility:
Coronary artery bypass surgery
Indicate date of admission for treatment and name of treatment facility:
Heart valve replacement
Specify valve(s) replaced and type of valve(s):
Indicate date of admission for treatment and name of treatment facility:
Heart transplants
Indicate date of admission for treatment and name of treatment facility:
Implanted cardiac pacemaker
Indicate date of admission for treatment and name of treatment facility:
Page 3
VA FORM 21-0960A-4, OCT 2012
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