VA Form 21-0960G-6 Peritoneal Adhesions Disability Benefits Questionnaire

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

PERITONEAL ADHESIONS DISABILITY BENEFITS QUESTIONNAIRE
IMPORTANT - 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 - The veteran has applied to the Department of Veterans Affairs (VA) for disability benefits. Please complete this questionnaire,
which VA needs for review of the veteran's application.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN HAVE A PERITONEAL ADHESION?
YES

(If "No," complete Item 1B)

NO

(If "Yes," complete Item 1C)

1B. PROVIDE RATIONALE

1C. PROVIDE ONLY DIAGNOSIS THAT PERTAIN TO PERITONEAL ADHESIONS
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 PERITONEAL ADHESIONS, LIST USING ABOVE FORMAT

SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE CAUSE/ONSET OF THE VETERAN'S CURRENT PERITONEAL ADHESIONS:

2B. DOES THE VETERAN HAVE A HISTORY OF OPERATIVE, TRAUMATIC OR INFECTIOUS (INTRAABDOMINAL) PROCESS?
YES

NO

(If "Yes," indicate organ(s) affected) (Check all that apply)
STOMACH

GALL BLADDER

LIVER

SMALL INTESTINES

LARGE INTESTINES

OTHER:

2C. HAS THE VETERAN HAD SEVERE PERITONITIS, RUPTURED APPENDIX, PERFORATED ULCER OR OPERATION WITH DRAINAGE?
YES

NO

2D. DOES THE VETERAN HAVE A CURRENT DIAGNOSES OF PERITONEAL ADHESIONS?
YES

NO

(If "Yes," indicate organ(s) affected) (Check all that apply)
STOMACH

GALL BLADDER

LIVER

SMALL INTESTINES

LARGE INTESTINES

OTHER:

2E. DOES THE VETERAN HAVE ANY SIGNS AND/OR SYMPTOMS DUE TO PERITONEAL ADHESIONS?
YES

NO

(If "Yes," indicate signs and symptoms) (Check all that apply)

DISTURBANCE OF MOTILITY
ACTUAL PARTIAL OBSTRUCTION
REFLEX DISTURBANCES
PRESENCE OF PAIN

SECTION III - SEVERITY OF MANIFESTATIONS OF PERITONEAL ADHESIONS
NOTE - Indicate level of severity of signs and/or symptoms, if present: (Check all boxes that apply)
3A. LEVEL I
MILD
3B. LEVEL II
MODERATE

PULLING PAIN ON ATTEMPTING
WORK OR AGGRAVATED BY
MOVEMENTS OF THE BODY

OCCASIONAL
EPISODES
OF COLIC PAIN

OCCASIONAL
EPISODES
OF NAUSEA

OCCASIONAL EPISODES
OF CONSTIPATION

(Perhaps alternating with diarrhea)

ABDOMINAL
DISTENSION

3C. LEVEL III
MODERATELY SEVERE

PARTIAL OBSTRUCTION MANIFESTED BY
DELAYED MOTILITY OF BARIUM MEAL

LESS FREQUENT
EPISODES OF PAIN

LESS PROLONGED
EPISODES OF PAIN

3D. LEVEL IV
SEVERE

DEFINITE PARTIAL OBSTRUCTION
SHOWN BY X-RAY

FREQUENT EPISODES OF SEVERE COLIC
DISTENSION, NAUSEA OR VOMITING

PROLONGED EPISODES OF SEVERE COLIC DISTENSION
VA FORM
SEP 2010

21-0960G-6

FREQUENT EPISODES
OF SEVERE NAUSEA

PROLONGED EPISODES OF SEVERE NAUSEA

FREQUENT EPISODES
OF SEVERE VOMITING

PROLONGED EPISODES OF SEVERE VOMITING

SECTION IV - FUNCTIONAL IMPACT AND REMARKS
4. DOES THE VETERAN'S PERITONEAL ADHESIONS IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe impact, providing one or more examples)

5. REMARKS (If any)

SECTION V - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
6A. PHYSICIAN'S SIGNATURE

6D. PHYSICIAN'S PHONE NUMBER

6B. PHYSICIAN'S PRINTED NAME

6E. PHYSICIAN'S MEDICAL LICENSE NUMBER

6C. DATE SIGNED

6F. 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 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-6, SEP 2010