VA Form 21-0960K-1 Breast Conditions and Disorders Disability Benefits Ques

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

BREAST CONDITIONS AND DISORDERS 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 ON
REVERSE 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 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 SHE EVER HAD A DISORDER OF THE BREAST(S)?
YES

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

NO

1B. PROVIDE RATIONALE (e.g. veteran does not currently have any known breast conditions)

1C. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO THE BREAST(S)
DIAGNOSIS # 1 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 2 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 3 -

ICD CODE -

DATE OF DIAGNOSIS -

1D. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO THE BREAST(S), LIST USING ABOVE FORMAT:

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

2B. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OF THE BREAST?
YES

NO

2C. IS THE NEOPLASM
BENIGN

MALIGNANT

2D. IF MALIGNANT, WERE THERE OR ARE THERE CURRENTLY ANY METASTASES?
YES

NO

(If "Yes," describe locations):
SECTION III - TREATMENT/SURGERY
3A. HAS THE VETERAN COMPLETED ANY TYPE OF TREATMENT OF IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT
NEOPLASM AND/OR METASTASES?
YES

NO

(If "Yes," indicate treatment type(s) (check all that apply)):
Watchful waiting
Surgery
If checked, describe:
Date(s) of surgery:
Radiation therapy
Date of most recent treatment:
Date of completion of treatment or anticipated date of completion:
Antineoplastic chemotherapy
Date of most recent treatment:
Date of completion of treatment or anticipated date of completion:
Other therapeutic procedure and/or treatment (describe):
Date of procedure:
Date of completion of treatment or anticipated date of completion:

VA FORM
FEB 2011

21-0960K-1

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SECTION III - TREATMENT/SURGERY (Continued)
3B. HAS THE VETERAN UNDERGONE BREAST SURGERY?
YES

NO

(If "Yes," indicate procedure type and severity (check all that apply)):
Wide local excision (For VA purposes, wide local excision means removal of a portion of the breast tissue and includes partial mastectomy,
lumpectomy, tylectomy, segmentectomy, and quadrantectomy)
Right

Left

Both

Simple (or total) mastectomy (For VA purposes, a simple (or total) mastectomy means removal of all of the breast tissue, nipple, and a small portion of
the overlying skin, but lymph nodes and muscles are left intact)
Right

Left

Both

Modified radical mastectomy (For VA purposes, a modified radical mastectomy means removal of the entire breast and axillary lymph nodes, in
continuity with the breast, with pectoral muscles are left intact)
Right

Left

Both

Radical mastectomy (For VA purposes, radical mastectomy means removal of the entire breast, underlying pectoral muscles, and regional lymph nodes
up to the coracoclavicular ligament)
Right

Left

Both

Axillary or sentinel lymph node excision

Right

Left

Both

Significant alteration of size or form

Right

Left

Both

Biopsy

Right

Left

Both

Other:

Right

Left

Both

3C. ARE THERE ANY RESIDUAL CONDITIONS CAUSED BY THE BENIGN OR MALIGNANT NEOPLASM OR ITS TREATMENT (e.g., arm swelling, nerve damage to arm)?
YES

NO

(If "Yes," also complete the VA Form 21-0960O-1, Tumors and Neoplasm's Disability Benefits Questionnaire)
SECTION IV - OBJECTIVE FINDINGS AND RESIDUALS

4. DID THE SURGERY OR RADIATION TREATMENT RESULT IN THE LOSS OF 25 PERCENT OR MORE TISSUE FROM A SINGLE BREAST OR BOTH BREASTS IN
COMBINATION?
YES

NO

SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
5A. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS?
YES

NO

(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?
YES

NO

(If "Yes," also complete the VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)
SECTION VI - DIAGNOSTIC TESTING

NOTE - If imaging and/or diagnostic test results are in the medical record and reflect the Veteran's current condition, repeat testing is not required.
6. HAS THE VETERAN HAD IMAGING AND/OR DIAGNOSTIC TESTING AND IF SO, ARE THERE SIGNIFICANT FINDINGS AND/OR RESULTS?
YES

NO

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

VA FORM 21-0960K-1, FEB 2011

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SECTION VII - FUNCTIONAL IMPACT
7. DOES THE VETERAN'S BREAST CONDITION(S) IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe the impact of each of the veteran's breast conditions, providing one or more examples)

SECTION VIII - REMARKS
8. REMARKS (If any)

SECTION IX - 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 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 21-0960K-1, FEB 2011

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