VA Form 21-0960A-2 Artery and Vein Conditions (Vascular Diseases including

OMB Approved No. 2900-0776
Respondent Burden: 30 minutes

ARTERY AND VEIN CONDITIONS (VASCULAR DISEASES INCLUDING VARICOSE VEINS)
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. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD A VASCULAR DISEASE (ARTERIAL OR VENOUS)?
YES

NO

(If "Yes," complete Item 1B)

1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO VASCULAR CONDITION(S):
DIAGNOSIS # 1 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 2 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 3 -

ICD CODE -

DATE OF DIAGNOSIS -

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO VASCULAR DISEASES, LIST USING ABOVE FORMAT

SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE CAUSE/ONSET OF THE VETERAN'S CURRENT VASCULAR CONDITION(S) (Provide a brief summary)

2B. TYPE OF VASCULAR DISEASE CONDITION (Check all that apply and then complete the corresponding Section(s) III-VIII regardless if condition(s) is/are checked.)
Section III: Varicose veins and/or post-phlebitic syndrome
Section IV: Peripheral vascular disease, aneurysm of any large artery (other than aorta),
arteriosclerosis obliterans or thrombo-angitis obliterans (Buerger's Disease)
Section V: Aortic aneurysm
Section VI: Aneurysm of a small artery
Section VII: Raynaud's syndrome
Section VIII: Arteriovenous (AV) fistula, angioneurotic edema or erythromelalgia

SECTION III - VARICOSE VEINS AND/OR POST- PHLEBITIC SYNDROME
3A. DOES THE VETERAN HAVE VARICOSE VEINS OR POST-PHLEBITIC SYNDROME OF ANY ETIOLOGY?
YES

NO

(If "Yes," complete Items 3B and 3C)

3B. CHECK ALL SYMPTOMS THAT APPLY AND INDICATE EXTREMITY AFFECTED:
Asymptomatic palpable varicose veins

Right

Left

Both

Asymptomatic visible varicose veins

Right

Left

Both

Aching and fatigue in leg after prolonged standing or walking

Right

Left

Both

Symptoms relieved by elevation of extremity

Right

Left

Both

Symptoms relieved by compression hosiery

Right

Left

Both

3C. CHECK ALL FINDINGS AND/OR SIGNS THAT APPLY AND INDICATE EXTREMITY AFFECTED:
Incipient stasis pigmentation or eczema

Right

Left

Persistent stasis pigmentation or eczema

Right

Left

Both

Intermittent ulceration

Right

Left

Both

Intermittent edema of extremity

Right

Left

Both

Persistent edema that is incompletely
relieved by elevation of extremity

Right

Left

Both

Persistent edema

Right

Left

Both

Persistent subcutaneous induration

Right

Left

Both

Massive board-like edema

Right

Left

Both

Constant pain at rest

Right

Left

Both

VA FORM
DEC 2011

21-0960A-2

Both

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SECTION IV - PERIPHERAL VASCULAR DISEASE, ANEURYSM OF ANY LARGE ARTERY (OTHER THAN AORTA) ARTERIOSCLEROSIS
OBLITERANS OR THROMBO-ANGIITIS OBLITERANS (BUERGER'S DISEASE)
4A. HAS THE VETERAN EVER BEEN DIAGNOSED WITH PERIPHERAL VASCULAR DISEASE, ANEURYSM OF ANY LARGE ARTERY (OTHER THAN AORTA)
ARTERIOSCLEROSIS OBLITERANS OR THROMBO-ANGIITIS OBLITERANS (BUERGER'S DISEASE?) (Check all that apply):
Peripheral vascular disease
Aneurysm of any large artery (other than aorta)
Arteriosclerosis obliterans
Thrombo-angiitis obliterans (Buerger's Disease)
None of the above
(If any of the above conditions are checked, answer questions 4b - 4d.)
4B. HAS THE VETERAN UNDERGONE SURGERY FOR ANY OF THESE LISTED CONDITIONS?
YES

(If "Yes," list type of surgery):

NO

Date of surgery:

)

4C. HAS THE VETERAN UNDERGONE ANY PROCEDURE (OTHER THAN SURGERY) FOR REVASCULARIZATION?
YES

(If "Yes," list type of procedure):

NO

Date of procedure:

)

4D. INDICATE SEVERITY OF CURRENT SIGNS AND SYMPTOMS AND INDICATE EXTREMITY AFFECTED: (Check all that apply)
Claudication on walking more than 100 yards

Right

Left

Both

Claudication on walking between 25 and 100 yards on a level grade at 2 miles per hour

Right

Left

Both

Claudication on walking less than 25 yards on a level grade at 2 miles per hour

Right

Left

Both

Persistent coldness of the extremity

Right

Left

Both

Diminished peripheral pulses

Right

Left

Both

Ischemic limb pain at rest

Right

Left

Both

Trophic changes (thin skin, absence of hair, dystrophic nails)

Right

Left

Both

1 or more deep ischemic ulcers

Right

Left

Both

SECTION V - AORTIC ANEURYSM
5A. HAS THE VETERAN EVER BEEN DIAGNOSED WITH AN AORTIC ANEURYSM?
YES

(If "Yes," complete Item 5B)

NO

5B. HAS THE VETERAN HAD A SURGICAL PROCEDURE FOR AN AORTIC ANEURYSM?
YES

(If "Yes," indicate type of surgery):

NO

Date of surgery:

)

5C. DOES THE VETERAN CURRENTLY HAVE AN AORTIC ANEURYSM?
YES

(If "Yes," indicate severity):

NO

5 centimeters or larger in diameter

YES

NO

Symptomatic

YES

NO

Precludes exertion

YES

NO

5D. DOES THE VETERAN HAVE ANY POST-SURGICAL RESIDUALS DUE TO TREATMENT FOR AORTIC ANEURYSM?
YES

NO

(If "Yes," describe):___________________________________________________________________________________________________

(If there are symptoms or post-surgical residuals, ALSO complete appropriate Questionnaire according to body system affected.)

SECTION VI - ANEURYSM OF A SMALL ARTERY
6A. HAS THE VETERAN BEEN DIAGNOSED WITH AN ANEURYSM OF A SMALL ARTERY?
NO (If "Yes," complete Item 6B)

YES

6B. HAS THE VETERAN HAD A SURGICAL PROCEDURE FOR AN ANEURYSM OF A SMALL ARTERY?
YES

NO (If "Yes," list type of surgery):

Date of surgery:

6C. DOES THE VETERAN CURRENTLY HAVE AN ANEURYSM OF A SMALL ARTERY?
NO (If "Yes," is the condition symptomatic?)

YES
YES

NO

(If "Yes," describe):________________________________________________________________________________________
(Also complete appropriate Questionnaire according to body system affected.)

6D. DOES THE VETERAN HAVE ANY POST-SURGICAL RESIDUALS DUE TO TREATMENT FOR AN ANEURYSM OF A SMALL ARTERY?
YES

NO

(If "Yes," describe):___________________________________________________________________________________________________

(If there are symptoms or post-surgical residuals, ALSO complete appropriate Questionnaire according to body system affected.).
SECTION VII - RAYNAUD'S SYNDROME
7A. DOES THE VETERAN HAVE RAYNAUD'S SYNDROME?
YES

NO (If "Yes," complete Item 7B)

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SECTION VII - RAYNAUD'S SYNDROME (Continued)
7B. DOES THE VETERAN HAVE CHARACTERISTIC ATTACKS?
YES

NO

(If "Yes," indicate frequency of characteristic attacks):

Less than once a week
1 to 3 times a week
4 to 6 times a week
At least daily

NOTE: Characteristic attacks consist of sequential color changes of the digits of one or more extremities lasting minutes to hours, sometimes with pain
and paresthesias, and precipitated by exposure to cold or by emotional upsets.
7C. DOES THE VETERAN HAVE TWO OR MORE DIGITAL ULCERS?
YES

NO

7D. DOES THE VETERAN HAVE AUTOAMPUTATION OF ONE OR MORE DIGITS?
YES

NO

SECTION VIII - ARTERIOVENOUS (AV) FISTULA, ANGIONEUROTIC EDEMA OR ERYTHROMELALGIA
8A. DOES THE VETERAN HAVE ARTERIOVENOUS (AV) FISTULA, ANGIONEUROTIC EDEMA OR ERYTHROMELALGIA?
NO (If "Yes," complete Items 8B through 8D)

YES

8B. DOES THE VETERAN HAVE A TRAUMATIC ARTERIOVENOUS (AV) FISTULA?
NO

YES

(If "Yes," indicate site of traumatic fistula):

Right upper extremity
Right lower extremity
Left upper extremity
Left lower extremity
Other location, (Specify):_____________________________________________________________________________
8C. INDICATE FINDINGS:
Edema
Stasis dermatitis
Ulceration
Cellulitis
Enlarged heart
Wide pulse pressure
Tachycardia
High output heart failure
8D. IS THERE MORE THAN ONE TRAUMATIC AV FISTULA?
YES

NO (If "Yes," provide location and findings for each):

8E. DOES THE VETERAN HAVE ANGIONEUROTIC EDEMA?
YES

NO (If "Yes," indicate severity and frequency of characteristic attacks):
Without laryngeal involvement
With laryngeal involvement
Lasts 1 to 7 days
Lasts longer than 7 days
Occurs once a year or less
Occurs 1 to 2 times a year
Occurs 2 to 4 times a year
Occurs 5 to 8 times a year
Occurs more than 8 times a year

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SECTION VIII - ARTERIOVENOUS (AV) FISTULA, ANGIONEUROTIC EDEMA OR ERYTHROMELALGIA (Continued)
8F. DOES THE VETERAN HAVE ERYTHROMELALGIA?

NOTE: Characteristic attack of erythromelalgia consists of burning pain in the hands, feet or both, usually bilateral and symmetrical, with increased skin
temperature and redness, occurring at warm ambient temperatures.
NO (If "Yes," indicate severity and frequency of characteristic attacks):

YES

Does not restrict most routine daily activities
Restricts most routine daily activities
Occurs less than 3 times a week
Occurs at least 3 times a week
Occurs daily
Occurs more than once a day
Lasts an average of more than 2 hours each
Responds to treatment
Responds poorly to treatment

SECTION IX - MISCELLANEOUS ISSUES
9A. HAS THE VETERAN HAD AN AMPUTATION OF AN EXTREMITY DUE TO A VASCULAR CONDITION?
NO (If "Yes," ALSO complete VA Form 21-0960M-1, Amputations Disability Benefits Questionnaire)

YES

9B. DOES THE VETERAN USE ANY ASSISTIVE DEVICE(S) AS A NORMAL MODE OF LOCOMOTION, ALTHOUGH OCCASIONAL LOCOMOTION BY OTHER
METHODS MAY BE POSSIBLE?
NO (If "Yes," identify assistive device(s) used.) (Check all that apply and indicate frequency):

YES

Wheelchair

Frequency of use:

Occasional

Regular

Constant

Brace(s)

Frequency of use:

Occasional

Regular

Constant

Crutch(es)

Frequency of use:

Occasional

Regular

Constant

Cane(s)

Frequency of use:

Occasional

Regular

Constant

Walker

Frequency of use:

Occasional

Regular

Constant

Other

Frequency of use:

Occasional

Regular

Constant

9C. IF THE VETERAN USES ANY ASSISTIVE DEVICES, SPECIFY THE CONDITION AND IDENTIFY THE ASSISTIVE DEVICE USED FOR EACH CONDITION:

9D. DUE TO A VASCULAR CONDITION, IS THERE FUNCTIONAL IMPAIRMAENT OF AN EXTREMITY SUCH THAT NO EFFECTIVE FUNCTION REMAINS OTHER THAN
THAT WHICH WOULD BE EQUALLY WELL SERVED BY AN AMPUTATION WITH PROSTHESIS? (Functions of the upper extremity include grasping, manipulation, etc., while
functions for the lower extremity include balance and propulsion, etc.)

YES, functioning is so diminished that amputation with prosthesis would equally serve the veteran.
NO

(If "Yes," indicate extremity(ies.) (Check all extremities for which this applies):
Right upper
Right lower
Left upper
Left lower
9E. DESCRIBE LOSS OF EFFECTIVE FUNCTION FOR EACH EXTREMITY CHECKED, IDENTIFY THE CONDITION CAUSING LOSS OF FUNCTION AND PROVIDE
SPECIFIC EXAMPLES (Brief summary):

SECTION X - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
10A. DOES THE VETERAN HAVE ANY SCARS (SURGICAL OR OTHERWISE) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED
IN SECTION I?
NO

YES

(If "Yes," are any of the scars painful and/or unstable, or is the total area of all related scars 39 square cm (6 square inches) or greater?)
YES

NO

(If "Yes," ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire

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SECTION X - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS (Continued)
10B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS RELATED TO THE
CONDITIONS LISTED IN SECTION I?
YES

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

SECTION XI - DIAGNOSTIC TESTING
11A. HAS ANKLE/BRACHIAL INDEX TESTING BEEN PERFORMED?

NOTE: An ankle/brachial index is required for peripheral vascular disease or aneurysm of any large artery (other than aorta), arteriosclerosis obliterans
or thrombo-angiitis obliterans (Buerger's disease) if not of record, or if there has been an intervening change in the veteran's peripheral vascular condition.
YES

NO

UNABLE TO PERFORM (Provide reason):__________________________________________________________________________

(If "Yes," provide most recent results):
Right ankle/brachial index:__________

Date:_________________

Left ankle/brachial index:___________

Date:_________________

11B. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES

NO

(If "Yes," provide type of test or procedure):________________________________________ Date of test or procedure:____________
Results (Brief summary):_______________________________________________________________________________________________________________
SECTION XI - FUNCTIONAL IMPACT AND REMARKS
11C. DOES THE VETERAN'S VASCULAR CONDITION(S) IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe impact of each of the veteran's vascular condition, providing one or more examples):

11D. REMARKS (If any)

SECTION XII - 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

12B. PHYSICIAN'S PRINTED NAME

12D. PHYSICIAN'S PHONE AND FAX NUMBER 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 30 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
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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 21-0960A-2, DEC 2011

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