Fillable Va Form 21-0960a-3 - Hypertension Disability Benefits Questionnaire printable pdf download

OMB Approved No. 2900-0776

Respondent Burden: 15 minutes

HYPERTENSION 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

NOTE: For VA disability rating purposes, the term hypertension means that the diastolic blood pressure is predominantly 90mm or greater, and isolated systolic

hypertension means that the systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. For VA purposes, the

INITIAL diagnosis of hypertension or isolated systolic hypertension must be confirmed by readings taken 2 or more times on at least 3 different days. Blood pressure

results may be obtained from existing medical records or through scheduled visits for blood pressure measurements.

1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH HYPERTENSION OR ISOLATED SYSTOLIC HYPERTENSION BASED ON

THE FOLLOWING CRITERIA?

(If "Yes," provide only diagnoses that pertain to hypertension):

YES

Hypertension

ICD code:

Date of diagnosis:

Isolated systolic hypertension

ICD code:

Date of diagnosis:

Other, specify:

Other diagnosis #1:

ICD code:

Date of diagnosis:

Other diagnosis #2:

ICD code:

Date of diagnosis:

NOTE: ALSO complete appropriate questionnaires for hypertension-related complications, if any (such as VA Form 21-0960J-1, Kidney Conditions (Nephrology)

Disability Benefits Questionnaire , if renal insufficiency is attributable to hypertension.)

1B. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO HYPERTENSION OR ISOLATED SYSTOLIC HYPERTENSION, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY

(Brief summary):

2A. DESCRIBE THE HISTORY (INCLUDING ONSET AND COURSE) OF THE VETERAN'S HYPERTENSION CONDITION

2B. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING CONTINUOUS MEDICATION FOR HYPERTENSION OR ISOLATED SYSTOLIC HYPERTENSION?

(If "Yes," list only those medications used for the diagnosed conditions):

YES

2C. WAS THE VETERAN'S INITIAL DIAGNOSIS OF HYPERTENSION OR ISOLATED SYSTOLIC HYPERTENSION CONFIRMED BY BLOOD PRESSURE READINGS

TAKEN 2 OR MORE TIMES ON AT LEAST 3 DIFFERENT DAYS?

(If, "Yes," provide BP readings used to establish initial diagnosis, if known.)

YES