OMB Approved No. 2900-0781
Respondent Burden: 15 minutes
URINARY TRACT (INCLUDING BLADDER AND URETHRA) CONDITIONS
(EXCLUDING MALE REPRODUCTIVE SYSTEM) 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 THIS 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 OR SHE EVER BEEN DIAGNOSED WITH A CONDITION OF THE BLADDER OR URETHRA OF THE URINARY
(This is the condition the veteran is claiming or for which an exam has been requested)
TRACT?
(If "Yes," complete Item 1B)
YES
NO
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO URINARY TRACT CONDITIONS OF THE BLADDER OR URETHRA:
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 URINARY TRACT CONDITIONS OF THE BLADDER OR URETHRA, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL RECORD REVIEW
2. INDICATE MEDICAL RECORDS REVIEWED IN PREPARATION OF THIS REPORT:
C-FILE (VA ONLY)
OTHER, DESCRIBE:
SECTION III - MEDICAL HISTORY
(including onset and course)
(brief summary):
3. DESCRIBE THE HISTORY
OF THE VETERAN'S URINARY TRACT CONDITION
SECTION IV - VOIDING DYSFUNCTION
4. DOES THE VETERAN HAVE A VOIDING DYSFUNCTION?
(If "Yes," complete Items 4A thru 4E):
NO
YES
(i.e., relationship of voiding dysfunction to any condition in Section I, Diagnosis):
A. ETIOLOGY OF VOIDING DYSFUNCTION
B. DOES THE VOIDING DYSFUNCTION CAUSE URINE LEAKAGE?
YES
NO
(If "Yes," 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
Other, describe:
C. DOES THE VOIDING DYSFUNCTION REQUIRE THE USE OF AN APPLIANCE?
(If "Yes," describe the appliance):
YES
NO
D. DOES THE VOIDING DYSFUNCTION CAUSE INCREASED URINARY FREQUENCY?
YES
NO
(If "Yes," check all that apply):
Daytime voiding interval between 2 and 3 hours
Daytime voiding interval between 1 and 2 hours
Daytime voiding interval less than 1 hour
Nighttime awakening to void 2 times
Nighttime awakening to void 3 to 4 times
Nighttime awakening to void 5 or more times
VA FORM
SUPERSEDES VA FORM 21-0960J-4, MAR 2011,
Page 1
21-0960J-4
OCT 2012
WHICH WILL NOT BE USED.