Va Form 21-0960j-1 - Kidney Conditions (Nephrology) Disability Benefits Questionnaire Page 3
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5SECTION V - INFECTIONS OF THE KIDNEY AND/OR URINARY TRACT
5A. DOES THE VETERAN HAVE A HISTORY OF RECURRENT SYMPTOMATIC URINARY TRACT OR KIDNEY INFECTIONS?
YES
NO
(If yes, complete questions 5B - 5C)
5B. ETIOLOGY OF RECURRENT URINARY TRACT OR KIDNEY INFECTIONS:
(check all that apply):
5C. INDICATE ALL TREATMENT MODALITIES USED FOR RECURRENT URINARY TRACT OR KIDNEY INFECTIONS
No treatment
Long-term drug therapy
If checked, list medications used and indicate dates for courses of treatment over the past 12 months:
Hospitalization
If checked, indicate frequency of hospitalization:
1 or 2 per year
More than 2 per year
Drainage
If checked, indicate dates when drainage was performed over the past 12 months:
Continuous intensive management
If checked, indicate types of treatment and medications used over the past 12 months:
Intermittent intensive management
If checked, indicate types of treatment and medications used over the past 12 months:
Other, describe:
SECTION VI - KIDNEY TRANSPLANT OR REMOVAL
6A. HAS THE VETERAN HAD A KIDNEY TRANSPLANT OR REMOVAL?
YES
NO
(If yes, complete questions 6B - 6C)
6B. HAS THE VETERAN HAD A KIDNEY REMOVED?
YES
NO
(If yes, provide reason):
Kidney donation
Due to disease
Due to trauma or injury
Other, describe:
6C. HAS THE VETERAN HAD A KIDNEY TRANSPLANT?
YES
NO
If yes, date of transplant:
Name of treatment facility, date of admission and date of discharge for transplant:
SECTION VII - TUMORS AND NEOPLASMS
7A. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DIAGNOSIS?
YES
NO
(If yes, complete questions 7B - 7E)
7B. IS THE NEOPLASM
BENIGN
MALIGNANT
7C. HAS THE VETERAN COMPLETED TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT NEOPLASM
OR METASTASES?
YES
NO; WATCHFUL WAITING
Page 3
VA FORM 21-0960J-1, OCT 2012
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