Va Form 21-0960g-7 - Stomach And Duodenal Conditions (Not Including Gerd Or Esophageal Disorders) Disability Benefits Questionnaire Page 2

Download a blank fillable Va Form 21-0960g-7 - Stomach And Duodenal Conditions (Not Including Gerd Or Esophageal Disorders) Disability Benefits Questionnaire in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Va Form 21-0960g-7 - Stomach And Duodenal Conditions (Not Including Gerd Or Esophageal Disorders) Disability Benefits Questionnaire with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

SECTION III - SIGNS AND SYMPTOMS
3. DOES THE VETERAN HAVE ANY OF THE FOLLOWING SIGNS OR SYMPTOMS DUE TO ANY STOMACH OR DUODENUM CONDITIONS?
YES
NO
(check all that apply)
IF YES,
:
Recurring episodes of symptoms that are not severe
If checked, indicate frequency of episodes of symptom recurrence per year:
0
1
2
3
4 or more
If checked, indicate average duration of episodes of symptoms:
Less than 1 day
1-9 days
10 days or more
Recurring episodes of severe symptoms
If checked, indicate frequency of episodes of symptom recurrence per year:
0
1
2
3
4 or more
If checked, indicate average duration of episodes of symptoms:
Less than 1 day
1-9 days
10 days or more
Abdominal Pain
(check all that apply)
If checked, indicate severity and frequency
:
Occurs less than monthly
Occurs at least monthly
Pronounced
Periodic
Continuous
Relieved by standard ulcer therapy
Only partially relieved by standard ulcer therapy
Unrelieved by standard ulcer therapy
Anemia
If checked, provide hemoglobin/hematocrit in diagnostic testing section.
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).
Nausea
If checked, indicate severity:
Mild
Transient
Recurrent
Periodic
If checked, indicate frequency of episodes of nausea per year:
0
1
2
3
4 or more
If checked, indicate average duration of episodes of nausea:
Less than 1 day
1-9 days
10 days or more
Vomiting
If checked, indicate severity:
Mild
Transient
Recurrent
Periodic
If checked, indicate frequency of episodes of vomiting per year:
0
1
2
3
4 or more
If checked, indicate average duration of episodes of vomiting:
Less than 1 day
1-9 days
10 days or more
Hematemesis
If checked, indicate severity:
Mild
Transient
Recurrent
Periodic
If checked, indicate frequency of episodes of hematemesis per year:
0
1
2
3
4 or more
If checked, indicate average duration of episodes of hematemesis:
Less than 1 day
1-9 days
10 days or more
Melena
If checked, indicate severity:
Mild
Transient
Recurrent
Periodic
If checked, indicate frequency of episodes of melena per year:
0
1
2
3
4 or more
If checked, indicate average duration of episodes of melena:
Less than 1 day
1-9 days
10 days or more
Page 2
VA FORM 21-0960G-7, OCT 2012

ADVERTISEMENT

00 votes

Related Articles

5 Things You Need To Know About The Gi Bill Benefits
Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids

Related forms

Va Form 21-0960g-2 - Gallbladder And Pancreas Conditions Disability Benefits Questionnaire Va Form 21-0960g-2 - Gallbladder And Pancreas Conditions Disability Benefits Questionnaire Legal
Va Form 21-0960m-7 - Hand And Finger Conditions Disability Benefits Questionnaire Va Form 21-0960m-7 - Hand And Finger Conditions Disability Benefits Questionnaire Legal
Va Form 21-0960g-1 - Esophageal Conditions (including Gastroesophageal Reflux Disease (gerd), Hiatal Hernia And Other Esophageal Disorders) Disability Benefits Questionnaire Va Form 21-0960g-1 - Esophageal Conditions (including Gastroesophageal Reflux Disease (gerd), Hiatal Hernia And Other Esophageal Disorders) Disability Benefits Questionnaire Legal
Va Form 21-0960g-1 - Esophageal Conditions (including Gastroesophageal Reflux Disease (gerd), Hiatal Hernia And Other Esophageal Disorders) Disability Benefits Questionnaire Va Form 21-0960g-1 - Esophageal Conditions (including Gastroesophageal Reflux Disease (gerd), Hiatal Hernia And Other Esophageal Disorders) Disability Benefits Questionnaire Legal
Va Form 21-0960d-1 - Oral And Dental Conditions Including Mouth, Lips And Tongue (other Than Temporomandibular Joint Conditions) Disability Benefits Questionnaire Va Form 21-0960d-1 - Oral And Dental Conditions Including Mouth, Lips And Tongue (other Than Temporomandibular Joint Conditions) Disability Benefits Questionnaire Legal
Va Form 21-0960b-2 - Hematologic And Lymphatic Conditions, Including Leukemia Disability Benefits Questionnaire Va Form 21-0960b-2 - Hematologic And Lymphatic Conditions, Including Leukemia Disability Benefits Questionnaire Legal
Va Form 21-0960h-2 - Rectum And Anus Conditions (including Hemorrhoids) Disability Benefits Questionnaire Va Form 21-0960h-2 - Rectum And Anus Conditions (including Hemorrhoids) Disability Benefits Questionnaire Legal
Va Form 21-0960a-2 - Artery And Vein Conditions (vascular Diseases Including Varicose Veins) Disability Benefits Questionnaire Va Form 21-0960a-2 - Artery And Vein Conditions (vascular Diseases Including Varicose Veins) Disability Benefits Questionnaire Legal
Va Form 21-0960e-3 - Thyroid And Parathyroid Conditions Disability Benefits Questionnaire Va Form 21-0960e-3 - Thyroid And Parathyroid Conditions Disability Benefits Questionnaire Legal
Va Form 21-0960m-4 - Elbow And Forearm Conditions Disability Benefits Questionnaire Va Form 21-0960m-4 - Elbow And Forearm Conditions Disability Benefits Questionnaire Legal

Related Categories

Parent category: Legal
Download
Go
Page of 5