VA Form 21-0960G-6 Peritoneal Adhesions Disability Benefits Questionnaire

OMB Control No. 2900-0778
Respondent Burden: 15 minutes

PERITONEAL ADHESIONS 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 PERITONEAL ADHESION?
YES

NO

(If "Yes," complete Item 1B)

1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO PERITONEAL ADHESIONS:
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 PERITONEAL ADHESIONS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including cause, onset and course) OF THE VETERAN'S PERITONEAL ADHESIONS (brief summary):

2B. DOES THE VETERAN HAVE A HISTORY OF OPERATIVE, TRAUMATIC OR INFECTIOUS (INTRAABDOMINAL) PROCESS?
YES

NO

IF YES, INDICATE ORGAN(S) AFFECTED (check all that apply):
STOMACH

GALL BLADDER

LIVER

SMALL INTESTINES

LARGE INTESTINES

OTHER:

2C. HAS THE VETERAN HAD SEVERE PERITONITIS, RUPTURED APPENDIX, PERFORATED ULCER OR OPERATION WITH DRAINAGE?
YES

NO

2D. DOES THE VETERAN HAVE A CURRENT DIAGNOSiS OF PERITONEAL ADHESIONS?
YES

NO

IF YES, INDICATE ORGAN(S) AFFECTED (check all that apply):
STOMACH

GALL BLADDER

LIVER

SMALL INTESTINES

LARGE INTESTINES

OTHER:

2E. DOES THE VETERAN HAVE ANY SIGNS AND/OR SYMPTOMS DUE TO PERITONEAL ADHESIONS?
YES

IF YES, INDICATE SIGNS AND SYMPTOMS: (check all that apply)

NO

DELAYED MOTILITY OF BARIUM MEAL (on X-ray)

NAUSEA

PARTIAL OR COMPLETE BOWEL OBSTRUCTION

VOMITING

REFLEX DISTURBANCES

ABDOMINAL DISTENTION

PAIN

CONSTIPATION (perhaps alternating with diarrhea)

2F. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING CONTINUOUS MEDICATION FOR THE DIAGNOSED CONDITION?
YES

NO

LIST MEDICATIONS:

SECTION III - SEVERITY OF MANIFESTATIONS OF PERITONEAL ADHESIONS
NOTE - Indicate level of severity of signs and/or symptoms, if present: (check all that apply in each level)
3A. LEVEL IV
SEVERE

DEFINITE PARTIAL OBSTRUCTION
SHOWN BY X-RAY

FREQUENT EPISODES OF SEVERE COLIC
DISTENSION

PROLONGED EPISODES OF SEVERE COLIC DISTENSION

FREQUENT EPISODES
OF SEVERE NAUSEA

PROLONGED EPISODES OF SEVERE NAUSEA

FREQUENT EPISODES
OF SEVERE VOMITING

PROLONGED EPISODES OF SEVERE VOMITING

3B. LEVEL III
MODERATELY SEVERE

PARTIAL OBSTRUCTION MANIFESTED BY
DELAYED MOTILITY OF BARIUM MEAL

LESS FREQUENT
EPISODES OF PAIN

LESS PROLONGED
EPISODES OF PAIN

3C. LEVEL II
MODERATE

PULLING PAIN ON ATTEMPTING
WORK OR AGGRAVATED BY
MOVEMENTS OF THE BODY

OCCASIONAL
EPISODES
OF COLIC PAIN

OCCASIONAL
EPISODES
OF NAUSEA

OCCASIONAL EPISODES
OF CONSTIPATION

(Perhaps alternating with diarrhea)

ABDOMINAL
DISTENSION

3D. LEVEL I
MILD, DESCRIBE:
VA FORM
FEB 2011

21-0960G-6

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SECTION IV - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
4A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
SECTION 1, DIAGNOSIS?
YES

NO

IF YES, ARE ANY OF THE SCARS PAINFUL/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)
4B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN DIAGNOSIS SECTION 1?
YES

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

NO

SECTION V - DIAGNOSTIC TESTING
5. HAS THE VETERAN HAD LABORATORY OR OTHER DIAGNOSTIC STUDIES PERFORMED AND ARE THE RESULTS AVAILABLE?
YES

NO

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

SECTION VI - FUNCTIONAL IMPACT AND REMARKS
6. BASED ON YOUR EXAMINATION AND/OR THE VETERAN'S HISTORY, DOES THE VETERAN'S PERITONEAL ADHESION(S) IMPACT HIS OR HER ABILITY TO
WORK?
YES

NO

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

7. REMARKS (If any)

SECTION VII - PHYSICIAN'S CERTIFICATION AND SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
8A. PHYSICIAN'S SIGNATURE

8D. PHYSICIAN'S PHONE AND FAX NUMBER

8C. DATE SIGNED

8B. PHYSICIAN'S PRINTED NAME

8E. PHYSICIAN'S MEDICAL LICENSE NUMBER

8F. 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-6, FEB 2011

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