Va Form 21-0960a-4 - Heart Conditions (Including Ischemic And Non-Ischemic Heart Disease, Arrhythmias, Valvular Disease And Cardiac Surgery) Disability Benefits Questionnaire Page 6
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7SECTION XIV - METs TESTING
NOTE: For VA purposes, all heart exams require METs testing (either exercise-based or interview-based) to determine the activity level at which symptoms such as
dyspnea, fatigue, angina, dizziness, or syncope develop (except exams for supraventricular arrhythmias.)
If a laboratory determination of METs by exercise testing cannot be done for medical reasons (e.g. chronic CHF or multiple episodes of acute CHF within the past 12
months), or if exercise-based METs test was not completed because it is not required as part of the veteran's treatment plan, or if exercise stress test results do no reflect
veteran's current cardiac function, perform an interview-based METs test based on the veteran's responses to a cardiac activity questionnaire and provide the results
below.
14A. INDICATE ALL TESTING COMPLETED PROVIDING ONLY MOST RECENT RESULTS WHICH REFLECT THE VETERAN'S CURRENT FUNCTIONAL STATUS.
(Check all that apply):
Exercise stress test
Date of most recent exercise stress test:
Results:
METs level the veteran performed, if provided:
Interview-based METs test
Date of interview-based METs test:
Symptoms during activity:
The METs level checked below reflects the lowest activity level at which the veteran reports any of the
(check all symptoms that the veteran reports at the indicated METs level of activity)
following symptoms
:
Dyspnea
Fatigue
Angina
Dizziness
Syncope
Other, describe:
Results:
METs level on most recent interview-based METs test:
This METs level has been found to be consistent with activities such as eating, dressing, taking a shower, slow
(1-3 METs)
walking (2 mph) for 1-2 blocks
This METs level has been found to be consistent with activities such as light yard work (weeding), mowing lawn
(>3-5 METs)
(power mower), brisk walking (4 mph)
This METs level has been found to be consistent with activities such as walking 1 flight of stairs, golfing (without
(>5-7 METs)
cart), mowing lawn (push mower), heavy yard work (digging)
This METs level has been found to be consistent with activities such as climbing stairs quickly, moderate
(>7-10 METs)
bicycling, sawing wood, jogging (6 mph)
The veteran denies experiencing above symptoms with any level of physical activity
14B. IF THE VETERAN HAS HAD BOTH AN EXERCISE STRESS TEST AND INTERVIEW-BASED METs TEST, INDICATE WHICH RESULTS MOST ACCURATELY
REFLECT THE VETERAN'S CURRENT CARDIAC FUNCTIONAL LEVEL:
Exercise stress test
Interview-based METs test
N/A
14C. IS THE METs LEVEL LIMITATION DUE SOLELY TO THE HEART CONDITIONS?
YES
NO
(If "No," estimate the percentage of the METs level limitation that is due solely to the heart condition(s)):
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
The limitation in METs level is due to multiple factors; it is not possible to accurately estimate this percentage.
(such as musculoskeletal or
14D. IN ADDITION TO THE HEART CONDITION(S), DOES THE VETERAN HAVE OTHER NON-CARDIAC MEDICAL CONDITIONS
pulmonary conditions)
LIMITING THE METs LEVEL?
YES
NO
(If "Yes," identify each condition and describe how each non-cardiac medical condition limits the veteran's METs level):
Other medical condition #1:
Effect on METs level:
Other medical condition #2:
Effect on METs level:
14E. IF THERE ARE ADDITIONAL MEDICAL CONDITIONS AFFECTING METs LEVEL, LIST USING ABOVE FORMAT:
Page 6
VA FORM 21-0960A-4, OCT 2012
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