VA Form 21-0960A-4 Heart Conditions (Including Ischemic and Non-Ischemic He

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

HEART CONDITIONS (INCLUDING ISCHEMIC AND NON-ISCHEMIC HEART DISEASE,
ARRHYTHMIAS, VALVULAR DISEASE AND CARDIAC SURGERY)
DISABILITY BENEFITS QUESTIONNAIRE
NOTE - For coronary artery disease, myocardial infarction, or hypertensive disease, complete VA Form 21-0960A-1, Ischemic Heart Disease 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 BEEN DIAGNOSED WITH A HEART CONDITION?
YES

NO

(If "Yes," complete Item 1B)

1B. SELECT THE VETERAN'S HEART CONDITION(S) (Check all that apply):
Acute, subacute, or old myocardial infarction
Atherosclerotic cardiovascular disease
Coronary artery disease

ICD Code:______________
ICD Code:______________
ICD Code:______________

Date of diagnosis:_____________
Date of diagnosis:_____________
Date of diagnosis:_____________

Stable angina

ICD Code:______________

Date of diagnosis:_____________

Unstable angina

ICD Code:______________

Date of diagnosis:_____________

Coronary spasm, including Prinzmetal's angina

ICD Code:______________

Date of diagnosis:_____________

Congestive heart failure

ICD Code:______________

Date of diagnosis:_____________

Supraventricular arrhythmia

ICD Code:______________

Date of diagnosis:_____________

Ventricular arrhythmia

ICD Code:______________

Date of diagnosis:_____________

Heart block

ICD Code:______________

Date of diagnosis:_____________

Valvular heart disease

ICD Code:______________

Date of diagnosis:_____________

Heart valve replacement

ICD Code:______________

Date of diagnosis:_____________

Cardiomyopathy

ICD Code:______________

Date of diagnosis:_____________

Hypertensive heart disease
Heart transplant

ICD Code:______________
ICD Code:______________

Date of diagnosis:_____________
Date of diagnosis:_____________

Implanted cardiac pacemaker

ICD Code:______________

Date of diagnosis:_____________

Implanted automatic implantable cardioverter defibrillator (AICD)
Infectious heart conditions (including active valvular infection, rheumatic heart
disease, endocarditis, pericarditis or syphilitic heart disease)
Pericardial adhesions

ICD Code:______________

Date of diagnosis:_____________

ICD Code:______________
ICD Code:______________

Date of diagnosis:_____________
Date of diagnosis:_____________

Diagnosis #1:_________________________________________________

ICD Code:______________

Date of diagnosis:_____________

Diagnosis #2:_________________________________________________

ICD Code:______________

Date of diagnosis:_____________

Other heart condition, specify below

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO HEART CONDITIONS, LIST USING ABOVE FORMAT:

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

2B. DO ANY OF THE VETERAN'S HEART CONDITIONS QUALIFY WITHIN THE GENERALLY ACCEPTED MEDICAL DEFINITION OF ISCHEMIC HEART DISEASE (IHD)?
YES

VA FORM
JAN 2011

NO

(If "Yes," list the conditions that qualify):

21-0960A-4

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SECTION II - MEDICAL HISTORY (Continued)

2C. PROVIDE THE ETIOLOGY, IF KNOWN, OF EACH OF THE VETERAN'S HEART CONDITIONS, INCLUDING THE RELATIONSHIP/CAUSALITY TO OTHER HEART
CONDITIONS, PARTICULARLY THE RELATIONSHIP/CAUSALITY TO THE VETERAN'S IHD CONDITIONS, IF ANY:
Heart condition #1 (provide etiology):________________________________________________________________
Heart condition #2 (provide etiology):________________________________________________________________
2D. IF THERE ARE ADDITIONAL HEART CONDITIONS, PROVIDE ETIOLOGY AND LIST USING THE ABOVE FORMAT:

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

NO

(If, "Yes," list medications required for the veteran's heart condition (include name of medication and heart condition it is used for, such as atenolol for myocardial
infarction or atrial fibrillation):

SECTION III - MYOCARDIAL INFARCTION (MI)
3A. HAS THE VETERAN HAD A MYOCARDIAL INFARCTION (MI)?
NO (If, "Yes," complete the following):

YES

MI #1: Date and treatment facility:________________________________________________________________
MI #2: Date and treatment facility:________________________________________________________________
3B. IF THE VETERAN HAS HAD ADDITIONAL MIs, LIST USING ABOVE FORMAT:

SECTION IV - CONGESTIVE HEART FAILURE (CHF)
4A. HAS THE VETERAN HAD CONGESTIVE HEART FAILURE (CHF)?
NO (If "Yes," complete Item 4B)

YES

4B. DOES THE VETERAN HAVE CHRONIC CHF?
YES

NO

4C. HAS THE VETERAN HAD ANY EPISODES OF ACUTE CHF IN THE PAST YEAR?
YES

NO

(If, "Yes," specify the number of episodes of acute CHF the veteran has had in the past year):
0

1

More than 1 Provide date of most recent episode of acute CHF:_______________

4D. WAS THE VETERAN ADMITTED FOR TREATMENT OF ACUTE CHF?
YES

NO

(If, "Yes," indicate name of treatment facility):_________________________________________________________
SECTION V - ARRHYTHMIA
5A. HAS THE VETERAN HAD A CARDIAC ARRHYTHMIA?
YES

NO (If "Yes," complete Item 5B)

5B. SELECT TYPE OF ARRHYTHMIA (Check all that apply):
Atrial fibrillation

(If checked, indicate frequency):

Constant

Intermittent (paroxysmal)

0
(If "Intermittent," indicate number of episodes in the past 12 months):
(Indicate how these episodes were documented.) (Check all that apply):
EKG

Holter

1-4

More than 4

1-4

More than 4

1-4

More than 4

Other, specify:___________________________

Atrial flutter

(If checked, indicate frequency):

Constant

Intermittent (paroxysmal)

0
(If "Intermittent," indicate number of episodes in the past 12 months):
(Indicate how these episodes were documented.) (Check all that apply):
EKG

Holter

Other, specify:___________________________

Supraventricular tachycardia

(If checked, indicate frequency):

Constant

Intermittent (paroxysmal)

0
(If "Intermittent," indicate number of episodes in the past 12 months):
(Indicate how these episodes were documented.) (Check all that apply):
EKG

Holter

Other, specify:___________________________

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SECTION V - ARRHYTHMIA (Continued)
5B. SELECT TYPE OF ARRHYTHMIA (Continued) (Check all that apply)
Atrioventricular block
I degree

II degree

III degree

Ventricular arrhythmia (sustained)

(Indicate date of hospital admission for initial evaluation and medical treatment in Section IX, Procedures)
Other cardiac arrhythmia, specify:_________________________________________________________

(If checked, indicate frequency):

Constant

Intermittent (paroxysmal)

0
(If "Intermittent," indicate number of episodes in the past 12 months):
(Indicate how these episodes were documented.) (Check all that apply):
EKG

Holter

1-3

More than 4

Other, specify:___________________________

SECTION VI - HEART VALVE CONDITIONS
6A. HAS THE VETERAN HAD A HEART VALVE CONDITION?
YES

NO (If "Yes," complete Item 6B)

6B. SELECT HEART VALVES AFFECTED (Check all that apply):
Mitral

Tricuspid

Aortic

Pulmonary

6C. DESCRIBE TYPE OF HEART VALVE CONDITION FOR EACH CHECKED VALVE:

SECTION VII - INFECTIOUS HEART CONDITIONS
7A. HAS THE VETERAN HAD ANY INFECTIOUS CARDIAC CONDITIONS, INCLUDING ACTIVE VALVULAR INFECTION (INCLUDING RHEUMATIC HEART DISEASE),
ENDOCARDITIS, PERICARDITIS OR SYPHILITIC HEART DISEASE?
YES

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

7B. HAS THE VETERAN UNDERGONE OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR ANY ACTIVE INFECTION?
YES

NO

(If, "Yes," describe treatment and site of infection being treated):________________________________________________________________________________
____________________________________________________________________________________________________________________________________
7C. HAS TREATMENT FOR AN ACTIVE INFECTION BEEN COMPLETED?
YES

NO

(If, "Yes," provide date completed):_____________
7D. HAS THE VETERAN HAD A SYPHILITIC AORTIC ANEUYSM?
YES

NO

(If "Yes," ALSO complete VA Form 21-0960A-2, Artery and Vein Conditions Disability Benefits Questionnaire)
SECTION VIII - PERICARDIAL ADHESIONS
8A. HAS THE VETERAN HAD PERICARDIAL ADHESIONS?
YES

NO (If "Yes," complete Item 8B)

8B. SELECT ETIOLOGY OF PERICARDIAL ADHESIONS:
Pericarditis

Cardiac surgery/bypass

Other, describe:_______________________________________________________________________

SECTION IX - PROCEDURES
9A. HAS THE VETERAN HAD ANY NON-SURGICAL OR SURGICAL PROCEDURES FOR THE TREATMENT OF A HEART CONDITION?
YES

NO (If "Yes," complete Item 9B)

9B. INDICATE THE NON-SURGICAL OR SURGICAL PROCEDURES THE VETERAN HAS HAD FOR THE TREATMENT OF HEART CONDITIONS (Check all that apply):
Percutaneous coronary intervention (PCI) (angioplasty)
Indicate date of treatment or date of admission if admitted for treatment and name of treatment facility:________________________________________
Coronary artery bypass surgery
Indicate date of admission for treatment and name of treatment facility:_________________________________________
Heart valve replacement
Specify valve(s) replaced and type of valve(s):___________________________________________________________________________
Indicate date of admission for treatment and name of treatment facility:_________________________________________
Heart translplant
Indicate date of admission for treatment and name of treatment facility:_________________________________________
Implanted cardiac pacemaker
Indicate date of admission and for treatment and name of treatment facility:________________________________________

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SECTION IX - PROCEDURES (Continued)
9B. INDICATE THE NON-SURGICAL OR SURGICAL PROCEDURES THE VETERAN HAS HAD FOR THE TREATMENT OF HEART CONDITIONS (Continued)
(Check all that apply):
Implanted automatic implantable cardioverter defibrillator (AICD)
Indicate date of admission for treatment and name of treatment facility:_____________________________________
Valve replacement
If checked indicate valve(s) that have been replaced (check all that apply)
Mitral
Tricuspid
Aortic
Pulmonary
Indicate date of admission for treatment and name of treatment facility for each checked valve:
________________________________________________________________________________________________________________________
Ventricular aneurysmectomy
Indicate date of admission for treatment and name of treatment facility:_________________________________________
Other surgical and/or non-surgical procedures for the treatment of a heart condition, describe:___________________________________________________
Indicate date of admission for treatment and name of treatment facility:_________________________________________________________________
Indicate the condition that resulted in the need for this procedure/treatment:_____________________________________________________________

SECTION X - HOSPITALIZATIONS
10. HAS THE VETERAN HAD ANY OTHER HOSPITALIZATIONS FOR THE TREATMENT OF HEART CONDITIONS (OTHER THAN FOR NON-SURGICAL AND SURGICAL
PROCEDURES DESCRIBED ABOVE)?
NO (If "Yes," provide the following):

YES

Date of admission for treatment and name of treatment facility:______________________________________________
Condition that resulted in the need for hospitalization:_______________________________________________________________________________________

SECTION XI - PHYSICAL EXAM
11. PHYSICAL EXAM:
Heart rate:________________
Rhythm:

Regular

Point of maximal impact:

Not palpable

4th intercostal space

Heart sounds:

Normal

Abnormal, specify:__________________________

Jugular-venous distension:

Yes

No

Auscultation of the lungs:

Clear

Bibasilar rales

Peripheral pulses:
Dorsalis pedis
Posterior tibial:
Peripheral edema:
Right lower extremity:
Left lower extremity:

Irregular

Dimished

Absent

Normal

Dimished

Absent

Trace
Trace

1+
1+

Other, specify:__________________________________

Other, describe:_____________________________________

Normal
None
None

5th intercostal space

2+
2+

3+
3+

4+
4+

Blood pressure:_____________

SECTION XII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
12A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED
IN SECTION I, DIAGNOSIS?
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 VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)
12B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO
ANY CONDITIONS LISTED IN SECTION I, DIAGNOSIS?
YES

NO

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

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SECTION XIII - DIAGNOSTIC TESTING
NOTE: For VA purposes, exams for all heart conditions require a determination of whether or not cardiac hypertrophy or dilatation is present. The suggested order
of testing for cardiac hypertrophy/dilatation is EKG, then chest x-ray (PA and lateral), then echocardiogram. An echodardiogram to determine heart size is only
necessary if the other two tests are negative.
For VA purposes, if LVEF testing is not of record, but available medical information sufficiently reflects the severity of the veteran's cardiovascular
condition, LVEF testing is not required.
13A. IS THERE EVIDENCE OF CARDIAC HYPERTROPHY?
YES

NO

(If "Yes," indicate how this condition was documented):
EKG

Chest x-ray

Echocardiogram

Date of test:_______________
13B. IS THERE EVIDENCE OF CARDIAC DILATATION?
YES

NO

(If "Yes," indicate how this condition was documented):
Chest x-ray

Echocardiogram

Date of test:_______________
13C. SELECT ALL TESTING COMPLETED AND PROVIDE MOST RECENT RESULTS WHICH REFLECT THE VETERAN'S CURRENT FUNCTIONAL STATUS

(Check all that apply):

EKG

Date of EKG:_______________
Result of EKG:
Normal
Arrhythmia, describe:__________________________________________________
Hypertrophy, describe:_________________________________________________
Ischemic, describe:___________________________________________________
Other, describe:______________________________________________________

Chest x-ray

Date of CXR:_______________
Result of CXR:
Normal
Abnormal, describe:__________________________________________________

Echocardiogram

Date of echocardiogram:_______________
Left ventricular ejection fraction (LVEF):______%
Normal
Abnormal, describe:________________________
Wall motion:
Wall thickness:

Holter monitor

Normal

Abnormal, describe:_________________________

Date of holter monitor test:_______________
Result:
Normal
Abnormal, describe:__________________________________________________

MUGA

Date of MUGA:_______________
Left ventricular ejection fraction (LVEF):______%
Result:
Normal
Abnormal, describe:__________________________________________________

Coronary artery angiogram

Date of angiogram:_______________
Result:
Normal
Abnormal, describe:__________________________________________________

CT angiography

Date of CT angiography:_______________
Result:
Normal
Abnormal, describe:__________________________________________________

Other test, specify:
____________________
____________________

VA FORM 21-0960A-4, JAN 2011

Date of test:_______________
Result:________________________________________________________________

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SECTION XIV - METs TESTING
NOTE: For VA purposes, all heart exams require METs testing (either exercise-based or interview-based) to determine the activity level at which symptoms such as
dyspnea, fatigue, angina, dizziness, or syncope develop (except exams for supraventricular arrhythmias.)
If a laboratory determination of METs by exercise testing cannot be done for medical reasons (e.g. chronic CHF or multiple episodes of acute CHF within the past 12
months), or if exercise-based METs test was not completed because it is not required as part of the veteran's treatment plan, or if exercise stress test results do no reflect
veteran's current cardiac function, perform an interview-based METs test based on the veteran's responses to a cardiac activity questionnaire and provide the results
below.
14A. INDICATE ALL TESTING COMPLETED PROVIDING ONLY MOST RECENT RESULTS WHICH REFLECT THE VETERAN'S CURRENT FUNCTIONAL STATUS.

(Check all that apply):

Exercise stress test

Date of most recent exercise stress test:_______________
Results:__________________________________________________________________________
METs level the veteran performed, if provided:____________________________________________

Interview-based METs test

Date of interview-based METs test:_______________
Symptoms during activity:
The METs level checked below reflects the lowest activity level at which the veteran reports any of the
following symptoms (check all symptoms that the veteran reports at the indicated METs level of activity):
Dyspnea

Fatigue

Angina

Dizziness

Syncope

Other, describe:_________________________
Results:
METs level on most recent interview-based METs test:
(1-3 METs)

This METs level has been found to be consistent with activities such as eating, dressing,
taking a shower, slow walking (2 mph) for 1-2 blocks

(>3-5 METs)

This METs level has been found to be consistent with activities such as light yard work (weeding),
mowing lawn (power mower), brisk walking (4 mph)

(>5-7 METs)

This METs level has been found to be consistent with activities such as walking 1 flight of stairs,
golfing (without cart), mowing lawn (push mower), heavy yard work (digging)

(>7-10 METs)

This METs level has been found to be consistent with activities such as climbing stairs quickly,
moderate bicycling, sawing wood, jogging (6 mph)

The veteran denies experiencing above symptoms with any level of physical activity
14B. IF THE VETERAN HAS HAD BOTH AN EXERCISE STRESS TEST AND INTERVIEW-BASED METs TEST, INDICATE WHICH RESULTS MOST ACCURATELY
REFLECT THE VETERAN'S CURRENT CARDIAC FUNCTIONAL LEVEL:
Exercise stress test
Interview-based METs test
N/A
14C. IS THE METs LEVEL LIMITATION DUE SOLELY TO THE HEART CONDITIONS?
YES

NO

(If "No," estimate the percentage of the METs level limitation that is due solely to the heart condition(s)):
0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

The limitation in METs level is due to multiple factors; it is not possible to accurately estimate this percentage.
14D. IN ADDITION TO THE HEART CONDITION(S), DOES THE VETERAN HAVE OTHER NON-CARDIAC MEDICAL CONDITIONS (such as musculoskeletal or

pulmonary conditions) LIMITING THE METs LEVEL?
YES

NO

(If "Yes," identify each condition and describe how each non-cardiac medical condition limits the veteran's METs level):
Other medical condition #1:______________________________________
Other medical condition #2:______________________________________

Effect on METs level:_________________________________
Effect on METs level:_________________________________

14E. IF THERE ARE ADDITIONAL MEDICAL CONDITIONS AFFECTING METs LEVEL, LIST USING ABOVE FORMAT:

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SECTION XV - FUNCTIONAL IMPACT
15. DOES THE VETERAN'S HEART CONDITION(S) IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe impact of each of the veteran's heart conditions, providing one or more examples)

SECTION XVI - REMARKS
16. REMARKS (If any)

SECTION XVII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
17A. PHYSICIAN'S SIGNATURE

17D. PHYSICIAN'S PHONE AND FAX NUMBER

17B. PHYSICIAN'S PRINTED NAME

17E. PHYSICIAN'S MEDICAL LICENSE NUMBER

17C. DATE SIGNED

17F. 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
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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 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 21-0960A-4, JAN 2011

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