VA Form 21-0960G-1 Esophageal Disorders (including GERD) Disability Benefit

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

ESOPHAGEAL DISORDERS (INCLUDING GERD)
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 THIS 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 consider the information you
provide on this questionnaire as part of their evaluation in processing the veteran's claim.
SECTION I - DIAGNOSIS
NOTE: The diagnosis of gastroesophageal reflux disease (GERD) can be made clinically by evidence of relief of typical symptoms of reflux, epigastric discomfort and/or burning, by treatment
with proton pump inhibitors, histamine 2 receptor antagonists and/or antacids. If upper endoscopy was indicated or performed, the findings of erythema, ulcers and/or strictures are consistent
with the diagnosis of GERD.
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH AN ESOPHAGEAL CONDITION?
YES

NO

(If "Yes," complete Item 1C)

(If "No," complete Item 1B)

1B. PROVIDE RATIONALE/REASON (e.g., veteran does not currently have any known esophageal conditions):
1C. DIAGNOSIS (Check all that apply)
GERD

ICD CODE:

DATE OF DIAGNOSIS:

HIATAL HERNIA

ICD CODE:

DATE OF DIAGNOSIS:

ESOPHAGEAL STRICTURE

ICD CODE:

DATE OF DIAGNOSIS:

ESOPHAGEAL SPASM

ICD CODE:

DATE OF DIAGNOSIS:

ESOPHAGEAL DIVERTICULUM

ICD CODE:

DATE OF DIAGNOSIS:

OTHER DIAGNOSIS #1:

ICD CODE:

DATE OF DIAGNOSIS:

OTHER DIAGNOSIS #2:

ICD CODE:

DATE OF DIAGNOSIS:

OTHER ESOPHAGEAL CONDITION(S)

(such as eosinophilic esophagitis, Barrett's
esophagitis, etc.)

1D. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO INFECTIOUS INTESTINAL CONDITIONS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY

2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S CURRENT ESOPHAGEAL CONDITIONS (brief summary):

2B. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING CONTINUOUS MEDICATION FOR THE DIAGNOSED CONDITION?
YES

NO

(If, "Yes," list only those medications used for the diagnosed condition):

SECTION III - SIGNS AND SYMPTOMS

3. DOES THE VETERAN HAVE ANY OF THE FOLLOWING SIGNS OR SYMPTOMS DUE TO ANY ESOPHAGEAL CONDITIONS (including GERD) ?
YES

NO

(If "Yes," check all that apply)
PERSISTENTLY RECURRENT EPIGASTRIC DISTRESS
If checked, indicate frequency of symptom recurrence per year:
1

2

3

4 or more

If checked, indicate average duration of episodes of symptoms:
1-9 days

Less than 1 day

10 days or more

DYSPHAGIA
If checked, indicate frequency of symptom recurrence per year:
1

2

3

4 or more

If checked, indicate average duration of episodes of symptoms:
1-9 days

Less than 1 day

10 days or more

PYROSIS (Heartburn)
If checked, indicate frequency of symptom recurrence per year:
1

2

3

4 or more

If checked, indicate average duration of episodes of symptoms:
Less than 1 day
VA FORM
FEB 2011

21-0960G-1

1-9 days

10 days or more

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SECTION III - SIGNS AND SYMPTOMS (Continued)
REFLUX
If checked, indicate frequency of symptom recurrence per year:
1

2

4 or more

3

If checked, indicate average duration of episodes of symptoms:
1-9 days

Less than 1 day

10 days or more

REGURGITATION
If checked, indicate frequency of symptom recurrence per year:
1

2

4 or more

3

If checked, indicate average duration of episodes of symptoms:
1-9 days

Less than 1 day

10 days or more

SUBSTERNAL ARM OR SHOULDER PAIN
If checked, indicate frequency of symptom recurrence per year:
1

2

3

4 or more

If checked, indicate average duration of episodes of symptoms:
1-9 days

Less than 1 day

10 days or more

SLEEP DISTURBANCE CAUSE BY ESOPHAGEAL REFLUX
If checked, indicate frequency of symptom recurrence per year:
1

2

3

4 or more

If checked, indicate average duration of episodes of symptoms:
1-9 days

Less than 1 day

10 days or more

ANEMIA
If checked, provide hemoglobin/hematocrit in diagnostic testing section.
WEIGHT LOSS
If checked, provide baseline weight:

and current weight:

(For VA purposes, baseline weight is the average weight for 2-year period preceding onset of disease)
NAUSEA
If checked, indicate severity:
Mild

Transient

Recurrent

Periodic

If checked, indicate frequency of episodes of nausea per year:
1

2

3

4 or more

If checked, indicate average duration of episodes of vomiting:
1-9 days

Less than 1 day

10 days or more

VOMITING
If checked, indicate severity:
Mild

Transient

Recurrent

Periodic

If checked, indicate frequency of episodes of vomiting per year:
1

2

3

4 or more

If checked, indicate average duration of episodes of vomiting:
1-9 days

Less than 1 day

10 days or more

HEMATEMESIS
If checked, indicate severity:
Mild

Transient

Recurrent

Periodic

If checked, indicate frequency of episodes of vomiting per year:
1

2

3

4 or more

If checked, indicate average duration of episodes of vomiting:
1-9 days

Less than 1 day

10 days or more

MELENA
If checked, indicate severity:
Mild

Transient

Recurrent

Periodic

If checked, indicate frequency of episodes of vomiting per year:
1

2

3

4 or more

If checked, indicate average duration of episodes of vomiting:
Less than 1 day
VA FORM 21-0960G-1, FEB 2011

1-9 days

10 days or more

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SECTION IV - ESOPHAGEAL STRICTURE, SPASM AND DIVERTICULA
4. DOES THE VETERAN HAVE AN ESOPHAGEAL STRICTURE, ESOPHAGEAL SPASM NOT AMENABLE TO DILATION, OR AN ACQUIRED DIVERTICULUM OF
THE ESOPHAGUS?
YES

NO

If Yes, indicate severity of condition:
ASYMPTOMATIC
MILD If checked, describe:
MODERATE If checked, describe:
SEVERE, PERMITTING PASSAGE OF LIQUIDS ONLY

If checked, describe:

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

5A. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS? IF YES, DESCRIBE
(brief summary):

5B. DOES THE VETERAN HAVE ANY SCARS (SURGICAL OR OTHERWISE) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS
LISTED IN THE DIAGNOSIS SECTION ABOVE?
NO

YES

IF YES, ARE ANY OF THE SCARS PAINFUL AND/OR UNSTABLE, OR IS THE TOTAL AREA OF ALL RELATED SCARS GREATER THAN 39 SQUARE CM
(6 square inches)?
NO (If yes, also complete a Scars Questionaire)

YES

SECTION 6 - DIAGNOSTIC TESTING

Note: If testing has been performed and reflects veteran's current condition, no further testing is required for this examination report.
6A. HAVE DIAGNOSTIC IMAGING STUDIES OR OTHER DIAGNOSTIC PROCEDURES BEEN PERFORMED?
YES

NO

If Yes, check all that apply:
UPPER ENDOSCOPY
Date:

Results:

UPPER GI RADIOLOGY STUDIES
Date:

Results:

ESOPHAGRAM (barium swallow)
Date:

Results:

MRI
Date:

Results:

CT
Date:

Results:

BIOPSY, SPECIFY SITE:
Date:

Results:

OTHER, SPECIFY:
Date:

Results:

6B. HAS LABORATORY TESTING BEEN PERFORMED?
YES

NO

If Yes, check all that apply:
CBC

Date of testing:

Hemoglobin:
HELICOBACTER PYLORI
OTHER, SPECIFY:

VA FORM 21-0960G-1, FEB 2011

Hematocrit:

White blood cell count:

Date of test:

Platelets:

Results:
Date of test:

Results:

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SECTION VI - DIAGNOSTIC TESTING (Continued)

6C. 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 VII - FUNCTIONAL IMPACT

7. DO ANY OF THE VETERAN"S ESOPHAGEAL CONDITIONS IMPACT ON HIS OR HER ABILITY TO WORK?
YES

NO

If Yes, describe impact of each of the veteran's esophageal conditions, providing one ore more examples:

8. REMARKS (If any)

SECTION IX - OPTOMETRIST/PHYSICIAN'S CERTIFICATION AND SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
9A. PHYSICIAN'S SIGNATURE

9D. PHYSICIAN'S PHONE NUMBER

9B. PHYSICIAN'S PRINTED NAME

9E. PHYSICIAN'S MEDICAL LICENSE NUMBER

9C. DATE SIGNED

9F. PHYSICIAN'S ADDRESS

NOTE - VA may request additional medical information, including additional examinations, 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
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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 21-0960G-1, FEB 2011

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