Va Form 21-0960g-8 - Infectious Intestinal Disorders, Including Bacterial And Parasitic Infections Disability Benefits Questionnaire Page 2

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SECTION IV - SYMPTOM EPISODES, ATTACKS AND EXACERBATIONS

4. DOES THE VETERAN HAVE EPISODES OF BOWEL DISTURBANCE WITH ABDOMINAL DISTRESS, OR EXACERBATIONS OR ATTACKS OF THE

INTESTINAL CONDITION?

YES

(check all that apply)

IF YES, INDICATE SEVERITY AND FREQUENCY

EPISODES OF BOWEL DISTURBANCE WITH ABDOMINAL DISTRESS. IF CHECKED, INDICATE FREQUENCY:

Occasional episodes

Frequent episodes

More or less constant abdominal distress

EPISODES OF EXACERBATIONS AND/OR ATTACKS OF THE INTESTINAL CONDITION

IF CHECKED, DESCRIBE TYPICAL EXACERBATION OR ATTACK:

INDICATE NUMBER OF EXACERBATIONS AND/OR ATTACKS IN PAST 12 MONTHS:

7 or more

SECTION V - WEIGHT LOSS

5. DOES THE VETERAN HAVE WEIGHT LOSS ATTRIBUTABLE TO AN INFECTIOUS INTESTINAL CONDITION?

YES

IF YES, PROVIDE VETERAN'S BASELINE WEIGHT:

AND CURRENT WEIGHT:

(NOTE: For VA purposes, baseline weight is the average weight for 2-year period preceding onset of disease)

SECTION VI - MALNUTRITION, COMPLICATIONS AND OTHER GENERAL HEALTH EFFECTS

6. DOES THE VETERAN HAVE MALNUTRITION, SERIOUS COMPLICATIONS OR OTHER GENERAL HEALTH EFFECTS ATTRIBUTABLE TO THE INTESTINAL

CONDITION?

YES

(check all that apply)

IF YES, INDICATE SEVERITY

Health only fair during remissions

Resulting in general debility

Resulting in serious complication such as liver abscess

Malnutrition. If checked, is malnutrition marked?

Yes

Other, describe:

SECTION VII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS

(surgical or otherwise)

7A. DOES THE VETERAN HAVE ANY SCARS

RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY

CONDITIONS LISTED IN SECTION I, DIAGNOSIS ?

YES

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 CM

(6 square inches

YES

(If "Yes," ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)

7B. 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

SECTION VIII - DIAGNOSTIC TESTING

NOTE: If imaging studies, diagnostic procedures or laboratory testing have been performed and reflect the veteran's current condition, provide most recent results; no

further studies or testing are required for this examination.

8A. HAS LABORATORY TESTING BEEN PERFORMED?

YES

IF YES, CHECK ALL THAT APPLY:

(if anemia due to any intestinal condition is suspected or present)

CBC

Date of test:

Hemoglobin:

Hematocrit:

White blood cell count:

Platelets:

Other, specify: