VA Form 21-0960J-1 Kidney Conditions (Nephrology) Disability Benefits Quest

OMB Approved No. 2900-XXXX
Respondent Burden: 30 minutes

KIDNEY CONDITIONS (NEPHROLOGY) 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 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 KIDNEY CONDITION?
YES

NO
)

(If "No," provide rationale/reason (e.g. veteran does not currently have any known kidney condition(s))
(If "Yes," indicate diagnosis/es: (check all that apply)
Diabetic nephropathy

ICD CODE:

DATE OF DIAGNOSIS:

Glomerulonephritis

ICD CODE:

DATE OF DIAGNOSIS:

Hydronephrosis

ICD CODE:

DATE OF DIAGNOSIS:

Interstitial nephritis

ICD CODE:

DATE OF DIAGNOSIS:

Kidney transplant

ICD CODE:

DATE OF DIAGNOSIS:

Nephrosclerosis

ICD CODE:

DATE OF DIAGNOSIS:

Nephrp;otjoasos

ICD CODE:

DATE OF DIAGNOSIS:

Renal artery stenosis

ICD CODE:

DATE OF DIAGNOSIS:

Ureterolithiasis

ICD CODE:

DATE OF DIAGNOSIS:

ICD CODE:

DATE OF DIAGNOSIS:

ICD CODE:

DATE OF DIAGNOSIS:

Other kidney condition
(specify diagnosis, providing
only diagnoses that pertain to
kidney conditions)
Other kidney condition
(specify diagnosis, providing
only diagnoses that pertain to
kidney conditions)

1B. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO KIDNEY CONDITION(S), LIST USING ABOVE FORMAT

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

SECTION III - RENAL DYSFUNCTION
3A. DOES THE VETERAN HAVE RENAL DYSFUNCTION?
NO
YES
(If "Yes," does the veteran require regular dialysis?
YES

NO

(If "Yes," skip to Item 3B)
(If "No," indicate severity of renal findings, signs and/or symptoms: (check all that apply)
No symptoms
Proteinuria (albuminuria)
(If checked, indicate frequency: (check all that apply)
Recurring

Constant

Persistent

Edema (due to renal dysfunction)
(If checked, indicate frequency: (check all that apply)
Some

Transient

Slight

Persistent

Anorexia (due to renal dysfunction)
Weight loss (due to renal dysfunction)
(If checked, provide percent of loss of individual's baseline weight:

%)

Note: "Baseline weight" means the average weight for the two-year period preceding onset of the disease.
Generalized poor health (due to renal dysfunction)
Lethargy (due to renal dysfunction)
Weakness (due to renal dysfunction)
Limitation of exertion (due to renal dysfunction)
Able to perform only sedentary activity, due to persistent edema caused by renal dysfunction
Markedly decreased function of other organ systems, especially the cardiovascular system, caused by renal dysfunction (If checked, describe):
3B. DOES THE VETERAN HAVE HYPERTENSION AND/OR HEART DISEASE DUE TO RENAL DYSFUNCTION OR CAUSED BY ANY KIDNEY CONDITION?
(If "Yes," also complete the VA Form 21-0960A-3, Hypertension Disability Benefits Questionnaire and VA Form 21-0960A-4,
NO
YES
Non-Ischemic Heat Disease Disability Benefits Questionnaire)
VA FORM
DEC 2010

21-0960J-1

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SECTION IV - NEPHROLITHIASIS, HYDRONEPHROSIS, URETEROLITHIASIS OR URETERAL STRICTURE
4A. DOES THE VETERAN HAVE NEPHROLITHIASIS, HYDRONEPHROSIS, URETEROLITHIASIS OR STRICTURE OF THE URETER?
YES

NO

(If "Yes,"does the veteran have any of the following: (check all that apply)
No symptoms or attacks of colic
Occasional attacks of colic
Frequent attacks of colic
Requires catheter drainage
Causing infection (pyonephrosis)
Causing hydronephrosis
Causing impaired kidney function
4B. DOES THE VETERAN HAVE RECURRENT STONE FORMATION?
YES

NO

(If "Yes," indicate treatment: (check all that apply))
No treatment (no diet or drug therapy)
Requiring diet therapy
Requiring drug therapy
Requiring invasive or non-invavsive procedures
(If checked, indicate average number of times per year recurrent stone formation
requires invavsive or non-invavsive procedures):
0 to 1/year

2/year

more than 2/year

SECTION V - INFECTIONS OF THE KIDNEY AND/OR URINARY TRACT
5. DOES THE VETERAN HAVE KIDNEY ABSCESS, BLADDER FISTULA, URINARY TRACT OR ANY OTHER KIDNEY OR URINARY TRACT INFECTIONS?
YES

NO

(If "Yes,"check all of the following treatment modalities that apply)
No treatment
Drainage
Hospitalization
(If checked, indicate frequency of hospitalization):
1 or 2 per year
More than 2 per year
Intensive management
Continuous
Intermittent
Long-term drug therapy
(If intensive management is checked, indicate treatment dates for courses of treatment):

SECTION VI - KIDNEY TRANSPLANT OR REMOVAL
6A. HAS A KIDNEY BEEN REMOVED?
YES

NO

(If "Yes," provide reason)
Kidney donation
Due to disease
Due to trauma or injury
6B. HAS A THE VETERAN HAD A KIDNEY TRANSPLANT?
YES
NO
(If "Yes," date of admission):

(Date of discharge):

SECTION VII - NEOPLASM
7. HAS THE VETERAN HAD A NEOPLASM OF THE URINARY SYSTEM?
YES
NO
(If "Yes," also complete the VA Form 21-0960O-1, Tumors and Neoplasms Disability Benefits Questionnaire)

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

8. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS?
YES

NO

(If "Yes," describe):

VA FORM 21-0960J-1, DEC 2010

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SECTION IX - DIAGNOSTIC TESTING
NOTE: If laboratory test results are in the medical record and reflect the veteran's current renal function, repeat testing is not required.
9A. HAS THE VETERAN HAD LABORATORY OR OTHER DIAGNOSTIC STUDIES PERFORMED?
YES

NO

(If "Yes,"provide most recent results, if available):

9B. LABORATORY STUDIES
BUN

Date:

Result:

Creatinine

Date:

Result:

EGFR

Date:

Result:

9C. URINALYSIS
Hyaline casts

Date:

Result:

Granular casts

Date:

Result:

RBC's/HPF

Date:

Result:

Protein (albumin)

Date:

Result:

Spot urine for
protein/creatinine ratio

Date:

Result:

24 hour protein (albumin)

Date:

Result:

9D. URINE MICROALBUMIN
Urine (microalbumin)

Date:

Result:

9E. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES
NO
(If "Yes,"provide type of test or procedure, date and results (brief summary):

SECTION X - FUNCTIONAL IMPACT AND REMARKS
10. DOES THE VETERAN'S KIDNEY CONDITION(S) IMPACT HIS OR HER ABILITY TO WORK?
YES

NO (If "Yes," describe impact of each of the veteran's kidney condition, providing one or more examples:

11. 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.
12A. PHYSICIAN'S SIGNATURE

12D. PHYSICIAN'S PHONE NUMBER

12B. PHYSICIAN'S PRINTED NAME

12E. PHYSICIAN'S MEDICAL LICENSE NUMBER

12C. DATE SIGNED

12F. 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 30
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 21-0960J-1, DEC 2010

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