Va Form 21-0960g-7 - Stomach And Duodenal Conditions (Not Including Gerd Or Esophageal Disorders) Disability Benefits Questionnaire Page 4

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SECTION VII - DIAGNOSTIC TESTING
NOTE: If testing has been performed and reflects veteran's current condition, no further testing is required for this examination report.
The diagnosis of gastric or duodenal ulcer or stenosis can be made by upper gastrointestinal imaging series or endoscopy.
7A. HAVE DIAGNOSTIC IMAGING STUDIES OR OTHER DIAGNOSTIC PROCEDURES BEEN PERFORMED?
YES
NO
IF YES, CHECK ALL THAT APPLY:
Upper endoscopy
Date:
Results:
Upper GI radiographic studies
Date:
Results:
MRI
Date:
Results:
CT
Date:
Results:
Biopsy, specify site:
Date:
Results:
Other, specify:
Date:
Results:
7B. HAS LABORATORY TESTING BEEN PERFORMED?
YES
NO
IF YES, CHECK ALL THAT APPLY:
CBC
Date of test:
Results:
Hemoglobin:
Hematocrit:
White blood cell count:
Platelets:
Helicobacter pylori
Date of test:
Results:
Other, specify:
Date of test:
Results:
7C. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES
NO
(brief summary)
IF YES, PROVIDE TYPE OF TEST OR PROCEDURE, DATE AND RESULTS
:
SECTION VIII - FUNCTIONAL IMPACT
8. DO ANY OF THE VETERAN'S STOMACH OR DUODENUM CONDITIONS IMPACT HIS OR HER ABILITY TO WORK?
YES
NO
IF YES, DESCRIBE IMPACT OF EACH OF THE VETERAN'S STOMACH OR DUODENUM CONDITIONS, PROVIDING ONE OR MORE EXAMPLES:
Page 4
VA FORM 21-0960G-7, OCT 2012

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