VA Form 21-0960G-2 Gallbladder and Pancreas Conditions Disability Benefits

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

GALLBLADDER AND PANCREAS 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 HE OR SHE EVER BEEN DIAGNOSED WITH A GALLBLADDER OR PANCREAS CONDITION?
YES

NO

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

1B. PROVIDE RATIONALE (e.g., veteran does not currently have any known gallbladder or pancreas condition):

1C. SELECT THE VETERAN'S CONDITION (check all that apply):
Chronic cholecystitis

ICD Code:

Date of Diagnosis:

Chronic cholelithiasis

ICD Code:

Date of Diagnosis:

Chronic cholangitis

ICD Code:

Date of Diagnosis:

Cholecystectomy

ICD Code:

Date of Diagnosis:

Pancreatitis

ICD Code:

Date of Diagnosis:

Total or partial pancreatectomy

ICD Code:

Date of Diagnosis:

Gallbladder neoplasm

ICD Code:

Date of Diagnosis:

(If checked, ALSO complete the VA Form 21-0960O-1, Tumors and Neoplasms Disability Benefits Questionnaire)
Pancreatic neoplasm

ICD Code:

Date of Diagnosis:

(If checked, ALSO complete the VA Form 21-0960O-1, Tumors and Neoplasms Disability Benefits Questionnaire)
Gallbladder or pancreas injury, with peritoneal adhesions resulting
from this injury

ICD Code:

Date of Diagnosis:

(If checked, ALSO complete the VA Form 21-0960G-6, Peritoneal Adhesions Disability Benefits Questionnaire)
Other gallbladder conditions:
Other Diagnosis #1:

ICD Code:

Date of Diagnosis:

Other Diagnosis #2:

ICD Code:

Date of Diagnosis:

1D. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO A GALLBLADDER OR PANCREAS CONDITIONS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S GALLBLADDER AND/OR PANCREAS CONDITION (brief summary):

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

VA FORM
FEB 2011

NO

(If "Yes," list only those medications required for the gallbladder or pancreas condition):

21-0960G-2

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SECTION III - GALLBLADDER CONDITIONS: SIGNS AND SYMPTOMS
3A. DOES THE VETERAN HAVE ANY OF THE FOLLOWING SIGNS OR SYMPTOMS ATTRIBUTABLE TO ANY GALLBLADDER CONDITIONS OR RESIDUALS OF
TREATMENT FOR GALLBLADDER CONDITIONS?
YES

NO

(If "Yes," check all that apply):
Gallbladder disease-induced dyspepsia (including sphincter of Oddi dysfunction and/or biliary dyskinesia)
(If checked, indicate number of episodes per year):
0

1

2

3

4 or more

Attacks of gallbladder colic

(If checked, indicate number of attacks per year):
0

1

2

3

4 or more

Jaundice

(If checked, provide bilirubin level in Diagnostic testing section)
Other signs or symptoms, describe:

SECTION IV - PANCREAS CONDITIONS: SIGNS AND SYMPTOMS
4A. DOES THE VETERAN HAVE ANY OF THE FOLLOWING SYMPTOMS ATTRIBUTABLE TO ANY PANCREAS CONDITIONS OR RESIDUALS OF TREATMENT FOR
PANCREAS CONDITIONS?
YES

NO

(If "Yes," check all that apply):
Abdominal pain, confirmed as resulting from pancreatitis by appropriate laboratory and clinical studies

(If checked, indicate severity and frequency of attacks (check all that apply)):
Severe

Typical

Disabling

(Indicate number of attacks of TYPICAL abdominal pain in the past 12 months):
1

0

2

3

4

5

6

7 or more

(Indicate number of attacks of SEVERE abdominal pain in the past 12 months):
0

1

2

3

4

5

6

7 or more

(Indicate number of attacks of DISABLING abdominal pain in the past 12 months):
0

1

2

3

4

5

6

7 or more

Remissions/pain-free intermissions between attacks

(If checked, indicate characteristics of remissions):
Good pain-free remissions between attacks
Few pain-free intermissions between attacks
Other symptoms, describe:
4B. DOES THE VETERAN HAVE ANY OF THE FOLLOWING SIGNS OR FINDINGS ATTRIBUTABLE TO ANY PANCREAS CONDITIONS OR RESIDUALS OF TREATMENT
FOR PANCREAS CONDITIONS?
YES

NO

(If "Yes," check all that apply):
Steatorrhea

(If checked, describe frequency and severity):
Malabsorption

(If checked, describe frequency and severity):
Diarrhea

(If checked, describe frequency and severity):
Severe malnutrition

(If checked, describe severity (such as beta-carotene, fat-soluble vitamin deficiencies)):
Weight loss

(If checked, provide baseline weight:
and current weight:
).
(For VA purposes, baseline weight is the average weight for 2-year period preceding onset of disease).
Other, describe:

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)):

VA FORM 21-0960G-2, FEB 2011

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SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS (Continued)
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," 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.)
SECTION VI - DIAGNOSTIC TESTING
NOTE: Diagnosis of pancreatitis must be confirmed by appropriate laboratory and clinical studies. If testing has been performed and reflects Veteran's current
condition, no further testing is required for this examination report.
6A. HAVE IMAGING STUDIES BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

(If "Yes," check all that apply):
EUS (Endoscopic ultrasound)

Date:

Results:

ERCP (Endoscopic retrograde cholangiopancreatography)

Date:

Results:

Transhepatic cholangiogram

Date:

Results:

MRI or MRCP (magnetic resonance cholangiopancreatography)

Date:

Results:

Gallbladder scan (HIDA scan or cholescintigraphy)

Date:

Results:

CT

Date:

Results:

Other, specify:

Date:

Results:

Date:

Results:

6B. HAS LABORATORY TESTING BEEN PERFORMED?
YES

NO

(If "Yes," check all that apply):
Alkaline phosphatase

Date:

Results:

Bilirubin

Date:

Results:

WBC

Date:

Results:

Amylase

Date:

Results:

Lipase

Date:

Results:

Other, specify:

6C. 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 VII - FUNCTIONAL IMPACT
7. DOES THE VETERAN'S GALLBLADDER AND/OR PANCREAS CONDITION(S) IMPACT ON HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe the impact of each of the Veteran's gallbladder and/or pancreas conditions, providing one or more examples):

VA FORM 21-0960G-2, FEB 2011

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SECTION VIII - REMARKS
8. REMARKS (If any)

SECTION XV - 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, 58VA21/22/28, 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 low 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 a 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-2, FEB 2011

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