VA Form 21-0960G-3 Intestinal Disorders (other than surgical or infectious)

OMB Control No. 2900-XXXX
Respondent Burden: 15 minutes
INTESTINAL DISORDERS (OTHER THAN SURGICAL OR INFECTIOUS)
(INCLUDING IRRITABLE BOWEL SYNDROME, CROHN'S DISEASE, ULCERATIVE COLITIS, AND
DIVERTICULITIS) 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 AN INTESTINAL CONDITION (Other than surgical or infectious)?
YES

NO

If no, provide rationale (e.g., Veteran does not currently have any known non-surgical or non-infectious intestinal conditions):

If yes, select the Veteran's condition (check all that apply);
Irritable bowel syndrome

ICD Code:

Date of Diagnosis:

Spastic colitis

ICD Code:

Date of Diagnosis:

Mucous colitis

ICD Code:

Date of Diagnosis:

Chronic diarrhea

ICD Code:

Date of Diagnosis:

Ulcerative colitis

ICD Code:

Date of Diagnosis:

Crohn's disease

ICD Code:

Date of Diagnosis:

Chronic enteritis

ICD Code:

Date of Diagnosis:

Chronic enterocolitis

ICD Code:

Date of Diagnosis:

Celiac disease

ICD Code:

Date of Diagnosis:

Diverticulitis
Intestinal neoplasm (If checked,
ALSO complete the Tumors and
Neoplasms Questionaire.)

ICD Code:

Date of Diagnosis:

ICD Code:

Date of Diagnosis:

Peritoneal adhesions attributable ICD Code:
to diverticulitis (If checked,ALSO
complete the Peritoneal Adhesions
Questionaire.)

Date of Diagnosis:

Other non-surgical or non-infectous intestinal conditions:
Other diagnosis #1:

ICD Code:

Date of Diagnosis:

Other diagnosis #2:

ICD Code:

Date of Diagnosis:

IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO INTESTINAL CONDITION(S) (OTHER THAN SURGICAL OR INFECTIOUS), LIST USING ABOVE FORMAT

SECTION II - MEDICAL HISTORY

2A. DESCRIBE THE HISTORY (INCLUDING ONSET AND COURSE) OF THE VETERAN'S INTESTINAL CONDITION (brief summary):

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

NO

If yes, list only those medications required for the intestinal condition:

2C. HAS THE VETERAN HAD SURGICAL TREATMENT FOR AN INTESTINAL CONDITION?
YES

NO

If yes, ALSO complete the Intestinal Surgery Questionaire.
VA FORM
FEB 2011

21-0960G-3

Page 1

SECTION III - SIGNS AND SYMPTOMS
3. DOES THE VETERAN HAVE ANY SIGNS OR SYMPTOMS ATTRIBUTABLE TO ANY NON-SURGICAL NON-INFECTIOUS INTESTINAL CONDITIONS?
YES

NO

If yes, check all that apply:
Diarrhea

If checked, describe:

Alternating diarrhea and constipation If checked, describe:
Abdominal distension If checked, describe:
Anemia If checked, describe:
Nausea If checked, describe:
Vomiting If checked, describe:
Other, describe:
SECTION IV - SYMPTOM EPISODES, ATTACKS AND EXACERBATIONS
4. DOES THE VETERAN HAVE EPISODES OF BOWEL DISTURBANCE WITH ABDOMINAL DISTRESS, OR EXACERBATIONS OR ATTACKS OF THE INTESTINAL
CONDITION?
YES

NO

If Yes, indicate severity and frequency: (check all that apply)

Episodes of bowel disturbance with abdominal distress
If checked, indicate frequency:
Occasional episodes
Frequent episodes
More or less constant abdominal distress
Episodes of exacerbations and/or attacks of the intestinal condition
If checked, describe typical exacerbation or attack:
Indicate number of exacerbations and/or attacks in past 12 months:
0

1

2

3

4

5

6

7 or more
SECTION V - WEIGHT LOSS

5. DOES THE VETERAN HAVE WEIGHT LOSS ATTRIBUTABLE TO A SURGICAL INTESTINAL CONDITION?
YES

NO

If yes, provide veteran's baseline weight:

and current weight:

(For VA purposes, baseline weight is the average weight for 2-year period preceding onset of disease)
SECTION VI - MALNUTRITION, COMPLICATIONS AND OTHER GENERAL HEALTH EFFECTS
6. DOES THE VETERAN HAVE MALNUTRITION, SERIOUS COMPLICATIONS OR OTHER GENERAL HEALTH EFFECTS ATTRIBUTABLE TO THE INTESTINAL
CONDITION?
YES

NO

If Yes, indicate severity: (check all that apply)
Health only fair during remissions
Resulting in general debility
Resulting in serious complication such as liver abscess
Malnutrition
If checked, is malnutrition marked?

YES

NO

Other, describe:
SECTION VII - OTHER PERTINENT FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS?
7A. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS?
YES

NO If "Yes," describe (brief summary):

7B. 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?
VA FORM 21-0960G-3, FEB 2011

Page 2

SECTION VIII - DIAGNOSTIC TESTING
NOTE: If imaging studies, diagnostic procedures or laboratory testing has been performed and reflects the veteran's current condition, provide the most recent results;
no further studies or testing are required for this examination.
8A. HAS LABORATORY TESTING BEEN PERFORMED?
YES

NO

If Yes, check all that apply:
CBC (if anemia due to any intestinal condition is suspected or present)
Date of test
Hemoglobin:
Other, specify:

Hematocrit:

Platelets:

White blood cell count:
Date of test:

Results:

8B. HAVE IMAGING STUDIES OR DIAGNOSTIC PROCEDURES BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

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

8C. 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 IX - FUNCTIONAL IMPACT
9. DOES THE VETERAN'S INTESTINAL CONDITION IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

If Yes, describe the impact of each of the veteran's intestinal conditions, providing one or more examples:

10. REMARKS (If any)

SECTION XI - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
11A. PHYSICIAN'S SIGNATURE
11D. PHYSICIAN'S PHONE NUMBER

11B. PHYSICIAN'S PRINTED NAME
11E. PHYSICIAN'S MEDICAL LICENSE NUMBER

11C. DATE SIGNED
11F. 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 21-0960G-3, FEB 2011

Page 3