VA Form 21-0960G-4 Intestinal Surgery (bowel resection, colostomy, iliostom

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

INTESTINAL SURGERY (BOWEL RESECTION, COLOSTOMY, ILIOSTOMY)
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 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. HAS THE VETERAN HAD INTESTINAL SURGERY?
(If "Yes," complete Item1B)
YES
NO
1B. SELECT THE VETERAN’S CONDITION (check all that apply)
RESECTION OF THE SMALL INTESTINE

ICD code:____________

Date of diagnosis:_______________

Reason for surgery:__________________________

RESECTION OF THE LARGE INTESTINE
PERITONEAL ADHESIONS ATTRIBUTABLE
TO RESECTION OF THE LARGE OR SMALL
INTESTINE (If checked, ALSO complete
VA Form 21-0960G-6, Peritoneal Adhesions
Disability Benefits Questionnaire)

ICD code:____________

Date of diagnosis:_______________

Reason for surgery:__________________________

ICD code:____________

Date of diagnosis:_______________

Reason for surgery:__________________________

PERSISTENT FISTULA

ICD code:____________

Date of diagnosis:_______________

Reason for surgery:__________________________

Other diagnosis #1:_____________________
_____________________________________

ICD code:____________

Date of diagnosis:_______________

Reason for surgery:__________________________

Other diagnosis #2:_____________________
_____________________________________

ICD code:____________

Date of diagnosis:_______________

Reason for surgery:__________________________

OTHER INTESTINAL SURGERY (specify)

1C. IF ADDITIONAL DIAGNOSES THAT PERTAIN TO INTESTINAL SURGERY, LIST USING ABOVE FORMAT

SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN’S INTESTINAL SURGERY (brief summary):

2B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF THE VETERAN’S INTESTINAL CONDITION(S)?
NO (If "Yes," list only those medications required for the intestinal condition(s))

YES

SECTION III - SIGNS AND SYMPTOMS
3A. DOES THE VETERAN HAVE ANY SIGNS OR SYMPTOMS ATTRIBUTABLE TO ANY INTESTINAL SURGERY?
YES

NO (If "Yes," check all that apply)
Slight symptoms attributable to resection of large intestine (If checked, describe):________________________________________________________________
Moderate symptoms attributable to resection of large intestine (If checked, describe):_____________________________________________________________
Severe symptoms, objectively supported by examination findings, attributable to resection of large intestine (If checked,describe):____________________
___________________________________________________________________________________________________________________________________
Abdominal pain and/or colic pain (If checked,
Diarrhea (If checked,
Alternating diarrhea and constipation (If checked,
Abdominal distension (If checked,
Anemia (If checked, provide hemoglobin/hematocrit in Section 9, Diagnostic Testing)
Nausea (If checked,
Vomiting (If checked,
Pulling pain on attempting work or aggravated by movements of the body (If checked, describe):___________________________________________________
Other (If checked,
describe):__________________________________________________________________________________________________________________

VA FORM
FEB 2011

21-0960G-4

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SECTION IV - WEIGHT LOSS
4A. DOES THE VETERAN HAVE WEIGHT LOSS OR INABILITY TO GAIN WEIGHT ATTRIBUTABLE TO INTESTINAL SURGERY?
YES

NO

(If "Yes," complete Items 4B thru 4D)

4B. PROVIDE VETERAN’S BASELINE WEIGHT AND CURRENT WEIGHT (NOTE: For VA purposes, baseline weight is the average weight for 2-year period preceding
onset of disease)
Baseline weight:____________

Current weight:____________

4C. HAS THE VETERAN’S WEIGHT LOSS BEEN SUSTAINED FOR 3 MONTHS OR LONGER?
YES
NO
4D. HAS THE VETERAN BEEN UNABLE TO REGAIN WEIGHT DESPITE APPROPRIATE THERAPY?
YES

NO

SECTION V - ABSORPTION AND NURTITION
5. DOES THE VETERAN HAVE ANY INTERFERENCE WITH ABSORPTION AND NUTRITION ATTRIBUTABLE TO RESECTION OF THE SMALL INTESTINE?
YES
NO
NOT APPLICABLE
(If "Yes," does this cause impairment of health objectively supported by examination findings including definite and/or material weight loss?)
Yes
No
(If "Yes," is impairment of health severe?)
Yes
No
(If "Yes," indicate severity of interference with absorption and nutrition)
Definite

Marked

SECTION VI - OSTOMY
6. DID THE VETERAN’S INTESTINAL CONDITION REQUIRE AN ILEOSTOMY OR COLOSTOMY?
YES

NO

(If "Yes," describe)

SECTION VII - FISTULA
7. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER HAD A PERSISTENT INTESTINAL FISTULA ATTRIBUTABLE TO A
SURGICAL INTESTINAL CONDITION?
YES

NO

(If "Yes," does the veteran have fecal discharge attributable to this?)
Yes
No
(If "Yes," indicate severity and frequency of fecal discharge (check all that apply))
Slight
Copious
Infrequent
Frequent
Constant
Other (describe):___________________________________________________

SECTION VIII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
8A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
SECTION I ?
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 cm (6 square inches)?
Yes
No
(If "Yes," ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)
8B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN SECTION I ?
YES

NO

(If "Yes," describe (brief summary)):

VA FORM 21-0960G-4, FEB 2011

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SECTION IX - DIAGNOSTIC TESTING
NOTE: If imaging studies, diagnostic procedures or laboratory testing has been performed and reflects the veteran’s current condition, no further studies
or testing are required for this examination.
9A. 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 if test:______________________
Hemoglobin:___________ Hematocrit:____________ White blood cell count:__________ Platelets:__________

Other
Date if test:______________________
Results:____________________________________________________________________________

9B. 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))

9C. 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 X - FUNCTIONAL IMPACT AND REMARKS
10. DO ANY OF THE VETERAN’S INTESTINAL SURGERY RESIDUALS IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe the impact of each of the veteran’s intestinal surgery residuals, including any ongoing symptoms of original cause of surgery that
may be hard to distinguish from post-surgical residuals, providing one or more examples)

11. 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.
12A. PHYSICIAN’S SIGNATURE

12D. PHYSICIAN’S PHONE NUMBER

12B. PHYSICIAN’S PRINTED NAME

12E. PHYSICIAN’S MEDICAL LICENSE NUMBER

12C. DATE SIGNED

12F. 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-4, FEB 2011

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