Va Form 21-0960g-5 - Hepatitis, Cirrhosis And Other Liver Conditions Disability Benefits Questionnaire

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OMB Control No. 2900-0778

Respondent Burden: 30 minutes

HEPATITIS, CIRRHOSIS AND OTHER LIVER CONDITIONS

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 OR SHE EVER BEEN DIAGNOSED WITH A LIVER CONDITION?

YES

(If "Yes," complete Item 1B)

(check all that apply):

1B. SELECT THE VETERAN'S CONDITION

(complete Section III)

Hepatitis A

ICD code:

Date of diagnosis:

(complete Section III)

Hepatitis B

ICD code:

Date of diagnosis:

(complete Section III)

Hepatitis C

ICD code:

Date of diagnosis:

(complete Section III)

Autoimmune hepatitis

ICD code:

Date of diagnosis:

(complete Section III)

Drug-induced hepatitis

ICD code:

Date of diagnosis:

(complete Section III)

Hemochromatosis

ICD code:

Date of diagnosis:

(complete Section IV)

Cirrhosis of the liver

ICD code:

Date of diagnosis:

(complete Section IV)

Primary biliary cirrhosis

ICD code:

Date of diagnosis:

(complete Section IV)

Sclerosing cholangitis

ICD code:

Date of diagnosis:

(complete Section V)

Liver transplant candidate

ICD code:

Date of diagnosis:

(complete Section V)

Liver transplant

ICD code:

Date of diagnosis:

Other liver conditions:

Other diagnosis #1:

ICD code:

Date of diagnosis:

Other diagnosis #2:

ICD code:

Date of diagnosis:

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO LIVER CONDITIONS, LIST USING ABOVE FORMAT:

NOTE: Determination of these conditions requires documentation by appropriate serologic testing, abnormal liver function tests, and/or abnormal liver biopsy or

imaging tests. If test results are documented in the medical record, additional testing is not required.

SECTION II - MEDICAL HISTORY

(including cause, onset and course)

(brief summary):

2A. DESCRIBE THE HISTORY

OF THE VETERAN'S LIVER CONDITIONS

2B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF THE VETERAN'S LIVER CONDITIONS?

YES

IF YES, LIST ONLY THOSE MEDICATIONS REQUIRED FOR THE LIVER CONDITIONS:

VA FORM

SUPERSEDES VA FORM 21-0960G-5, FEB 2011,

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