Va Form 21-0960a-4 - Heart Conditions (Including Ischemic And Non-Ischemic Heart Disease, Arrhythmias, Valvular Disease And Cardiac Surgery) Disability Benefits Questionnaire Page 4

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(Continued)
SECTION IX - PROCEDURES
(Continued)
9B. INDICATE THE NON-SURGICAL OR SURGICAL PROCEDURES THE VETERAN HAS HAD FOR THE TREATMENT OF HEART CONDITIONS
(Check all that apply):
Implanted automatic implantable cardioverter defibrillator (AICD)
Indicate date of admission for treatment and name of treatment facility:
Valve replacement
(check all that apply):
If checked indicate valve(s) that have been replaced
Mitral
Tricuspid
Aortic
Pulmonary
Indicate date of admission for treatment and name of treatment facility for each checked valve:
Ventricular aneurysmectomy
Indicate date of admission for treatment and name of treatment facility:
Other surgical and/or non-surgical procedures for the treatment of a heart condition, describe:
Indicate date of admission for treatment and name of treatment facility:
Indicate the condition that resulted in the need for this procedure/treatment:
SECTION X - HOSPITALIZATIONS
10. HAS THE VETERAN HAD ANY OTHER HOSPITALIZATIONS FOR THE TREATMENT OF HEART CONDITIONS (OTHER THAN FOR NON-SURGICAL AND SURGICAL
PROCEDURES DESCRIBED ABOVE)?
(If "Yes," provide the following):
YES
NO
Date of admission for treatment and name of treatment facility:
Condition that resulted in the need for hospitalization:
SECTION XI - PHYSICAL EXAM
11. PHYSICAL EXAM:
Heart rate:
Rhythm:
Regular
Irregular
Point of maximal impact:
Not palpable
4th intercostal space
5th intercostal space
Other, specify:
Heart sounds:
Normal
Abnormal, specify:
Jugular-venous distension:
Yes
No
Auscultation of the lungs:
Clear
Bibasilar rales
Other, describe:
Peripheral pulses:
Dorsalis pedis:
Normal
Diminished
Absent
Posterior tibial:
Normal
Diminished
Absent
Peripheral edema:
Right lower extremity:
None
Trace
1+
2+
3+
4+
Left lower extremity:
None
Trace
1+
2+
3+
4+
Blood pressure:
SECTION XII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
(surgical or otherwise)
12A. DOES THE VETERAN HAVE ANY SCARS
RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
SECTION I, 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 cm (6 square inches)?)
(If "Yes," ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)
YES
NO
12B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN SECTION I, DIAGNOSIS?
(If "Yes," describe - brief summary):
YES
NO
Page 4
VA FORM 21-0960A-4, OCT 2012

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