Form VA Form 21-0960a VA Form 21-0960a Ischemic Heart Disease (IHD) Disability Benefits Questio

OMB Approved No. 2900-XXXX
Respondent Burden: 15 minutes

ISCHEMIC HEART DISEASE (IHD) DISABILITY BENEFITS QUESTIONNAIRE
IMPORTANT - PLEASE READ THE PRIVACY ACT AND RESPONDENT BURDEN INFORMATION ON REVERSE BEFORE COMPLETING FORM.
NAME OF PATIENT/VETERAN

PATIENT/VETERAN’S SOCIAL SECURITY NUMBER

NOTE TO PHYSICIAN - The veteran has applied to the Department of Veterans Affairs (VA) for disability benefits. Please complete this
questionnaire, which VA needs for review of the veteran’s application.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN HAVE ISCHEMIC HEART DISEASE (IHD)?

(If "No," please skip to section VII)
YES
NO
1B. DIAGNOSIS (Note: IHD includes but is not limited to acute, sub-acute and old myocardial infarction; atherosclerotic
cardiovascular disease including coronary artery disease, including coronary spasm and coronary bypass surgery; and stable,
unstable and Prinzmetal’s angina. IHD does not include hypertension or peripheral manifestations of arteriosclerosis such as
peripheral vascular disease or stroke)

1C. DATE OF DIAGNOSIS

SECTION II - MEDICAL HISTORY
2A. DOES THE VETERAN’S TREATMENT PLAN INCLUDE TAKING CONTINUOUS MEDICATION FOR THE DIAGNOSED CONDITION?
YES

NO

2B. LIST MEDICATIONS:

2C. IS THERE A HISTORY OF: (Check all that apply and provide treatment facility and treatment date)
CONDITION

YES (Check) NO (Check)

TREATMENT FACILITY

DATE OF TREATMENT

PERCUTANEOUS CORONARY
INTERVENTION (PCI)
MYOCARDIAL INFARCTION

CORONARY BYPASS SURGERY
HEART TRANSPLANT
(If "Yes,"is it likely that the veteran’s heart
transplant is due to IHD?
YES
NO)
IMPLANTED CARDIAC PACEMAKER
(If "Yes," is it likely that the veteran’s pacemaker is
due to IHD?
YES
NO)

SECTION III - CONGESTIVE HEART FAILURE (CHF)
3A. DOES THE VETERAN HAVE CHRONIC CHF?
NO

YES

3B. HAS THE VETERAN HAD MORE THAN ONE EPISODE OF ACUTE CHF IN THE PAST YEAR?
YES

NO

3C. PROVIDE THE NAME OF THE TREATMENT FACILITY AND THE DATE OF THE MOST RECENT EPISODE OF CHF BELOW:

SECTION IV - CARDIAC FUNCTIONAL ASSESSMENT
4A. LEVEL OF METABOLIC EQUIVALENT OF TASK (METs) THE VETERAN CAN PERFORM AS SHOWN BY DIAGNOSTIC EXERCISE TESTING:_______________ METs
(If diagnostic exercise test results are not of record, complete Item 4B)
4B. IF METs TESTING WAS NOT COMPLETED BECAUSE IT IS NOT REQUIRED AS PART OF THE VETERAN’S TREATMENT PLAN, COMPLETE THE FOLLOWING
METs TEST BASED ON THE VETERAN’S RESPONSES:

Lowest level of activity at which veteran reports symptoms: (Check all symptoms that apply)
DYSPNEA

FATIGUE

ANGINA

DIZZINESS

SYNCOPE

This METs level has been found to be consistent with activities such as:
1-3 METs (This METs level has been found to be consistent with
activities such as eating, dressing, taking a shower, slow walking
(2 mph) for 1-2 blocks)

>7-10 METs (This METs level has been found to be consistent with
activities such climbing stairs quickly, moderate bicycling, sawing wood,
jogging (6 mph)

>3-5 METs (This METs level has been found to be consistent with
activities such as light yard work (weeding), mowing lawn (power
mower, brisk walking (4 mph)

Veteran denies experiencing above symptoms with any level of physical
activity

>5-7 METs (This METs level has been found to be consistent with
activities such as golfing (without cart), mowing lawn (push mower), heavy
yard work (digging)

VA FORM
MAY 2010

21-0960A

SECTION V - DIAGNOSTIC TESTING
5A. IS THERE EVIDENCE OF CARDIAC HYPERTROPHY OR DILATION?

YES

NO

BASED ON DIAGNOSTIC TEST:

EKG

CXR (PA AND LATERAL)

ECHOCARDIOGRAM

NOTE - Determination of cardiac hypertrophy/dilation is required; the suggested order of testing for cardiac hypertrophy/dilation is
EKG, then chest x-ray (PA and lateral), then echocardiogram. Echocardiogram is only necessary if the other two tests are negative.
5B. LEFT VENTRICULAR EJECTION FRACTION (LVEF), IF KNOWN:__________________________%
(If LVEF testing is not of record, but available medical information sufficiently reflects the severity of the veteran’s cardiovascular condition, LVEF testing is not
required)

SECTION VI - REMARKS
6. REMARKS (Including impact of IHD condition on veteran’s ability to work)

SECTION VII - PHYSICIAN’S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
7A. PHYSICIAN’S SIGNATURE

7D. PHYSICIAN’S PHONE NUMBER

7B. PHYSICIAN’S PRINTED NAME

7E. PHYSICIAN’S MEDICAL LICENSE NUMBER

7C. DATE SIGNED

7F. PHYSICIAN’S ADDRESS

NOTE - VA may obtain additional medical information, including an examination, if necessary to complete VA’s
review of the veteran’s application.
IMPORTANT - Physician please fax the completed form to _________________________________________
(VA Regional Office FAX No.)
PRIVACY ACT NOTICE: VA will not disclose information collected on this form to any source other than what has been authorized under the Privacy Act of 1974 or Title 38,
Code of Federal Regulations 1.576 for routine uses (i.e., civil or criminal law enforcement, congressional communications, epidemiological or research studies, the collection
of money owed to the United States, litigation in which the United States is a party or has an interest, the administration of VA programs and delivery of VA benefits,
verification of identity and status, and personnel administration) as identified in the VA system of records, 58/VA21/22/28, Compensation, Pension, Education and Vocational
Rehabilitation and Employment Records - VA, published in the Federal Register. Your obligation to respond is required to obtain or retain benefits. VA uses your SSN to
identify your claim file. Providing your SSN will help ensure that your records are properly associated with your claim file. Giving us your SSN account information is voluntary.
Refusal to provide your SSN by itself will not result in the denial of benefits. VA will not deny an individual benefits for refusing to provide his or her SSN unless the disclosure
of the SSN is required by a Federal Statute of law in effect prior to January 1, 1975, and still in effect. The requested information is considered relevant and necessary to
determine maximum benefits under the law. The responses you submit are considered confidential (38 U.S.C. 5701). Information submitted is subject to verification through
computer matching programs with other agencies.
RESPONDENT BURDEN: We need this information to determine entitlement to benefits (38 U.S.C. 501). Title 38, United States Code, allows us to ask for this information.
We estimate that you will need an average of 15 minutes to review the instructions, find the information, and complete the form. VA cannot conduct or sponsor a collection of
information unless a valid OMB control number is displayed. You are not required to respond to a collection of information if this number is not displayed. Valid OMB control
numbers can be located on the OMB Internet Page at www.whitehouse.gov/omb/library/OMBINV.VA.EPA.html#VA. If desired, you can call 1-800-827-1000 to get information
on where to send comments or suggestions about this form.
VA FORM MAY 2010, 21-0960A