OMB Approved No. 2900-0778
Respondent Burden: 15 minutes
INFECTIOUS INTESTINAL DISORDERS, INCLUDING BACTERIAL AND
PARASITIC INFECTIONS 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 BEEN DIAGNOSED WITH AN INFECTIOUS INTESTINAL CONDITION?
(If "Yes," complete Item 1B)
YES
NO
(check all that apply)
1B. SELECT THE VETERAN'S CONDITION
:
BACILLARY DYSENTERY
ICD code:
Date of diagnosis:
(intestinal fluke)
INTESTINAL DISTOMIASIS
ICD code:
Date of diagnosis:
PARASITIC INFECTION OF THE INTESTINES
ICD code:
Date of diagnosis:
AMEBIASIS
ICD code:
Date of diagnosis:
NOTE: If the veteran has a lung abscess due to amebiasis, ALSO complete VA Form 21-0960L-1, Respiratory Conditions Disability Benefits Questionnaire.
OTHER INFECTIOUS INTESTINAL CONDITION
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 INFECTIOUS INTESTINAL CONDITIONS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset, course, and past treatment)
(brief summary)
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S INFECTIOUS INTESTINAL CONDITIONS
:
2B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF THE VETERAN'S INTESTINAL CONDITIONS?
YES
NO
IF YES, LIST ONLY THOSE MEDICATIONS REQUIRED FOR THE INTESTINAL CONDITIONS:
2C. HAS THE VETERAN HAD SURGICAL TREATMENT FOR AN INTESTINAL CONDITION?
YES
NO
(If "Yes," ALSO complete VA Form 21-0960G-4, Intestinal Surgery (Bowel Resection, Colostomy, Ileostomy) Disability Benefits Questionnaire)
SECTION III - SIGNS AND SYMPTOMS
3. DOES THE VETERAN HAVE ANY SIGNS OR SYMPTOMS ATTRIBUTABLE TO ANY INFECTIOUS INTESTINAL CONDITIONS?
YES
NO
IF YES, CHECK ALL THAT APPLY
(If checked, describe)
MILD SYMPTOMS ATTRIBUTABLE TO DISTOMIASIS, INTESTINAL OR HEPATIC
:
(If checked, describe)
MODERATE SYMPTOMS ATTRIBUTABLE TO DISTOMIASIS, INTESTINAL OR HEPATIC
:
(If checked, describe)
SEVERE SYMPTOMS ATTRIBUTABLE TO DISTOMIASIS, INTESTINAL OR HEPATIC
:
(If checked, describe)
MILD GASTROINTESTINAL DISTURBANCES
:
If checked, describe
LOWER ABDOMINAL CRAMPS.
:
(If checked, describe)
GASEOUS DISTENTION
:
(If checked, describe)
CHRONIC CONSTIPATION INTERRUPTED BY DIARRHEA
:
ANEMIA (If checked, provide hemoglobin/hematocrit in Section 8, Diagnostic Testing)
(If checked, describe)
NAUSEA
:
(If checked, describe)
VOMITING
:
(describe)
OTHER,
:
NOTE - Complete the appropriate Disability Benefits Questionnaire(s) when the infectious disease affects other organs such as the liver, lung, kidney, etc. (schedule with
appropriate provider).
VA FORM
SUPERSEDES VA FORM 21-0960G-8, FEB 2011,
Page 1
21-0960G-8
OCT 2012
WHICH WILL NOT BE USED.