VA Form 21-0960K-2 Gynecological Conditions Disability Benefits Questionnai

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

GYNECOLOGICAL 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 SHE EVER HAD A GYNECOLOGICAL CONDITION?

(If "Yes," complete Item 1C) (If "No," complete Item 1B)
YES
NO
1B. PROVIDE RATIONALE / REASON (e.g. veteran does not currently have any known gynecological condition(s))

1C. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO GYNECOLOGICAL CONDITION(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 GYNECOLOGICAL DIAGNOSES, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY

2. DESCRIBE THE HISTORY (including cause, onset and course) OF THE VETERAN'S CURRENT GYNECOLOGICAL CONDITION(S):

SECTION III - FINDINGS, SIGNS AND SYMPTOMS
3. DOES THE VETERAN CURRENTLY HAVE SIGNS AND/OR SYMPTOMS RELATED A GYNECOLOGICAL CONDITION, INCLUDING ANY DISEASES, INJURIES OR
ADHESIONS OF THE FEMALE REPRODUCTIVE ORGANS?
YES

NO

(If yes, indicate current signs, symptoms and/or severity of pain, if any: (check all that apply))
No pain
Intermittent pain
Constant pain
Mild pain
Moderate pain
Severe pain
Pelvic pressure
Irregular menstruation
Frequent or continuous menstrual disturbances
Other signs and/or symptoms, describe:

SECTION IV - TREATMENT
4A. HAS THE VETERAN HAD TREATMENT FOR SYMPTOMS RELATED TO ANY DISEASES, INJURIES AND/OR ADHESIONS OF THE REPRODUCTIVE TRACT?
YES

NO

(If yes, specify organ(s) affected and treatment):
Date of Treatment:
4B. DOES THE VETERAN CURRENTLY REQUIRE TREATMENT OR MEDICATIONS FOR SYMPTOMS RELATED TO REPRODUCTIVE TRACT CONDITIONS?
YES

NO

(If yes, list current treatment/medications prescribed for symptoms related to reproductive tract conditions):

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SECTION IV - FINDINGS, SIGNS AND SYMPTOMS (Continues)
4C. If yes, indicate effectiveness of treatment in controlling symptoms:
Symptoms do not require continuous treatment
Symptoms require continuous treatment
Symptoms are not controlled by continuous treatment

SECTION V - CONDITIONS OF THE VULVA
5. HAS THE VETERAN HAS BEEN DIAGNOSED WITH ANY DISEASES, INJURIES OR OTHER CONDITIONS OF THE VULVA (to include vulvovaginitis)?
YES

NO

(If yes, describe):

SECTION VI - CONDITIONS OF THE VAGINA
6. HAS THE VETERAN HAVE BEEN DIAGNOSED WITH ANY DISEASES, INJURIES OR OTHER CONDITIONS OF THE VAGINA?
YES

NO

(If yes, describe):

SECTION VII - CONDITIONS OF THE CERVIX
7. HAS THE VETERAN HAVE BEEN DIAGNOSED WITH ANY DISEASES, INJURIES, ADHESIONS OR OTHER CONDITIONS OF THE CERVIX?
YES

NO

(If yes, describe):

SECTION VIII - CONDITIONS OF THE UTERUS
8A. HAS THE VETERAN HAVE BEEN DIAGNOSED WITH ANY DISEASES, INJURIES, ADHESIONS OR OTHER CONDITIONS OF THE UTERUS?
YES

NO

8B. HAS THE VETERAN HAD A HYSTERECTOMY?
YES

NO

(If yes, provide date(s) of surgery and facility(ies) where performed):

8C. DOES THE VETERAN HAVE UTERINE PROLAPSE?
YES

NO

(If yes, indicate severity):
Incomplete
Complete (through vagina and introitus)
If yes, does the condition currently cause symptoms?
NO

YES

(If yes, describe):

8D. DOES THE VETERAN HAVE UTERINE FIBROIDS, ENLARGEMENT OF THE UTERUS AND/OR DISPLACEMENT OF THE UTERUS?
YES

NO

If yes, does the condition currently cause symptoms?
YES

NO

(If yes, check all that apply):
Adhesions
Marked displacement
Marked enlargement
Uterine fibroids
Irregular menstruation
Frequent or continuous menstrual disturbances
Other, describe:
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SECTION VIII - CONDITIONS OF THE UTERUS (Continues)
8E. HAS THE VETERAN HAVE BEEN DIAGNOSED WITH ANY OTHER DISEASES, INJURIES, ADHESIONS OR OTHER CONDITIONS OF THE UTERUS?
YES
NO

(If yes, describe):

SECTION IX - CONDITIONS OF THE FALLOPIAN TUBES
9. HAS THE VETERAN HAVE BEEN DIAGNOSED WITH ANY DISEASES, INJURIES, ADHESIONS OR OTHER CONDITIONS OF THE FALLOPIAN TUBES

(to include pelvic inflammatory disease)?
YES

NO

(If yes, describe):

SECTION X - CONDITIONS OF THE OVARIES
10A. HAS THE VETERAN HAVE BEEN DIAGNOSED WITH ANY DISEASES, INJURIES, ADHESIONS OR OTHER CONDITIONS OF THE OVARIES
(including oophorectomy)?
YES

NO

10B. HAS THE VETERAN UNDERGONE NATURAL MENOPAUSE?
YES

NO

10C. HAS THE VETERAN UNDERGONE SURGICAL, CHEMICAL-INDUCED, RADIATION-INDUCED OR PREMATURE MENOPAUSE PRIOR TO AGE
40 DUE TO ANY OTHER CAUSE?
YES

NO

10D. HAS THE VETERAN UNDERGONE OOPHORECTOMY?
YES

NO

(If yes, check all that apply):
Partial removal of 1 or both ovaries
Complete removal of 1 ovary
Complete removal of both ovaries

(If yes, provide date(s) of surgery and facility(ies) where performed):
10E. DOES THE VETERAN HAVE EVIDENCE OF ATROPHY OF 1 OR BOTH OVARIES?
YES

NO

UNKNOWN

If yes, indicate severity:
Partial atrophy of 1 or both ovaries
Complete atrophy of 1 ovary
Complete atrophy of both ovaries (excluding natural menopause)
10F. HAS THE VETERAN HAVE BEEN DIAGNOSED WITH ANY OTHER DISEASES, INJURIES, ADHESIONS AND/OR OTHER CONDITIONS OF THE OVARIES?
YES

NO

(If yes, describe):

SECTION XI - INCONTINENCE
11. DOES THE VETERAN HAVE URINARY INCONTINENCE/LEAKAGE?
YES

NO

If yes, is the urinary incontinence/leakage due to a gynecologic condition?
YES

NO

(If yes, check all that apply):
Does not require/does not use absorbent material
Stress incontinence
Requires absorbent material that is changed less than 2 times per day
Requires absorbent material that is changed 2 to 4 times per day
Requires absorbent material that is changed more than 4 times per day
Requiring the use of an appliance
If checked, describe appliance:

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SECTION XII - FISTULAE
12A. DOES THE VETERAN HAVE A RECTOVAGINAL FISTULA?
YES

NO

If yes, does the Veteran have vaginal-fecal leakage?
YES

NO

If yes, indicate frequency (check all that apply):
Less than once a week
1-3 times per week
4 or more times per week
Daily or more often
Requires wearing of pad or absorbent material
12B. DOES THE VETERAN HAVE AN URETHROVAGINAL FISTULA?
YES
NO
If yes, does the Veteran have urine leakage?
NO

YES

(If yes, check all that apply):
Does not require/does not use absorbent material
Requires absorbent material that is changed less than 2 times per day
Requires absorbent material that is changed 2 to 4 times per day
Requires absorbent material that is changed more than 4 times per day
Requires the use of an appliance
If checked, describe appliance:

SECTION XIII - ENDOMETRIOSIS

NOTE - A diagnosis of endometriosis must be substantiated by laparoscopy.
13. HAS THE VETERAN HAVE BEEN DIAGNOSED WITH ENDOMETRIOSIS?
YES

NO

If yes, does the Veteran currently have any findings, signs or symptoms due to endometriosis?
YES

NO

(If yes, check all that apply):
Pelvic pain
Heavy or irregular bleeding requiring continuous treatment for control
Heavy or irregular bleeding not controlled by treatment
Lesions involving bowel or bladder confirmed by laparoscopy
Bowel or bladder symptoms from endometriosis
Anemia caused by endometriosis
Other, describe:

SECTION XIV - COMPLICATIONS AND RESIDUALS OF PREGNANCY OR OTHER GYNECOLOGIC PROCEDURES
14A. HAS THE VETERAN HAD ANY SURGICAL COMPLICATIONS OF PREGNANCY?
YES

NO

(If yes, check all that apply):
Relaxation of perineum
Rectocele
Cystocele
Other, describe:
14B. HAS THE VETERAN HAD ANY OTHER COMPLICATIONS RESULTING FROM OBSTETRICAL OR GYNECOLOGIC CONDITIONS OR PROCEDURES?
YES

NO

(If yes, describe):

NOTE - If obstetrical or gynecologic complications impact other body systems, also complete the additional appropriate Questionnaire(s)
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SECTION XV - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
15A. DOES THE VETERAN HAVE ANY OTHER PERTINENT FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS?
YES

NO

(If yes, describe (brief summary)):

15B. 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 VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)
SECTION XVI - NEOPLASM

16. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT GYNECOLOGIC NEOPLASM?
YES

NO

(If "Yes," also complete VA Form 21-0960O-1, Tumors and Neoplasms Disability Benefits Questionnaire)
SECTION XVII - DIAGNOSTIC TESTING

NOTE - If laboratory test results are in the medical record and reflect the Veteran's current condition, repeat testing is not required.
17A. HAS THE VETERAN HAD LAPAROSCOPY?
YES

NO

If yes, provide date(s) and facility where performed, and results:
17B. HAS THE VETERAN BEEN DIAGNOSED WITH ANEMIA?
YES

NO

If yes, provide most recent test results:

Hgb:

Date of test:

17C. HAS THE VETERAN HAD ANY OTHER 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):

SECTION XVIII - FUNCTIONAL IMPACT
18. BASED ON YOUR EXAMINATION AND/OR THE VETERAN'S HISTORY DOES THE VETERAN'S GYNECOLOGICAL CONDITION(S) IMPACT HER ABILITY TO WORK?
YES

NO

If yes, describe impact of each of the Veteran's gynecological condition, providing one or more examples:

SECTION XIX - REMARKS
19. REMARKS (If any)

SECTION XX - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
20A. PHYSICIAN'S SIGNATURE

20D. PHYSICIAN'S PHONE NUMBER

20B. PHYSICIAN'S PRINTED NAME

20E. PHYSICIAN'S MEDICAL LICENSE NUMBER

20C. DATE SIGNED

20F. 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.
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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
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VA FORM 21-0960K-2, FEB 2011

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