VA Form 21-0960H-1 Hernias (Including Abdominal, Inguinal, and Femoral Hern

OMB Approved No. 2900-0781
Respondent Burden: 15 Minutes
Expiration Date: XX/XX/XXXX

HERNIAS (INCLUDING ABDOMINAL, INGUINAL AND FEMORAL HERNIAS)
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 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. VA reserves the right to confirm the authenticity of ALL DBQs completed by
private health care providers.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER HAD ANY HERNIA CONDITIONS? (This is the condition the veteran is claiming or for which an

exam has been requested)

NO (If "Yes," complete Item 1B)

YES

1B. SELECT THE VETERAN'S CONDITION (Check all that apply):
INGUINAL HERNIA (If checked, complete Section IV.1)

ICD code:

Date of diagnosis:

FEMORAL HERNIA (If checked, complete Section IV.2)

ICD code:

Date of diagnosis:

VENTRAL HERNIA (If checked, complete Section IV.3)

ICD code:

Date of diagnosis:

ICD code:

Date of diagnosis:

ICD code:

Date of diagnosis:

OTHER (Specify):
OTHER DIAGNOSIS #1:
OTHER DIAGNOSIS #2:

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO INGUINAL, FEMORAL OR VENTRAL HERNIAS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL RECORD REVIEW
2. INDICATE MEDICAL RECORDS REVIEWED IN PREPARATION OF THIS REPORT:
C-FILE (VA ONLY)
OTHER, DESCRIBE:

SECTION III - MEDICAL HISTORY
3. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S HERNIA CONDITIONS (brief summary):

SECTION IV - HERNIA CONDITIONS
1. INGUINAL HERNIA
A. SURGICAL STATUS (check all that apply):
Surgery performed (If "Yes," indicate side, date and type of surgery):
Right:

Date and type of surgery:

Left:

Date and type of surgery:

No previous surgery but hernia appears operable and remediable (If checked, indicate side):

Right:

Left:

(If checked, indicate side):
(If checked, indicate side):

Irremediable, provide reason:
Inoperable, provide reason:

Right:

Left:

Right:

Left:

Right:

Left:

Right:

Left:

Recurrent hernia following surgical repair (If checked, indicate status of postoperative recurrent hernia):
Recurrent hernia appears operable and remediable (If checked, indicate side):

Right:

Left:

(If checked, indicate side):
(If checked, indicate side):

Irremediable, provide reason:
Inoperable, provide reason:
B. EXAM
Right:

No hernia detected

No true hernia protrusion

Small hernia

Large hernia

Left:

No hernia detected

No true hernia protrusion

Small hernia

Large hernia

C. ABILITY TO BE REDUCED
Right:

Readily reducible

Not readily reducible

Left:

Readily reducible

Not readily reducible

D. INDICATION FOR SUPPORT (Is there an indication for a supporting belt?)
YES

NO

(If "Yes," can the hernia be supported by truss or belt?):

Yes, can be well supported by truss or belt (If checked, indicate side well supported):

Right:

Left:

Not well supported by truss or belt (If checked, indicate side not well supported):

Right:

Left:

N/A, no truss or belt tried or used
VA FORM
XXX XXXX

21-0960H-1

SUPERSEDES VA FORM 21-0960H-1, OCT 2012,
WHICH WILL NOT BE USED.

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SECTION IV - HERNIA CONDITIONS (Continued)
2. FEMORAL HERNIA
A. SURGICAL STATUS (check all that apply):
Surgery performed (If "Yes," indicate side, date and type of surgery):
Right:

Date and type of surgery:

Left:

Date and type of surgery:

No previous surgery but hernia appears operable and remediable (If checked, indicate side):

Right:

Left:

Irremediable, provide reason:

(If checked, indicate side):

Right:

Left:

Inoperable, provide reason:

(If checked, indicate side):

Right:

Left:

Right:

Left:

Right:

Left:

Recurrent hernia following surgical repair (If checked, indicate status of postoperative recurrent hernia):
Recurrent hernia appears operable and remediable (If checked, indicate side):

Right:

Left:

(If checked, indicate side):
(If checked, indicate side):

Irremediable, provide reason:
Inoperable, provide reason:
B. EXAM
Right:

No hernia detected

No true hernia protrusion

Small hernia

Large hernia

Left:

No hernia detected

No true hernia protrusion

Small hernia

Large hernia

C. ABILITY TO BE REDUCED
Right:

Readily reducible

Not readily reducible

Left:

Readily reducible

Not readily reducible

D. INDICATION FOR SUPPORT (Is there an indication for a supporting belt?)
YES

NO

(If "Yes," can the hernia be supported by truss or belt?):

Yes, can be well supported by truss or belt (If checked, indicate side well supported):

Right:

Left:

Not well supported by truss or belt (If checked, indicate side not well supported):

Right:

Left:

N/A, no truss or belt tried or used
3. VENTRAL HERNIA
A. SURGICAL STATUS (check all that apply):
Surgery performed (If "Yes," indicate date and type of surgery):
Date and type of surgery:
No previous surgery but hernia appears operable and remediable
Irremediable, provide reason:
Inoperable, provide reason:
Recurrent hernia following surgical repair (If checked, indicate status of postoperative recurrent hernia):
Recurrent hernia appears operable and remediable (If checked, indicate side):
Irremediable, provide reason:
Inoperable, provide reason:
B. EXAM (check all that apply):
No hernia detected
Healed postoperative ventral hernia repair
Healed postoperative wounds with weakening of abdominal wall
Small ventral hernia
Large ventral hernia
Massive, persistent, severe diastasis of recti muscles
Extensive diffuse destruction or weakening of muscular and fascial support of abdominal wall so as to be inoperable
Other, describe:
C. INDICATION FOR SUPPORT (Is there an indication for a supporting belt?)
YES

NO

(If "Yes," can the hernia be supported by truss or belt?):

Yes, can be well supported by truss or belt
Not well supported by truss or belt
N/A, no truss or belt tried or used

VA FORM 21-0960H-1, XXX XXXX

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SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, SCARS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
5A. 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 or equal to 39 square cm (6 square inches)?)
YES

NO

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

5B. 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 VI - DIAGNOSTIC TESTING
NOTE - If testing has been performed and reflects veteran's current condition, repeat testing is not required. Specific diagnostic testing is not required for
hernia examination.
6. ARE THERE ANY SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES

NO

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

SECTION VII - FUNCTIONAL IMPACT
7. DOES THE VETERAN'S HERNIA CONDITION(S) IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

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

SECTION VIII - REMARKS
8. REMARKS (If any):

SECTION IX - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
9A. PHYSICIAN'S SIGNATURE

9D. PHYSICIAN'S PHONE AND FAX NUMBERS

9B. PHYSICIAN'S PRINTED NAME

9E. PHYSICIAN'S MEDICAL LICENSE NUMBER

9C. DATE SIGNED

9F. 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.benefits.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 voluntary. 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 21-0960H-1, XXX XXXX

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