OMB Approved No. 2900-0779
Respondent Burden: 15 minutes
PROSTATE CANCER 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 EVER BEEN DIAGNOSED WITH PROSTATE CANCER?
(If "Yes," complete Item 1B)
YES
NO
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO PROSTATE CANCER
DIAGNOSIS # 1 -
ICD CODE -
DATE OF DIAGNOSIS -
DIAGNOSIS # 2 -
ICD CODE -
DATE OF DIAGNOSIS -
DIAGNOSIS # 3 -
ICD CODE -
DATE OF DIAGNOSIS -
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO PROSTATE CANCER, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(Brief summary)
2A. DESCRIBE THE HISTORY (INCLUDING ONSET AND COURSE) OF THE VETERAN'S PROSTATE CANCER CONDITION
2B. INDICATE STATUS OF THE DISEASE
ACTIVE
REMISSION
SECTION III - TREATMENT
3. HAS THE VETERAN COMPLETED ANY TREATMENT FOR PROSTATE CANCER OR IS THE VETERAN CURRENTLY UNDERGOING ANY TREATMENT FOR
PROSTATE CANCER?
(If "Yes," specify treatment type(s)) (Check all that apply)
YES
NO, WATCHFUL WAITING
TREATMENT COMPLETED, CURRENTLY IN WATCHFUL WAITING STATUS
SURGERY
PROSTATECTOMY
RADICAL PROSTATECTOMY
TRANSURETHRAL RESECTION PROSTATECTOMY
OTHER (DESCRIBE):
(DATE OF SURGERY):
OTHER SURGICAL PROCEDURE (DESCRIBE):
RADIATION THERAPY (DATE OF COMPLETION OF TREATMENT OR ANTICIPATED DATE OF COMPLETION):
BRACHYTHERAPY (DATE OF TREATMENT):
ANTINEOPLASTIC CHEMOTHERAPY (DATE OF COMPLETION OF TREATMENT OR ANTICIPATED DATE OF COMPLETION):
ANDROGEN DEPRIVATION THERAPY (HORMONAL THERAPY) (DATE OF COMPLETION OF TREATMENT OR ANTICIPATED DATE OF COMPLETION):
OTHER THERAPEUTIC PROCEDURE AND/OR TREATMENT (DESCRIBE):
(DATE OF PROCEDURE):
(DATE OF COMPLETION OF TREATMENT OR ANTICIPATED DATE OF COMPLETION):
VA FORM
SUPERSEDES VA FORM 21-0960J-3, DEC 2010,
21-0960J-3
Page 1
WHICH WILL NOT BE USED.
OCT 2012