VA Form 21-0960H-2 Rectum and Anus Disability Benefits Questionnaire

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

RECTUM AND ANUS 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 HAVE A CONDITION OF THE RECTUM OR ANUS?

(If "No," complete Item 1B)
YES
NO
1B. PROVIDE RATIONALE

(If "Yes," complete Item 1C)

1C. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO RECTUM OR ANUS 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 RECTUM OR ANUS CONDITIONS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY
2. DESCRIBE THE CAUSE/ONSET OF THE VETERAN'S CURRENT CONDITION OF THE RECTUM OR ANUS:

SECTION III - SYMPTOMS OF RECTUM OR ANUS CONDITION(S)
3A. DOES THE VETERAN HAVE IMPAIRMENT OF SPHINCTER CONTROL OF THE RECTUM AND ANUS OR AN ANAL FISTULA?
YES

NO (If "Yes," indicate severity)
NO SYMPTOMS
HEALED OR SLIGHT, WITHOUT LEAKAGE
CONSTANT SLIGHT, OR OCCASIONAL MODERATE LEAKAGE
OCCASIONAL INVOLUNTARY BOWEL MOVEMENTS, NECESSITATING WEARING OF PAD
EXTENSIVE LEAKAGE AND FAIRLY FREQUENT INVOLUNTARY BOWEL MOVEMENTS
COMPLETE LOSS OF SPHINCTER CONTROL

3B. DOES THE VETERAN HAVE STRICTURE OF THE RECTUM AND ANUS?
YES

NO (If "Yes," indicate severity)
NO SYMPTOMS
MODERATE REDUCTION OF LUMEN, OR MODERATE CONSTANT LEAKAGE
GREAT REDUCTION OF LUMEN, OR EXTENSIVE LEAKAGE
REQUIRING COLOSTOMY

3C. DOES THE VETERAN HAVE PROLAPSE OF THE RECTUM?
YES
NO (If "Yes," indicate the severity)
NO SYMPTOMS
MILD WITH CONSTANT SLIGHT OR OCCASIONAL MODERATE LEAKAGE
MODERATE, PERSISTENT OR FREQUENTLY RECURRING
SEVERE (OR COMPLETE), PERSISTENT

VA FORM
FEB 2011

21-0960H-2

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SECTION III - SYMPTOMS OF RECTUM OR ANUS CONDITION(S) (Continued)
3D. DOES THE VETERAN HAVE A DIAGNOSIS OF INTERNAL OR EXTERNAL HEMORRHOIDS?
YES

NO (If "Yes," indicate severity)
NO SYMPTOMS
MILD OR MODERATE
LARGE OR THROMBOTIC, IRREDUCIBLE, WITH EXCESSIVE REDUNDANT TISSUE, EVIDENCING FREQUENT RECURRENCES
WITH PERSISTENT BLEEDING AND WITH SECONDARY ANEMIA, OR WITH FISSURES

3E. DOES THE VETERAN HAVE A DIAGNOSIS OF ANAL PRURITUS?
YES

NO

(If "Yes," indicate underlying condition and describe below)
(If appropriate, complete Questionnaire for underlying condition, such as skin)

3F. DOES THE VETERAN HAVE A DIAGNOSIS OF VISCEROPTOSIS?
YES

NO (If "Yes," complete Item 3G)

3G. IS IT MARKEDLY SYMPTOMATIC?
YES

NO

SECTION IV - FUNCTIONAL IMPACT AND REMARKS
4. DOES THE VETERAN'S CONDITION OF THE RECTUM OR ANUS 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 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
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 21-0960H-2, FEB 2011

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