VA Form 21-0960G-5 Hepatitis, Cirrhosis and other Liver Conditions Disabili

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

HEPATITIS, CIRRHOSIS AND OTHER LIVER 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 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
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH A LIVER CONDITION?
YES

NO

(If "No," complete Item 1B) (If "Yes," complete Item 1C)

1B. PROVIDE RATIONALE (e.g., veteran does not currently have any known liver condition):

1C. SELECT THE VETERAN'S CONDITION (check all that apply):
Hepatitis A

ICD Code:

Date of Diagnosis:

Hepatitis B

ICD Code:

Date of Diagnosis:

Hepatitis C

ICD Code:

Date of Diagnosis:

Autoimmune hepatitis

ICD Code:

Date of Diagnosis:

Drug-induced hepatitis

ICD Code:

Date of Diagnosis:

Hemochromatosis

ICD Code:

Date of Diagnosis:

Cirrhosis of the liver

ICD Code:

Date of Diagnosis:

Primary biliary cirrhosis

ICD Code:

Date of Diagnosis:

Sclerosing cholangitis

ICD Code:

Date of Diagnosis:

Liver transplant candidate

ICD Code:

Date of Diagnosis:

Liver transplant

ICD Code:

Date of Diagnosis:

(complete Section III)
(complete Section III)
(complete Section III)
(complete Section III)
(complete Section III)
(complete Section III)
(complete Section IV)
(complete Section IV)
(complete Section IV)
(complete Section V)
(complete Section V)

Other liver conditions:
Other Diagnosis #1:

ICD Code:

Date of Diagnosis:

Other Diagnosis #2:

ICD Code:

Date of Diagnosis:

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

NOTE: Determination of these conditions requires documentation by appropriate serologic testing, abnormal liver function tests, and/or abnormal liver biopsy or
imaging tests. If test results are documented in the medical record, additional testing is not required.
SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S CURRENT LIVER CONDITION (brief summary):

2B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF THE VETERAN'S LIVER CONDITION?
YES

VA FORM
FEB 2011

NO

(If "Yes," list only those medications required for the liver condition):

21-0960G-5

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SECTION III - HEPATITIS

(Including hepatitis A, B and C, autoimmune or drug-induced hepatitis, any other infectious liver disease and chronic liver disease without cirrhosis)
3A. DOES THE VETERAN CURRENTLY HAVE SIGNS OR SYMPTOMS ATTRIBUTABLE TO CHRONIC OR INFECTIOUS LIVER DISEASES?
YES

NO

(If "Yes," indicate signs and symptoms attributable to chronic or infectious liver diseases (check all that apply)):
Fatigue

(If checked, indicate frequency and severity):

Intermittent

Daily

Near constant and debilitating

Intermittent

Daily

Near constant and debilitating

Intermittent

Daily

Near constant and debilitating

Intermittent

Daily

Near constant and debilitating

Intermittent

Daily

Near constant and debilitating

Intermittent

Daily

Near constant and debilitating

Malaise

(If checked, indicate frequency and severity):
Anorexia

(If checked, indicate frequency and severity):
Nausea

(If checked, indicate frequency and severity):
Vomiting

(If checked, indicate frequency and severity):
Arthralgia

(If checked, indicate frequency and severity):
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).
Right upper quadrant pain

(If checked, indicate frequency and severity):

Intermittent

Daily

Near constant and debilitating

Hepatomegaly
Condition requires dietary restriction

(If checked, describe dietary restrictions):
Condition results in other indications of malnutrition

(If checked, describe other indications of malnutrition):
Other, describe:
3B. HAS THE VETERAN BEEN DIAGNOSED WITH HEPATITIS C?
YES

NO

(If "Yes," indicate risk factors (check all that apply)):
Unknown
No known risk factors
Organ transplant before 1992
Transfusions of blood or blood products before 1992
Hemodialysis
Accidental exposure to blood by health care workers (to include combat medic or corpsman)
Intravenous drug use or intranasal cocaine use
High risk sexual activity
Other direct percutaneous exposure to blood (such as by tattooing, body piercing, acupuncture with non-sterile needles,

shared toothbrushes and/or shaving razors)
(If checked describe):
Other, describe:

3C. HAS THE VETERAN HAD ANY INCAPACITATING EPISODES (with symptoms such as fatigue, malaise, nausea, vomiting, anorexia, arthralgia, and right upper
quadrant pain) DUE TO THE LIVER CONDITIONS DURING THE PAST 12 MONTHS?
YES

NO

(If "Yes," provide the total duration of the incapacitating episodes over the past 12 months):
Less than 1 week
At least 1 week but less than 2 weeks
At least 2 weeks but less than 4 weeks
At least 4 weeks but less than 6 weeks
6 weeks or more

NOTE: For VA purposes, an incapacitating episode means a period of acute symptoms severe enough to require bed rest and treatment by a physician.
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SECTION IV - CIRRHOSIS OF THE LIVER, BILIARY CIRRHOSIS AND CIRRHOTIC PHASE OF SCLEROSING CHOLANGITIS
4A. DOES THE VETERAN CURRENTLY HAVE SIGNS OR SYMPTOMS ATTRIBUTABLE TO CIRRHOSIS OF THE LIVER, BILIARY CIRRHOSIS OR CIRRHOTIC PHASE
OF SCLEROSING CHOLANGITIS?
NO

YES

(If "Yes," indicate signs and symptoms attributable to cirrhosis of the liver, biliary cirrhosis or cirrhotic phase of sclerosing cholangitis (check all that apply)):
Weakness

(If checked, indicate frequency and severity):

Intermittent

Daily

Near constant and debilitating

Intermittent

Daily

Near constant and debilitating

Intermittent

Daily

Near constant and debilitating

Intermittent

Daily

Near constant and debilitating

Anorexia

(If checked, indicate frequency and severity):
Abdominal Pain

(If checked, indicate frequency and severity):
Malaise

(If checked, indicate frequency and severity):
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).
Ascites

(If checked, indicate frequency and severity (check all that apply)):
1 episode

2 or more episodes

Periods of remission between attacks

Refractory to treatment

Date of last episode of ascites:
Hepatic encephalopathy

(If checked, indicate frequency and severity (check all that apply)):
1 episode

2 or more episodes

Periods of remission between attacks

Refractory to treatment

Date of last episode of hepatic encephalopathy:
Hemorrhage from varices or portal gastropathy (erosive gastritis)

(If checked, indicate frequency and severity (check all that apply)):
1 episode

2 or more episodes

Periods of remission between attacks

Refractory to treatment

Date of last episode of hemorrhage from varices or portal gastropathy:
Portal hypertension
Splenomegaly
Persistent jaundice

SECTION V - LIVER TRANSPLANT AND/OR LIVER INJURY
5A. IS THE VETERAN A LIVER TRANSPLANT CANDIDATE?
YES

NO

5B. IS THE VETERAN CURRENTLY HOSPITALIZED AWAITING TRANSPLANT?
YES

NO

Date of hospital admission for this condition:
5C. HAS THE VETERAN UNDERGONE A LIVER TRANSPLANT?
YES

NO

Date(s) of surgery:
Date of hospital discharge:
5D. HAS THE VETERAN HAD AN INJURY TO THE LIVER?
YES

NO

(If "Yes," does the Veteran have peritoneal adhesions resulting from an injury to the liver?)
YES

NO

(If "Yes," ALSO complete the Peritoneal Adhesions Questionnaire.)
SECTION VI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
6A. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS?
YES

NO

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

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SECTION VI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS (Continued)
6B. 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?
YES

NO

(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))?)
YES

NO

(If "Yes," also complete a Scars Questionnaire.)
SECTION VII - DIAGNOSTIC TESTING
NOTE: Diagnosis of hepatitis C must be confirmed by recombinant immunoblot assay (RIBA). If this information is of record, repeat RIBA test is not required.
If testing has been performed and reflects Veteran's current condition, no further testing is required for this examination report.
7A. HAVE IMAGING STUDIES BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

(If "Yes," check all that apply):
EUS (Endoscopic ultrasound)

Date:

Results:

ERCP (Endoscopic retrograde cholangiopancreatography)

Date:

Results:

Transhepatic cholangiogram

Date:

Results:

MRI or MRCP (magnetic resonance cholangiopancreatography)

Date:

Results:

CT

Date:

Results:

Other, describe:

Date:

Results:

7B. HAVE LABORATORY STUDIES BEEN PERFORMED?
YES

NO

(If "Yes," check all that apply):
Recombinant immunoblot assay (RIBA)

Date:

Results:

Hepatitis C genotype

Date:

Results:

Hepatitis C viral titers

Date:

Results:

AST

Date:

Results:

ALT

Date:

Results:

Alkaline phosphatase

Date:

Results:

Bilirubin

Date:

Results:

INR (PT)

Date:

Results:

Creatinine

Date:

Results:

MELD score

Date:

Results:

Other, describe:

Date:

Results:

7C. HAS A LIVER BIOPSY BEEN PERFORMED?
YES

NO

Date of test:

Results:

7D. 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 VIII - FUNCTIONAL IMPACT
8. DOES THE VETERAN'S LIVER CONDITION IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe the impact of each of the Veteran's liver conditions, providing one or more examples):

VA FORM 21-0960G-5, FEB 2011

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SECTION IX - REMARKS
9. 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.
10A. PHYSICIAN'S SIGNATURE

10D. PHYSICIAN'S PHONE NUMBER

10B. PHYSICIAN'S PRINTED NAME

10E. PHYSICIAN'S MEDICAL LICENSE NUMBER

10C. DATE SIGNED

10F. 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, 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 low 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 21-0960G-5, FEB 2011

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