VA Form 21-0960K-2 Gynecological Conditions Disability Benefits Questionnai

OMB Approved No. 2900-0778
Respondent Burden: 30 minutes

GYNECOLOGICAL 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 SHE EVER HAD A GYNECOLOGICAL CONDITION?
YES

NO

(If "Yes," complete Item 1B)

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

SECTION II - MEDICAL HISTORY

2. DESCRIBE THE HISTORY (including cause, onset and course) OF EACH OF THE VETERAN'S GYNECOLOGICAL CONDITION(S):

SECTION III - SYMPTOMS
3. DOES THE VETERAN CURRENTLY HAVE SYMPTOMS RELATED TO A GYNECOLOGICAL CONDITION, INCLUDING ANY DISEASES, INJURIES OR ADHESIONS OF
THE FEMALE REPRODUCTIVE ORGANS?
YES

NO

(If yes, indicate current symptoms including frequency and severity of pain, if any: (check all that apply))
Intermittent pain
Constant pain
Mild pain
Moderate pain
Severe pain
Pelvic pressure
Irregular menstruation
Frequent or continuous menstrual disturbances
Other signs and/or symptoms, describe and indicate condition(s) causing them:

SECTION IV - TREATMENT
4A. HAS THE VETERAN HAD TREATMENT FOR SYMPTOMS/FINDINGS FOR ANY DISEASES, INJURIES AND/OR ADHESIONS OF THE REPRODUCTIVE ORGANS?
YES

NO

(If yes, specify condition(s), organ(s) affected and treatment):
Date of Treatment:
4B. DOES THE VETERAN CURRENTLY REQUIRE TREATMENT OR MEDICATIONS FOR SYMPTOMS RELATED TO REPRODUCTIVE TRACT CONDITIONS?
YES

NO

(If yes, list current treatment/medications and the reproductive organ conditions being treated):

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SECTION IV - SYMPTOMS (Continues)
4C. If yes, indicate effectiveness of treatment in controlling symptoms:
Symptoms do not require continuous treatment for the following organ/condition:_____________________________________________________________________
Symptoms require continuous treatment for the following organ/condition:___________________________________________________________________________
Symptoms are not controlled by continuous treatment for the following organ/condition:________________________________________________________________

SECTION V - CONDITIONS OF THE VULVA
5. HAS THE VETERAN BEEN DIAGNOSED WITH ANY DISEASES, INJURIES OR OTHER CONDITIONS OF THE VULVA (to include vulvovaginitis)?
YES

NO

(If yes, describe):

SECTION VI - CONDITIONS OF THE VAGINA
6. HAS THE VETERAN BEEN DIAGNOSED WITH ANY DISEASES, INJURIES OR OTHER CONDITIONS OF THE VAGINA?
YES

NO

(If yes, describe):

SECTION VII - CONDITIONS OF THE CERVIX
7. HAS THE VETERAN BEEN DIAGNOSED WITH ANY DISEASES, INJURIES, ADHESIONS OR OTHER CONDITIONS OF THE CERVIX?
YES

NO

(If yes, describe):

SECTION VIII - CONDITIONS OF THE UTERUS
8A. HAS THE VETERAN BEEN DIAGNOSED WITH ANY DISEASES, INJURIES, ADHESIONS OR OTHER CONDITIONS OF THE UTERUS?
YES

NO

8B. HAS THE VETERAN HAD A HYSTERECTOMY?
YES

NO

(If yes, provide date(s) of surgery, facility(ies) where performed and cause):

8C. DOES THE VETERAN HAVE UTERINE PROLAPSE?
YES

NO

(If yes, indicate severity):
Incomplete
Complete (through vagina and introitus)
If yes, does the condition currently cause symptoms?
NO

YES

(If yes, describe):

8D. DOES THE VETERAN HAVE UTERINE FIBROIDS, ENLARGEMENT OF THE UTERUS AND/OR DISPLACEMENT OF THE UTERUS?
YES

NO

If yes, are there signs and symptoms?
YES

NO

(If yes, check all that apply):
Adhesions
Marked displacement: If checked, indicate cause:_____________________________________________________________________________________________
Marked enlargement: If checked, indicate cause:______________________________________________________________________________________________
Uterine fibroids
Irregular menstruation: If checked, indicate cause:_____________________________________________________________________________________________
Frequent or continuous menstrual disturbances: If checked, indicate cause:_________________________________________________________________________
Other, describe and indicate cause:_________________________________________________________________________________________________________
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SECTION VIII - CONDITIONS OF THE UTERUS (Continues)
8E. HAS THE VETERAN BEEN DIAGNOSED WITH ANY OTHER DISEASES, INJURIES, ADHESIONS OR OTHER CONDITIONS OF THE UTERUS?
YES

NO

(If yes, describe):

SECTION IX - CONDITIONS OF THE FALLOPIAN TUBES
9. HAS THE VETERAN BEEN DIAGNOSED WITH ANY DISEASES, INJURIES, ADHESIONS OR OTHER CONDITIONS OF THE FALLOPIAN TUBES

(to include pelvic inflammatory disease)?
YES

NO

(If yes, describe):

SECTION X - CONDITIONS OF THE OVARIES
10A. HAS THE VETERAN UNDERGONE MENOPAUSE?
NO (If yes, indicate):

YES

Natural menopause
Premature menopause
Surgical menopasue
Chemical-induced menopause
Radiation-induced menopause
10B. HAS THE VETERAN UNDERGONE PARTIAL OR COMPLETE OOPHORECTOMY?
NO (If yes, check all that apply):

YES

Partial removal of an ovary
Right

Left

Both

Complete removal of an ovary
Right

Left

Both

(If yes, provide date(s) of surgery, facility(ies) where performed and reason for surgery):__________________________________________________________________
10C. DOES THE VETERAN HAVE EVIDENCE OF COMPLETE ATROPHY OF 1 OR BOTH OVARIES?
YES

NO

UNKNOWN (If yes, etiology):____________________________________________________________

(If yes, indicate severity):
Partial atrophy of 1 or both ovaries
Complete atrophy of 1 ovary
Complete atrophy of both ovaries (excluding natural menopause)
10D. HAS THE VETERAN BEEN DIAGNOSED WITH ANY OTHER DISEASES, INJURIES, ADHESIONS AND/OR OTHER CONDITIONS OF THE OVARIES?
YES

NO

(If yes, describe):

SECTION XI - INCONTINENCE
11. DOES THE VETERAN HAVE URINARY INCONTINENCE/LEAKAGE?
YES

NO (If yes, condition causing it):____________________________________________________________

If yes, is the urinary incontinence/leakage due to a gynecologic condition?
YES

NO

(If yes, check all that apply):
Does not require/does not use absorbent material
Stress incontinence
Requires absorbent material that is changed less than 2 times per day
Requires absorbent material that is changed 2 to 4 times per day
Requires absorbent material that is changed more than 4 times per day
Requiring the use of an appliance
If checked, describe appliance:
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SECTION XII - FISTULAE
12A. DOES THE VETERAN HAVE A RECTOVAGINAL FISTULA?
NO (If yes, cause):____________________________________________________________

YES

If yes, does the Veteran have vaginal-fecal leakage?
YES

NO

If yes, indicate frequency (check all that apply):
Less than once a week
1-3 times per week
4 or more times per week
Daily or more often
Requires wearing of pad or absorbent material
12B. DOES THE VETERAN HAVE AN URETHROVAGINAL FISTULA?
YES
NO (If yes, cause):____________________________________________________________
If yes, does the Veteran have urine leakage?
NO

YES

(If yes, check all that apply):
Does not require/does not use absorbent material
Requires absorbent material that is changed less than 2 times per day
Requires absorbent material that is changed 2 to 4 times per day
Requires absorbent material that is changed more than 4 times per day
Requires the use of an appliance
If checked, describe appliance:

SECTION XIII - ENDOMETRIOSIS

NOTE - A diagnosis of endometriosis must be substantiated by laparoscopy.
13. HAS THE VETERAN BEEN DIAGNOSED WITH ENDOMETRIOSIS?
YES

NO

If yes, does the Veteran currently have any findings, signs or symptoms due to endometriosis?
YES

NO

(If yes, check all that apply):
Pelvic pain
Heavy or irregular bleeding requiring continuous treatment for control
Heavy or irregular bleeding not controlled by treatment
Lesions involving bowel or bladder confirmed by laparoscopy
Bowel or bladder symptoms from endometriosis
Anemia caused by endometriosis
Other, describe:

SECTION XIV - COMPLICATIONS AND RESIDUALS OF PREGNANCY OR OTHER GYNECOLOGIC PROCEDURES
14A. HAS THE VETERAN HAD ANY SURGICAL COMPLICATIONS OF PREGNANCY?
YES

NO

(If yes, check all that apply):
Relaxation of perineum
Rectocele
Cystocele
Other, describe:
14B. HAS THE VETERAN HAD ANY OTHER COMPLICATIONS RESULTING FROM OBSTETRICAL OR GYNECOLOGIC CONDITIONS OR PROCEDURES?
YES

NO

(If yes, describe):

NOTE - If obstetrical or gynecologic complications impact other body systems, also complete the additional appropriate Questionnaire(s)
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SECTION XV - TUMORS AND NEOPLASMS
15A. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I?
YES

NO

(If "Yes," also complete Items 15B through 15E)

15B. IS THE NEOPLASM:
Benign

Malignant

15C. HAS THE VETERAN COMPLETED TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT NEOPLASM
OR METASTASES?
YES

NO; watchful waiting

(If "Yes," indicate type of treatment the veteran is currently undergoing or has completed) (Check all that apply):
Treatment completed; currently in watchful waiting status
Surgery
If checked, describe:____________________________________________________________ Date(s) of surgery:________________, __________________
Radiation therapy
Date of most recent treatment:______________________ Date of completion of treatment or anticipated date of completion:___________________
Antineoplastic chemotherapy
Date of most recent treatment:______________________ Date of completion of treatment or anticipated date of completion:___________________
Other therapeutic procedure
If checked, describe procedure:____________________________________________________ Date of most recent procedure:_______________
Other therapeutic treatment
If checked, describe treatment:_____________________________________________________
Date of completion of treatment or anticipated date of completion:________________
15D. DOES THE VETERAN CURRENTLY HAVE ANY RESIDUAL CONDITIONS OR COMPLICATIONS DUE TO THE NEOPLASM (INCLUDING METASTASES) OR ITS
TREATMENT, OTHER THAN THOSE ALREADY DOCUMENTED IN THE REPORT ABOVE?
YES

NO

(If "Yes," list residual conditions and complications (brief summary)):

15E. IF THERE ARE ADDITIONAL BENIGN OR MALIGNANT NEOPLASMS OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DESCRIBE
USING THE ABOVE FORMAT:

SECTION XVI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS

16A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
SECTION I 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 VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)
16B. DOES THE VETERAN HAVE ANY OTHER PERTINENT FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY CONDITIONS
LISTED IN SECTION I ABOVE?
YES

NO

(If yes, describe (brief summary)):

SECTION XVII - DIAGNOSTIC TESTING

NOTE - If laboratory test results are in the medical record and reflect the Veteran's current condition, repeat testing is not required.
17A. HAS THE VETERAN HAD LAPAROSCOPY?
YES

NO

If yes, provide date(s), facility where performed, and results:

17B. HAS THE VETERAN BEEN DIAGNOSED WITH ANEMIA?
YES

NO

If yes, provide most recent test results:

Hgb:____________

Hct:___________

Date of test:_______________

17C. HAS THE VETERAN HAD ANY OTHER DIAGNOSTIC TESTING AND IF SO, ARE THERE SIGNIFICANT FINDINGS AND/OR RESULTS?
YES

NO

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

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SECTION XVIII - FUNCTIONAL IMPACT
18. DOES THE VETERAN'S GYNECOLOGICAL CONDITION(S) IMPACT HER ABILITY TO WORK?
YES

NO

If yes, describe impact of each of the Veteran's gynecological condition, providing one or more examples:

SECTION XIX - REMARKS
19. REMARKS (If any)

SECTION XX - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
20A. PHYSICIAN'S SIGNATURE

20D. PHYSICIAN'S PHONE AND FAX NUMBER

20B. PHYSICIAN'S PRINTED NAME

20E. PHYSICIAN'S MEDICAL LICENSE NUMBER

20C. DATE SIGNED

20F. 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.
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VA FORM 21-0960K-2, FEB 2011

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