VA Form 21-0960J-2 Male Reproductive Organ Conditions Disability Benefits Q

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

MALE REPRODUCTIVE ORGAN CONDITIONS
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 EVER BEEN DIAGNOSED WITH A CONDITION OF THE MALE REPRODUCTIVE SYSTEM?
YES

NO

(If "No," complete Item 1B)

(If "Yes," complete Item 1C)

1B. PROVIDE RATIONALE/REASON (e.g., veteran does not currently have any known male reproductive organ conditions)
1C. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO MALE REPRODUCTIVE ORGAN CONDITIONS
DIAGNOSIS # 1 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 2 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 3 -

ICD CODE -

DATE OF DIAGNOSIS -

1D. IF ADDITIONAL DIAGNOSES THAT PERTAIN TO THE MALE REPRODUCTIVE ORGAN CONDITION(S), LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY
2. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S CURRENT MALE REPRODUCTIVE ORGAN CONDITION(S) (brief summary):

SECTION III - FINDINGS, SIGNS AND SYMPTOMS
3A. DOES THE VETERAN HAVE ERECTILE DYSFUNCTION?
YES

NO

(If "Yes," is the erectile dysfunction as likely as not (at least 50% probability) attributable to MS (including treatment or residuals of treatment)
YES

NO

(If "No," provide the etiology of the erectile dysfunction):
(If "Yes," is the veteran able to achieve an erection (without medication) sufficient for penetration and ejaculation?)
YES

NO

(If "No," is the veteran able to achieve an erection (with medication) sufficient for penetration and ejaculation?)
YES

NO

3B. DOES THE VETERAN HAVE DEFORMITY OF THE PENIS (such as Peyronie's disease)?
YES

NO

(If "Yes,"describe):
3C. DOES THE VETERAN HAVE VOIDING DYSFUNCTION CAUSING URINE LEAKAGE?
YES

NO

(If "Yes,"check all that apply)
Does not require/does not use absorbent material
Requires absorbent material that is changed less than 2 times per day
Requires absorbent material that is changed 2 to 4 times per day
Requires absorbent material that is changed more than 4 times per day
3D. DOES THE VETERAN HAVE VOIDING DYSFUNCTION CAUSING SIGNS AND/OR SYMPTOMS OF URINARY FREQUENCY?
YES

NO

(If "Yes,"check all that apply)
Daytime voiding interval between 2 and 3 hours
Daytime voiding interval between 1 and 2 hours
Daytime voiding interval less than 1 hour
Nighttime awakening to void 2 times
Nighttime awakening to void 3 to 4 times
Nighttime awakening to void 5 or more times
VA FORM
DEC 2010

21-0960J-2

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SECTION III - FINDINGS, SIGNS AND SYMPTOMS (Continued)
3E. DOES THE VETERAN HAVE VOIDING DYSFUNCTION CAUSING FINDINGS, SIGNS AND/OR SYMPTOMS OF OBSTRUCTED VOIDING?
YES

NO

(If "Yes,"check all signs and symptoms that apply)
Hesitancy

(If checked, is hesitancy marked?)
YES

NO

Slow or weak stream

(If checked, is stream markedly slow or weak?)
YES

NO

Decreased force of stream

(If checked, is force of stream markedly decreased?)
YES

NO

Stricture disease requiring dilatation 1 to 2 times per year
Stricture disease requiring periodic dilatation every 2 to 3 months
Recurrent urinary tract infections secondary to obstruction
Uroflowmetry peak flow rate less than 10 cc/sec
Post void residuals greater than 150 cc
Urinary retention requiring intermittent or continuous catheterization
3F. DOES THE VETERAN HAVE VOIDING DYSFUNCTION REQUIRING THE USE OF AN APPLIANCE?
YES

NO

(If "Yes,"describe):

3G. DOES THE VETERAN HAVE A HISTORY OF RECURRENT SYMPTOMATIC URINARY TRACT INFECTIONS, CHRONIC EPIDIDYMITIS, EPIDIDYMO-ORCHITIS
AND/OR PROSTATITIS?
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

(If checked, indicate frequency of management)
Continuous
Intermittent
Long-term drug therapy

(If intensive management is checked, indicate treatment dates for courses of treatment):
SECTION IV - OTHER CONDITIONS
4A. DOES THE VETERAN HAVE ANY PROSTATE CONDITIONS?
YES

NO

(If "Yes,"check all that apply)
Benign prostatic hypertrophy
Prostate injury
Prostatitis
Post-operative residuals
4B. DOES THE VETERAN HAVE ANY CONDITIONS OF THE URETHRA?
YES

NO

(If "Yes,"check all that apply)
Urethral stricture
Urethral fistula
Multiple urethroperineal fistulas
4C. DOES THE VETERAN HAVE ANY NON-FUNCTIONING TESTES?
YES, UNILATERAL
VA FORM 21-0960J-2, DEC 2010

YES, BILATERAL

NO

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SECTION V - EXAM
5A. PENIS EXAM
NORMAL

ABNORMAL

NOT EXAMINED PER VETERAN'S REQUEST
NOT EXAMINED; PENIS EXAM NOT RELEVANT TO CONDITION

(If abnormal is checked, indicate severity)
Loss/removal of half or more of penis
Loss/removal of glans penis
Penis deformity: if checked, describe:
5B. TESTES EXAM
NORMAL

ABNORMAL

NOT EXAMINED PER VETERAN'S REQUEST
NOT EXAMINED; TESTICULAR EXAM NOT RELEVANT TO CONDITION

(If abnormal, check all that apply)
Testicle is considerably harder than (corresponding) normal testicle

(If checked, indicate):

Right

Left

Both

Testicle is considerably softer than (corresponding) normal testicle

(If checked, indicate):

Right

Left

Both

Diameter of affected testicle reduced to one-half or less of (corresponding) normal testicle

(If checked, indicate):

Right

Left

Both

Diameter of affected testicle reduced to one-third of (corresponding) normal testicle

(If checked, indicate):

Right

Left

Both

Right

Left

Both

Removal of testicle

(If checked, indicate):

Congenitally undeveloped or undescended testicle

(If checked, indicate):

Right

Left

Both

Other, describe:
5C. PROSTATE EXAM
NORMAL

ABNORMAL

NOT EXAMINED PER VETERAN'S REQUEST
NOT EXAMINED; PROSTATE EXAM NOT RELEVANT TO CONDITION

(If abnormal, describe):
5D. EPIDIDYMIS EXAM
ABNORMAL

NORMAL

NOT EXAMINED PER VETERAN'S REQUEST
NOT EXAMINED; EPIDIDYMIS EXAM NOT RELEVANT TO CONDITION
TENDERNESS TO PALPATION

(If checked, indicate):
(If abnormal, describe):

Right

Left

Both

SECTION VI - NEOPLASM
6. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OF THE MALE REPRODUCTIVE SYSTEM?
YES

NO

(If "Yes,"complete the VA Form 21-0960J-3, Prostate Cancer Disability Benefits Questionnaire and VA Form 21-0960O-1, Tumors and Neoplasm, Disability
Benefits Questionnaire)
SECTION VII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
7. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS?
YES

NO

(If "Yes," describe):

VA FORM 21-0960J-2, DEC 2010

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SECTION VIII - DIAGNOSTIC TESTING

NOTE: If laboratory test results are in the medical record and reflect the veteran's current male reproductive system condition, repeat
testing is not required.
8. HAS THE VETERAN HAD DIAGNOSTIC TESTING AND IF SO, ARE THERE SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES

NO

(If "Yes," provide type of test or procedure, date and results (brief summary):

SECTION IX - FUNCTIONAL IMPACT AND REMARKS
9. DOES THE VETERAN'S MALE REPRODUCTIVE SYSTEM CONDITION(S) IMPACT HIS ABILITY TO WORK?
YES

NO

(If "Yes," describe impact of each of the veteran's male reproductive system condition, providing one or more examples)

10. REMARKS (If any)

SECTION X - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
11A. PHYSICIAN'S SIGNATURE
11D. PHYSICIAN'S PHONE NUMBER

11B. PHYSICIAN'S PRINTED NAME
11E. PHYSICIAN'S MEDICAL LICENSE NUMBER

11C. DATE SIGNED
11F. 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, 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
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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-2, DEC 2010

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