Va Form 21-0960j-1 - Kidney Conditions (Nephrology) Disability Benefits Questionnaire Page 2
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SECTION III - RENAL DYSFUNCTION
3C. DOES THE VETERAN HAVE ANY SIGNS OR SYMPTOMS DUE TO RENAL DYSFUNCTION?
YES
NO
(If yes check all that apply):
(albuminuria)
Proteinuria
(If checked, indicate frequency: (check all that apply)
Recurring
Constant
Persistent
(due to renal dysfunction)
Edema
(If checked, indicate frequency: (check all that apply)
Some
Transient
Slight
Persistent
(due to renal dysfunction)
Anorexia
(due to renal dysfunction)
Weight loss
(average weight for 2-year period preceding onset of disease):
Provide current weight:
If checked, provide baseline weight
(due to renal dysfunction)
Generalized poor health
(due to renal dysfunction)
Lethargy
(due to renal dysfunction)
Weakness
(due to renal dysfunction)
Limitation of exertion
Able to perform only sedentary activity, due to persistent edema caused by renal dysfunction
(If checked, describe):
Markedly decreased function of other organ systems, especially the cardiovascular system, caused by renal dysfunction
(If checked, describe):
Other
3D. DOES THE VETERAN HAVE HYPERTENSION AND/OR HEART DISEASE DUE TO RENAL DYSFUNCTION OR CAUSED BY ANY KIDNEY CONDITION?
YES
NO
(If Yes, also complete VA Form 21-0960A-3, Hypertension Disability Benefits Questionnaire and/or VA Form 21-0960A-4, Heart Conditions (Including Ischemic and
Non-Ischemic Heart Disease, Arrhythmias, Valvular Disease and Cardiac Surgery) Disability Benefits Questionnaire, as appropriate.))
SECTION IV - UROLITHIASIS
4A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD KIDNEY, URETAL OR BLADDER CALCULI (UROLITHIASIS)?
YES
NO
(If yes, complete questions 4B - 4D)
4B. INDICATE CURRENT/PAST LOCATION OF CALCULI
KIDNEY
URETER
BLADDER
4C. HAS THE VETERAN HAD TREATMENT FOR RECURRENT STONE FORMATION IN THE KIDNEY, URETER OR BLADDER?
YES
NO
(If yes, indicate treatment (Check all that apply)):
Diet therapy
If checked, specify diet and dates of use:
Drug therapy
If checked, list medication and dates of use:
Invasive or non-invasive procedures
If checked, indicate average number of times per year invasive or non-invasive procedures were required:
0 to 1/year
2/year
more than 2/year
Date and facility of most recent invasive or non-invasive procedure:
4D. DOES THE VETERAN HAVE ANY SIGNS OR SYMPTOMS DUE TO UROLITHIASIS?
YES
NO
(If yes, indicate severity (Check all that apply)):
Causing infection (pyonephrosis)
No symptoms or attacks of colic
Occasional attacks of colic
Causing hydronephrosis
Frequent attacks of colic
Causing impaired kidney function
Causing voiding dysfunction
Other, describe:
Requires catheter drainage
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VA FORM 21-0960J-1, OCT 2012
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