OMB Control No. 2900-0778
Respondent Burden: 15 minutes
STOMACH AND DUODENAL CONDITIONS (NOT INCLUDING GERD OR
ESOPHAGEAL DISORDERS) 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 HAD ANY STOMACH OR DUODENUM CONDITIONS?
(If "Yes," complete Item 1B)
YES
NO
(check all that apply):
1B. SELECT THE VETERAN'S CONDITION
GASTRIC ULCER
ICD code:
Date of diagnosis:
DUODENAL ULCER
ICD code:
Date of diagnosis:
STENOSIS OF THE STOMACH
ICD code:
Date of diagnosis:
MARGINAL (GASTROJEJUNAL) ULCER
ICD code:
Date of diagnosis:
HYPERTROPHIC GASTRITIS
ICD code:
Date of diagnosis:
POSTGASTRECTOMY SYNDROME
ICD code:
Date of diagnosis:
STATUS POST VAGOTOMY WITH PYLOROPLASTY
ICD code:
Date of diagnosis:
GASTROENTEROSTOMY
ICD code:
Date of diagnosis:
PERITONEAL ADHESIONS FOLLOWING INJURY OR
SURGERY OF THE STOMACH
ICD code:
Date of diagnosis:
HELICOBACTER PYLORI
ICD code:
Date of diagnosis:
OTHER STOMACH OR DUODENAL 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 STOMACH OR DUODENUM CONDITIONS, LIST USING ABOVE FORMAT:
NOTE: The diagnosis of gastric or duodenal ulcer or stenosis can be made by upper gastrointestinal imaging series or endoscopy. The diagnosis of gastritis requires
endoscopic confirmation. If testing is of record and is consistent with veteran's current condition, repeat testing is not required.
SECTION II - MEDICAL HISTORY
(including onset and course)
(brief summary):
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S STOMACH OR DUODENUM CONDITIONS
2B. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING CONTINUOUS MEDICATION FOR THE DIAGNOSED CONDITION?
YES
NO
IF YES, LIST ONLY THOSE MEDICATIONS USED FOR THE DIAGNOSED CONDITION:
VA FORM
SUPERSEDES VA FORM 21-0960G-7, FEB 2011,
21-0960G-7
Page 1
OCT 2012
WHICH WILL NOT BE USED.