Va Form 21-0960g-2 - Gallbladder And Pancreas Conditions Disability Benefits Questionnaire
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4OMB Control No. 2900-0778
Respondent Burden: 15 minutes
GALLBLADDER AND PANCREAS 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 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 GALLBLADDER OR PANCREAS CONDITION?
(If "Yes," complete Item 1B)
YES
NO
(check all that apply):
1B. SELECT THE VETERAN'S CONDITION
Chronic cholecystitis
ICD Code:
Date of Diagnosis:
Chronic cholelithiasis
ICD Code:
Date of Diagnosis:
Chronic cholangitis
ICD Code:
Date of Diagnosis:
Cholecystectomy
ICD Code:
Date of Diagnosis:
Pancreatitis
ICD Code:
Date of Diagnosis:
Total or partial pancreatectomy
ICD Code:
Date of Diagnosis:
Gallbladder neoplasm
ICD Code:
Date of Diagnosis:
Pancreatic neoplasm
ICD Code:
Date of Diagnosis:
Gallbladder or pancreas injury, with peritoneal adhesions resulting
ICD Code:
Date of Diagnosis:
from this injury
(If checked, ALSO complete VA Form 21-0960G-6, Peritoneal Adhesions Disability Benefits Questionnaire)
Other gallbladder 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 GALLBLADDER OR PANCREAS CONDITIONS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
(brief summary):
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S GALLBLADDER AND/OR PANCREAS CONDITION
2B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF THE VETERAN'S GALLBLADDER OR PANCREAS CONDITION?
(If "Yes," list only those medications required for the gallbladder or pancreas condition):
YES
NO
VA FORM
SUPERSEDES VA FORM 21-0960G-2, FEB 2011,
21-0960G-2
Page 1
OCT 2012
WHICH WILL NOT BE USED.
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