Va Form 21-0960g-7 - Stomach And Duodenal Conditions (Not Including Gerd Or Esophageal Disorders) Disability Benefits Questionnaire Page 3
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5SECTION IV - INCAPACITATING EPISODES
4. DOES THE VETERAN HAVE INCAPACITATING EPISODES DUE TO SIGNS OR SYMPTOMS OF ANY STOMACH OR DUODENUM CONDITION?
YES
NO
IF YES, DESCRIBE INCAPACITATING EPISODES:
Indicate frequency of incapacitating episodes per year:
0
1
2
3
4 or more
Indicate average duration of incapacitating episodes:
Less than 1 day
1-9 days
10 days or more
SECTION V - OTHER CONDITIONS
5. DOES THE VETERAN HAVE ANY OF THE FOLLOWING CONDITIONS?
YES
NO
(check all that apply):
IF YES, INDICATE CONDITIONS AND COMPLETE APPROPRIATE SECTIONS
Hypertrophic gastritis
If checked, indicate severity:
No symptoms or findings
Chronic, with small nodular lesions, and symptoms
Chronic, with multiple small eroded or ulcerated areas, and symptoms
Chronic, with severe hemorrhages, or large ulcerated or eroded areas
NOTE: If atrophic gastritis is present, state the underlying cause:
Postgastrectomy syndrome
If checked, indicate severity:
No symptoms or findings
Mild; infrequent episodes of epigastric distress with characteristic mild circulatory symptoms after
meals but with diarrhea and weight loss
Moderate; less frequent episodes of epigastric disorders with characteristic mild circulatory
symptoms after meals but with diarrhea and weight loss
Severe; associated with nausea, sweating, circulatory disturbance after meals, diarrhea,
hypoglycemic symptoms, and weight loss with malnutrition and anemia
Vagotomy with pyloroplasty or gastroenterostomy
If checked, indicate the severity of residuals following vagotomy with pyloroplasty or gastroenterostomy:
No symptoms or findings
Recurrent ulcer with incomplete vagotomy
Symptoms and confirmed diagnosis of alkaline gastritis, or of confirmed persisting diarrhea
Demonstrably confirmative postoperative complications of stricture or continuing gastric retention
Peritoneal adhesions following an injury or surgical procedure of the stomach or duodenum
If checked, ALSO complete the VA Form 21-0960G-6, Peritoneal Adhesions Disability Benefits Questionnaire.
SECTION VI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
(surgical or otherwise)
6A. 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
(6 square inches)
CM
?)
(If "Yes," ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)
YES
NO
6B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO
ANY CONDITIONS LISTED IN SECTION I, DIAGNOSIS?
(brief summary):
YES
NO
IF YES, DESCRIBE
Page 3
VA FORM 21-0960G-7, OCT 2012
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