Va Form 21-0960j-3 - Prostate Cancer Disability Benefits Questionnaire Page 2
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3SECTION IV - VOIDING DYSFUNCTION
4. DOES THE VETERAN HAVE A VOIDING DYSFUNCTION?
(If "Yes," provide etiology of voiding dysfunction)
YES
NO
(If the veteran has a voiding dysfunction, complete Items 4A through 4D)
A. DOES THE VOIDING DYSFUNCTION CAUSE URINE LEAKAGE?
YES
NO
(Check one)
INDICATE SEVERITY
DOES NOT REQUIRE THE WEARING OF ABSORBENT MATERIAL
REQUIRES ABSORBENT MATERIAL WHICH MUST BE CHANGED LESS THAN 2 TIMES PER DAY
REQUIRES ABSORBENT MATERIAL WHICH MUST BE CHANGED 2 TO 4 TIMES PER DAY
REQUIRES ABSORBENT MATERIAL WHICH MUST BE CHANGED MORE THAN 4 TIMES PER DAY
(Describe)
OTHER
B. DOES THE VOIDING DYSFUNCTION REQUIRE THE USE OF AN APPLIANCE?
(If "Yes," describe the appliance)
YES
NO
C. DOES THE VOIDING DYSFUNCTION CAUSE INCREASED URINARY FREQUENCY?
YES
NO
(If "Yes," check all that apply)
INDICATE FREQUENCY
NIGHTTIME AWAKENING TO VOID 2 TIMES
DAYTIME VOIDING INTERVAL BETWEEN 2 AND 3 HOURS
NIGHTTIME AWAKENING TO VOID 3 TO 4 TIMES
DAYTIME VOIDING INTERVAL BETWEEN 1 AND 2 HOURS
NIGHTTIME AWAKENING TO VOID 5 OR MORE TIMES
DAYTIME VOIDING INTERVAL LESS THAN 1 HOUR
D. DOES THE VOIDING DYSFUNCTION CAUSE SIGNS OR SYSTEMS OF OBSTRUCTED VOIDING?
YES
(If "Yes," check all that apply)
NO
(If checked, is hesitancy marked?)
STRICTURE DISEASE REQUIRING DILATATION 1 TO 2 TIMES PER YEAR
HESITANCY
YES
STRICTURE DISEASE REQUIRING PERIODIC DILATATION EVERY 2 TO 3 MONTHS
NO
SLOW OR WEAK STREAM
RECURRENT URINARY TRACT INFECTIONS SECONDARY TO OBSTRUCTION
(If checked, is stream markedly slow or weak?)
UROFLOWMETRY PEAK FLOW RATE LESS THAN 10 CC/SEC
YES
NO
POST VOID RESIDUALS GREATER THAN 150 CC
(If checked,
URINARY RETENTION REQUIRING INTERMITTENT CATHETERIZATION
DECREASED FORCE OF STREAM
is force of stream markedly decreased?)
URINARY RETENTION REQUIRING CONTINUOUS CATHETERIZATION
YES
NO
(Describe)
OTHER
SECTION V - URINARY TRACT/KIDNEY INFECTION
5. DOES THE VETERAN HAVE A HISTORY OF RECURRENT SYMPTOMATIC URINARY TRACT OR KIDNEY INFECTIONS?
(If "Yes," provide etiology)
YES
NO
IF THE VETERAN HAS HAD RECURRENT SYMPTOMATIC URINARY TRACT OR KIDNEY INFECTIONS, INDICATE ALL TREATMENT MODALITIES THAT APPLY:
NO TREATMENT
(If checked, list medications used and indicate dates for courses of treatment over the past 12 months)
LONG-TERM DRUG THERAPY
(If checked, indicate frequency of hospitalization)
HOSPITALIZATION
1 OR 2 PER YEAR
> 2 PER YEAR
(If checked, indicate dates when drainage performed over past 12 months)
DRAINAGE
(If checked, indicate types of treatment and medications used over past 12 months)
CONTINUOUS INTENSIVE MANAGEMENT
(If checked, indicate types of treatment and medications used over past 12 months)
INTERMITTENT INTENSIVE MANAGEMENT
(Describe)
OTHER
SECTION VI - ERECTILE DYSFUNCTION
6A. DOES THE VETERAN HAVE ERECTILE DYSFUNCTION?
YES
NO
(If "Yes," provide etiology)
6B. IF THE VETERAN HAS ERECTILE DYSFUNCTION, IS IT AS LIKELY AS NOT (AT LEAST A 50%PROBABILITY) ATTRIBUTABLE TO ONE OF THE DIAGNOSES IN
SECTION I, INCLUDING RESIDUALS OF TREATMENT FOR THIS DIAGNOSIS?
(If "Yes," specify the diagnosis to which the erectile dysfunction is as likely as not attributable)
YES
NO
6C. IF THE VETERAN HAS ERECTILE DYSFUNCTION, IS HE ABLE TO ACHIEVE AN ERECTION SUFFICIENT FOR PENETRATION AND EJACULATION (WITHOUT
MEDICATION)?
(If "No," is the veteran able to achieve an erection sufficient for penetration and ejaculation (with medication)?
YES
NO
YES
NO
Page 2
VA FORM 21-0960J-3, OCT 2012
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