Form VA Form 29-8146 VA Form 29-8146 Supplemental Physical Examination Report

OMB Control No. 2900-0324
Respondent Burden: 45 Mins.

SUPPLEMENTAL PHYSICAL EXAMINATION REPORT
PRIVACY ACT INFORMATION: This report is authorized by law (38 CFR 8.8, 8.9, and 8.22). The information is required to help us make a decision on the
veteran’s claim for the insurance benefits under consideration. Responses may be disclosed outside VA only if the disclosure is authorized by the Privacy Act,
including the routine uses identified in the VA system of records, 36VA00, Veterans and Armed Forces Personnel U.S. Government Life Insurance Records - VA,
published in the Federal Register.
RESPONDENT BURDEN: VA may not conduct or sponsor, and respondent is not required to respond to this collection of information unless it displays a valid OMB
Control Number. Public reporting burden for this collection of information is estimated to average 45 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have
comments regarding this burden estimate or any other aspect of this collection of information, call 1-800-827-1000 for mailing information on where to send your
comments.
1. NAME OF APPLICANT (Type or print)
2. INSURANCE FILE NUMBER
NOTICE TO APPLICANT
Any examinations required in connection with V, RS, W, RH or K insurance or in
connection with reinstatement or change of plan of "J" insurance may be made by
medical officers in active service or physicians of the U.S. Public Health Service, for
those entitled, or may be made free of charge by a physician of the VA Regional
Office or Medical Center. The examination may also be made at the applicant’s own
expense by a physician duly licensed for practice of medicine by a State, Territory or
Possession of the United States, or District of Columbia, who is not related to the
applicant, by blood or marriage, associated with his/her business, or financially
interested in the granting of this insurance. Any medical examination required in
connection with the issuance of the Total Disability Income Provision to "J"
insurance must be made at the applicant’s own expense.

NOTICE TO PHYSICIAN
Please furnish all pertinent information. If more space is needed, you may use
the reverse of this form. The completed form should be sent to the office
checked below. Please do not return it to the applicant. Thank you.
RETURN TO:

Department of Veterans Affairs
Regional Office and Insurance Center
P.O. Box 7208
Philadelphia, PA 19101

3. LIST ALL BLOOD PRESSURE READINGS BEFORE TREATMENT
A. DATE

4A. HAS APPLICANT EVER
BEEN TREATED FOR
HYPERTENSION? (If
"Yes," complete Items
4B, 4C, and 4D)

YES

B. SYSTOLIC

4B. DATE TREATMENT
BEGAN

C. DIASTOLIC

4C. DATE ALL TREATMENT
ENDED

4D. NAME OF DRUGS USED, DOSAGE AND FREQUENCY

NO

5. LIST ALL BLOOD PRESSURE READINGS AFTER TREATMENT
A. DATE

B. SYSTOLIC

C. DIASTOLIC

6. DIAGNOSIS

7. IS ANY CARDIAC DISEASE PRESENT? (Explain)

8. REMARKS (Include cause if known)

9. NAME OF EXAMINING PHYSICIAN (Type or print)

10. DATE EXAMINED

11. STATE IN WHICH LICENSED TO
PRACTICE

12. SIGNATURE OF PHYSICIAN (Do not print)

13. ADDRESS OF PHYSICIAN (City, county, State and ZIP Code)

PENALTY: The law provides severe penalties which include fine or imprisonment, or both, for the willful submission of any statement or evidence of a material fact,
knowing it to be false.
VA FORM
MAR 2002

29-8146

SUPERSEDES VA FORM 29-8146, MAY 1989,
WHICH WILL NOT BE USED.