Form VA Form 21-0960B-2 VA Form 21-0960B-2 Hematologic and Lymphatic Conditions, Including Leukemia

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

HEMATOLOGIC AND LYMPHATIC CONDITIONS, INCLUDING LEUKEMIA
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 ON REVERSE 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 use the information you provide
on this questionnaire to process the Veteran's claim.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER BEEN DIAGNOSED WITH A HEMATOLOGIC AND/OR LYMPHATIC CONDITION?
YES
NO
(If "No," provide rationale (e.g. veteran does not currently have any known hematologic or lymphatic condition(s):

)

(If "Yes," check the veteran's condition and provide ICD code and date of diagnosis:
Acute lymphocytic leukemia (ALL)

ICD CODE:

DATE OF DIAGNOSIS:

Acute myelogenous leukemia (AML)

ICD CODE:

DATE OF DIAGNOSIS:

Chronic myelogenous leukemia (CML)

ICD CODE:

DATE OF DIAGNOSIS:

Hodgkin's disease

ICD CODE:

DATE OF DIAGNOSIS:

Non-Hodgkin's lymphoma

ICD CODE:

DATE OF DIAGNOSIS:

Anemia

ICD CODE:

DATE OF DIAGNOSIS:

Thrombocytopenia

ICD CODE:

DATE OF DIAGNOSIS:

Polycythemia vera

ICD CODE:

DATE OF DIAGNOSIS:

Sickle cell anemia

ICD CODE:

DATE OF DIAGNOSIS:

Splenectomy

ICD CODE:

DATE OF DIAGNOSIS:

Hairy cell leukemia: if checked, complete the Hairy Cell and other B-Cell Leukemias Disability Questionnaire, VA Form 21-0960B-1
Other hematologic or lymphatic condition(s): if checked complete Item 1B
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO HEMATOLOGIC OR LYMPHATIC CONDITION(S)
DIAGNOSIS # 1 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 2 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 3 -

ICD CODE -

DATE OF DIAGNOSIS -

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO HEMATOLOGIC OR LYMPHATIC CONDITION(S), LIST USING ABOVE FORMAT

SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (INCLUDING ONSET AND COURSE) OF THE VETERAN'S CURRENT CONDITION(S) (Give a brief summary)

2B. INDICATE THE STATUS OF THE CONDITION
ACTIVE

REMISSION

NOT APPLICABLE

SECTION III - TREATMENT
3A. HAS THE VETERAN COMPLETED ANY TYPE OF TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR ANY
LYMPHATIC OR HEMATOLOGIC CONDITION, INCLUDING LEUKEMIA?
(If "Yes," indicate treatment type(s)) (Check all that apply)
YES
NO
Watchful waiting
Bone marrow transplant, if checked provide: Date of hospital admission and location
Date of hospital discharge after transplant
Surgery, if checked describe:
Radiation therapy, if checked provide: Date of most recent treatment
Date of completion of treatment or anticipated date of completion
Antineoplastic chemotherapy, if checked provide: Date of most recent treatment
Date of completion of treatment or anticipated date of completion
Other therapeutic procedure and/or treatment (describe):
Date of procedure:
Date of completion of treatment or anticipated date of completion:
3B. DOES THE VETERAN HAVE AN ANEMIA AND/OR THROMBOCYTOPENIA CONDITION, INCLUDING ANEMIA AND/OR THROMBOCYTOPENIA CAUSED BY
TREATMENT FOR A HEMATOLOGIC OR LYMPHATIC CONDITION?
YES

NO

(If "Yes," is continuous medication required for control?)
VA FORM
DEC 2010

21-0960B-2

YES

NO (If "Yes," list medication(s):

)

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SECTION IV - CONDITIONS, COMPLICATIONS AND/OR RESIDUALS
4A. DOES THE VETERAN CURRENTLY HAVE ANY CONDITIONS, COMPLICATIONS AND/OR RESIDUALS DUE TO A HEMATOLOGIC OR LYMPHATIC DISORDER
OR DUE TO TREATMENT FOR A HEMATOLOGIC OR LYMPHATIC DISORDER?
YES

NO

(If "Yes,"do they cause any of the following findings, signs or symptoms?
YES

NO (If "Yes," check all that apply)
Weakness
Easy fatigability
Light-headedness
Shortness of breath
Headaches
Dyspnea on mild exertion
Dyspnea at rest
Tachycardia
Syncope
Cardiomegaly
High output congestive heart failure
Complications or residuals of treatment requiring transfusion of platelets or red blood cells
(If checked, indicate frequency:
At least once per year but less than once every 3 months
At least once every 3 months
At least once every 6 weeks

4B. DOES THE VETERAN CURRENTLY HAVE ANY OTHER CONDITIONS, COMPLICATIONS AND/OR RESIDUALS OF TREATMENT FROM A HEMATOLOGIC OR
LYMPHATIC DISORDER?
YES

NO

(If "Yes," describe (brief summary))

SECTION V - RECURRING INFECTIONS
5. DOES THE VETERAN CURRENTLY HAVE ANY CONDITIONS, COMPLICATIONS AND/OR RESIDUALS OF TREATMENT FOR A HEMATOLOGIC OR LYMPHATIC
DISORDER THAT RESULT IN RECURRING INFECTIONS?
YES
NO
(If "Yes,"indicate frequency of infections:
Less than once per year
At least once per year but less than once every 3 months
At least once every 3 months
At least once every 6 weeks

SECTION VI - THROMBOCYTOPENIA (Primary, Idiopathic or Immune)
6. DOES THE VETERAN HAVE THROMBOCYTOPENIA?
YES

NO

(If "Yes,"check all that apply)
Stable platelet count of 100,000 or more
Stable platelet count between 70,000 and 100,000
Platelet count between 20,000 and 70,000
Platelet count of less than 20,000
With active bleeding
Requiring treatment with medication
Requiring treatment with transfusions
7. DOES THE VETERAN HAVE POLYCYTHEMIA VERA?
YES

SECTION VII - POLYCYTHEMIA VERA

NO

(If "Yes,"check all that apply)
Stable with or without continuous medication
Requiring phlebotomy
Requiring myelosuppressant treatment
NOTE: If there are complications due to polycythemia vera such as hypertension, gout, stroke or thrombotic disease, also complete appropriate questionnaire(s).
VA FORM DEC 2010, 21-0960B-2

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SECTION VIII - SICKLE CELL ANEMIA
8. DOES THE VETERAN HAVE SICKLE CELL ANEMIA?
YES

NO

(If "Yes,"check all that apply)
Asymptomatic
In remission
With identifiable organ impairment
Following repeated hemolytic sickling crises with continuing impairment of health
Painful crises several times a year
Repeated painful crises, occurring in skin, joints, bones or any major organs
With anemia, thrombosis and infarction
Symptoms preclude other than light manual labor
Symptoms preclude even light manual labor

SECTION IX - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
9. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS?
NO (If "Yes," describe (brief summary))

YES

SECTION X - DIAGNOSTIC TESTING
NOTE: If testing has been performed and reflects veteran's current condition, no further testing is required. Provide most recent CBC, hemoglobin level or platelet count appropriate to the
veteran's condition:
Date

10A. HEMOGLOBIN LEVEL (gm/100ml):
10B. PLATELET COUNT:

Date

10C. Are there any other significant diagnostic test findings and/or results?
NO (If "Yes," provide type of test or procedure, date and results (brief summary):

YES

SECTION XI - FUNCTIONAL IMPACT AND REMARKS
11. DOES THE VETERAN'S HEMATOLOGIC AND/OR LYMPHATIC CONDITION(S) IMPACT HIS OR HER ABILITY TO WORK?
YES

NO (If "Yes," describe impact of each of the veteran's hematologic and/or lymphatic conditions, providing one or more examples:

12. REMARKS (If any)

SECTION XII - PHYSICIAN'S CERTIFICATION AND SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
13A. PHYSICIAN'S SIGNATURE

13D. PHYSICIAN'S PHONE NUMBER

13B. PHYSICIAN'S PRINTED NAME

13E. PHYSICIAN'S MEDICAL LICENSE NUMBER

13C. DATE SIGNED

13F. 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.)

NOTE - A list of VA Regional Office FAX Numbers can be found at www.vba.va.gov/disabilityexams or obtained by calling 1-800-827-1000.
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, 58VA21/22/28, 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 a 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.reginfo.gov/public/do/PRAMain. If desired, you can call 1-800-827-1000 to get information on where to send comments or suggestions about this form.
VA FORM DEC 2010, 21-0960B-2

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