VA Form 21-0960G-8 Infectious Intestinal Disorders, Including Bacterial and

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

INFECTIOUS INTESTINAL DISORDERS, INCLUDING BACTERIAL AND
PARASITIC INFECTIONS 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 AN INFECTIOUS INTESTINAL CONDITION?
YES

NO

(If "Yes," complete Item 1B)

1B. SELECT THE VETERAN'S CONDITION (check all that apply):
BACILLARY DYSENTERY

ICD code:

INTESTINAL DISTOMIASIS (intestinal fluke)

ICD code:

Date of diagnosis:
Date of diagnosis:

PARASITIC INFECTION OF THE INTESTINES

ICD code:

Date of diagnosis:

AMEBIASIS

ICD code:

Date of diagnosis:

NOTE: If the veteran has a lung abscess due to amebiasis, ALSO complete VA Form 21-0960L-1, Respiratory Conditions Disability Benefits Questionnaire.
OTHER INFECTIOUS INTESTINAL CONDITION
OTHER DIAGNOSIS #1:

ICD code:

Date of diagnosis:

OTHER DIAGNOSIS #2:

ICD code:

Date of diagnosis:

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

SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset, course, and past treatment) OF THE VETERAN'S INFECTIOUS INTESTINAL CONDITIONS (brief summary):

2B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF THE VETERAN'S INTESTINAL CONDITIONS?
YES

NO

IF YES, LIST ONLY THOSE MEDICATIONS REQUIRED FOR THE INTESTINAL CONDITIONS?

2C. HAS THE VETERAN HAD SURGICAL TREATMENT FOR AN INTESTINAL CONDITION?
YES

NO

If "Yes," ALSO complete VA Form 21-0960G-4, Intestinal Surgery (Bowel Resection, Colostomy, Ileostomy) Disability Benefits Questionnaire)

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

NO

IF YES, CHECK ALL THAT APPLY:

MILD SYMPTOMS ATTRIBUTABLE TO DISTOMIASIS, INTESTINAL OR HEPATIC. If checked, describe:
MODERATE SYMPTOMS ATTRIBUTABLE TO DISTOMIASIS, INTESTINAL OR HEPATIC. If checked, describe:
SEVERE SYMPTOMS ATTRIBUTABLE TO DISTOMIASIS, INTESTINAL OR HEPATIC. If checked, describe:
MILD GASTROINTESTINAL DISTURBANCES. If checked, describe:
LOWER ABDOMINAL CRAMPS. If checked, describe:
GASEOUS DISTENTION. If checked, describe:
CHRONIC CONSTIPATION INTERRUPTED BY DIARRHEA. If checked, describe:
ANEMIA. If checked, provide hemoglobin/hematocrit in Diagnostic testing section.
NAUSEA. If checked, describe:
VOMITING. If checked, describe:
OTHER, describe:

NOTE - Complete the appropriate Disability Benefits Questionnaire(s) when the infectious disease affects other organs such as the liver, lung, kidney, etc.
(schedule with appropriate provider).
VA FORM
FEB 2011

21-0960G-8

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SECTION IV - SYMPTOM EPISODES, ATTACKS AND EXACERBATIONS
4. DOES THE VETERAN HAVE EPISODES OF BOWEL DISTURBANCE WITH ABDOMINAL DISTRESS, OR EXACERBATIONS OR ATTACKS OF THE
INTESTINAL CONDITION?
YES

NO

IF YES, INDICATE SEVERITY AND FREQUENCY: (check all that apply)

EPISODES OF BOWEL DISTURBANCE WITH ABDOMINAL DISTRESS. IF CHECKED, INDICATE FREQUENCY:
Occasional episodes
Frequent episodes
More or less constant abdominal distress
EPISODES OF EXACERBATIONS AND/OR ATTACKS OF THE INTESTINAL CONDITION
IF CHECKED, DESCRIBE TYPICAL EXACERBATION OR ATTACK:
INDICATE NUMBER OF EXACERBATIONS AND/OR ATTACKS IN PAST 12 MONTHS:
7 or more
5
6
1
2
3
4

SECTION V - WEIGHT LOSS
5. DOES THE VETERAN HAVE WEIGHT LOSS ATTRIBUTABLE TO AN INFECTIOUS INTESTINAL CONDITION?
YES

NO

IF YES, 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)
SECTION VI - MALNUTRITION, COMPLICATIONS AND OTHER GENERAL HEALTH EFFECTS
6. DOES THE VETERAN HAVE MALNUTRITION, SERIOUS COMPLICATIONS OR OTHER GENERAL HEALTH EFFECTS ATTRIBUTABLE TO THE INTESTINAL
CONDITION?
YES

NO

IF YES, INDICATE SEVERITY: (check all that apply)

Health only fair during remissions
Resulting in general debility
Resulting in serious complication such as liver abscess
Malnutrition. If checked, is malnutrition marked?

Yes

No

Other, describe:

SECTION VII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
7A. 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)
7B. 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):

SECTION VIII - DIAGNOSTIC TESTING
NOTE: If imaging studies, diagnostic procedures or laboratory testing has been performed and reflects the veteran's current condition, provide most recent results; no
further studies or testing are required for this examination.
8A. 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 of test:
Hemoglobin:

Hematocrit:

White blood cell count:

Platelets:

Other, specify:
Date of test:
Results:
8B. 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):

8C. 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):

VA FORM 21-0960G-8, FEB 2011

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SECTION IX - FUNCTIONAL IMPACT
9. DO ANY OF THE VETERAN'S INFECTIOUS INTESTINAL CONDITIONS IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

IF YES, DESCRIBE THE IMPACT OF EACH OF THE VETERAN'S INFECTIOUS INTESTINAL CONDITIONS, PROVIDING ONE OR MORE EXAMPLES:

SECTION X - REMARKS
10. 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.
11A. PHYSICIAN'S SIGNATURE
11D. PHYSICIAN'S PHONE AND FAX NUMBER

11C. DATE SIGNED

11B. PHYSICIAN'S PRINTED NAME
11E. PHYSICIAN'S MEDICAL LICENSE NUMBER

11F. 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-8, FEB 2011

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