Va Form 21-0960g-2 - Gallbladder And Pancreas Conditions Disability Benefits Questionnaire Page 3
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SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
(surgical or otherwise)
5B. DOES THE VETERAN HAVE ANY SCARS
RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
SECTION I, DIAGNOSIS?
YES
NO
(If "Yes," are any of the scars painful and/or unstable, or is the total area of all related scars greater than or equal to 39 square cm (6 square inches)?)
YES
NO
(If "Yes," also complete a VA Form 21-0960F-1 Scars/Disfigurement Disability Benefits Questionnaire)
SECTION VI - DIAGNOSTIC TESTING
NOTE: Diagnosis of pancreatitis must be confirmed by appropriate laboratory and clinical studies. If testing has been performed and reflects veteran's current condition,
no further testing is required for this examination report.
6A. HAVE IMAGING STUDIES BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES
NO
(If "Yes," check all that apply):
(Endoscopic ultrasound)
EUS
Date:
Results:
(Endoscopic retrograde cholangiopancreatography)
ERCP
Date:
Results:
Transhepatic cholangiogram
Date:
Results:
(magnetic resonance cholangiopancreatography)
MRI or MRCP
Date:
Results:
(HIDA scan or cholescintigraphy)
Gallbladder scan
Date:
Results:
CT
Date:
Results:
Other, specify:
Date:
Results:
6B. HAS LABORATORY TESTING BEEN PERFORMED?
YES
NO
(If "Yes," check all that apply):
Alkaline phosphatase
Date:
Results:
Bilirubin
Date:
Results:
WBC
Date:
Results:
Amylase
Date:
Results:
Lipase
Date:
Results:
Other, specify:
Date:
Results:
6C. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES
NO
(If "Yes," provide type of test or procedure, date and results in a brief summary):
SECTION VII - FUNCTIONAL IMPACT
7. DOES THE VETERAN'S GALLBLADDER AND/OR PANCREAS CONDITION(S) IMPACT ON HIS OR HER ABILITY TO WORK?
(If "Yes," describe the impact of each of the veteran's gallbladder and/or pancreas conditions, providing one or more examples):
YES
NO
Page 3
VA FORM 21-0960G-2, OCT 2012
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