Va Form 21-0960j-1 - Kidney Conditions (Nephrology) Disability Benefits Questionnaire
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5OMB Approved No. 2900-0779
Respondent Burden: 30 minutes
KIDNEY CONDITIONS (NEPHROLOGY) 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 KIDNEY CONDITION?
(If "Yes," complete Item 1B)
YES
NO
(check all that apply):
1B. INDICATE DIAGNOSIS
Diabetic nephropathy
ICD CODE:
DATE OF DIAGNOSIS:
Glomerulonephritis
ICD CODE:
DATE OF DIAGNOSIS:
Hydronephrosis
ICD CODE:
DATE OF DIAGNOSIS:
Interstitial nephritis
ICD CODE:
DATE OF DIAGNOSIS:
Kidney transplant
ICD CODE:
DATE OF DIAGNOSIS:
Nephrosclerosis
ICD CODE:
DATE OF DIAGNOSIS:
Nephrolithiasis
ICD CODE:
DATE OF DIAGNOSIS:
Renal artery stenosis
ICD CODE:
DATE OF DIAGNOSIS:
Ureterolithiasis
ICD CODE:
DATE OF DIAGNOSIS:
Neoplasm of the kidney
ICD CODE:
DATE OF DIAGNOSIS:
Cholesterol emboli
ICD CODE:
DATE OF DIAGNOSIS:
Cystic kidney disease
ICD CODE:
DATE OF DIAGNOSIS:
Congenital kidney disorder
ICD CODE:
DATE OF DIAGNOSIS:
Other inherited kidney disorder
ICD CODE:
DATE OF DIAGNOSIS:
Specify:
(Specify
Other kidney condition
diagnosis, providing only diagnoses
that pertain to kidney conditions)
Other diagnosis #1:
ICD CODE:
DATE OF DIAGNOSIS:
Other diagnosis #2:
ICD CODE:
DATE OF DIAGNOSIS:
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO KIDNEY CONDITION(S), LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including cause, onset and course)
(Give a brief summary):
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S CURRENT KIDNEY CONDITION(S)
2B. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING CONTINUOUS MEDICATION FOR THE DIAGNOSED CONDITION?
YES
NO
List medications taken for the diagnosed condition:
SECTION III - RENAL DYSFUNCTION
(Evidence of renal dysfunction includes either persistent proteinuria, hematuria or GFR < 60 cc/min/1.73m2)
3A. DOES THE VETERAN HAVE RENAL DYSFUNCTION?
(If yes complete questions 3B - 3D)
YES
NO
3B. DOES THE VETERAN REQUIRE REGULAR DIALYSIS?
YES
NO
VA FORM
SUPERSEDES VA FORM 21-0960J-1, DEC 2010,
21-0960J-1
Page 1
OCT 2012
WHICH WILL NOT BE USED.
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