Va Form 21-0960g-2 - Gallbladder And Pancreas Conditions Disability Benefits Questionnaire Page 2
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4SECTION III - GALLBLADDER CONDITIONS: SIGNS AND SYMPTOMS
3. DOES THE VETERAN HAVE ANY OF THE FOLLOWING SIGNS OR SYMPTOMS ATTRIBUTABLE TO ANY GALLBLADDER CONDITIONS OR RESIDUALS
OF TREATMENT FOR GALLBLADDER CONDITIONS?
YES
NO
(If "Yes," check all that apply):
(including sphincter of oddi dysfunction and/or biliary dyskinesia)
Gallbladder disease-induced dyspepsia
(If checked, indicate number of episodes per year):
0
1
2
3
4 or more
Attacks of gallbladder colic
(If checked, indicate number of attacks per year):
0
1
2
3
4 or more
Jaundice
(If checked, provide bilirubin level in Section VI, Diagnostic Testing)
Other signs or symptoms, describe:
SECTION IV - PANCREAS CONDITIONS: SIGNS AND SYMPTOMS
4A. DOES THE VETERAN HAVE ANY OF THE FOLLOWING SYMPTOMS ATTRIBUTABLE TO ANY PANCREAS CONDITIONS OR RESIDUALS OF TREATMENT FOR
PANCREAS CONDITIONS?
YES
NO
(If "Yes," check all that apply):
Abdominal pain, confirmed as resulting from pancreatitis by appropriate laboratory and clinical studies
(If checked, indicate severity and frequency of attacks, check all that apply):
Mild (typical)
Moderately Severe
Severe (disabling)
(Indicate number of attacks of MILD (TYPICAL) abdominal pain in the past 12 months):
0
1
2
3
4
5
6
7
8 or more
(Indicate number of attacks of MODERATELY SEVERE abdominal pain in the past 12 months):
0
1
2
3
4
5
6
7
8 or more
(Indicate number of attacks of SEVERE (DISABLING) abdominal pain in the past 12 months):
0
1
2
3
4
5
6
7
8 or more
Remissions/pain-free intermissions between attacks
(If checked, indicate characteristics of remissions):
Good pain-free remissions between attacks
Few pain-free intermissions between attacks
Continuing pancreatic insufficiency between attacks
Other symptoms, describe:
4B. DOES THE VETERAN HAVE ANY OF THE FOLLOWING SIGNS OR FINDINGS ATTRIBUTABLE TO ANY PANCREAS CONDITIONS OR RESIDUALS OF TREATMENT
FOR PANCREAS CONDITIONS?
YES
NO
(If "Yes," check all that apply):
Steatorrhea
(If checked, describe frequency and severity):
Malabsorption
(If checked, describe frequency and severity):
Diarrhea
(If checked, describe frequency and severity):
Severe malnutrition
(If checked, describe deficiency (such as beta-carotene, fat-soluble vitamin deficiencies)):
Weight loss
(If checked, provide baseline weight:
and current weight:
).
(For VA purposes, baseline weight is the average weight for 2-year period preceding onset of disease).
Other, describe:
SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
5A. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN SECTION I, DIAGNOSIS?
YES
NO
(If "Yes," describe in a brief summary):
Page 2
VA FORM 21-0960G-2, OCT 2012
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