VA Form 21-0960G-7 STOMACH AND DUODENAL CONDITIONS (NOT INCLUDING GERD OR E

OMB Control No. 2900-0778
Respondent Burden: 15 Minutes
Expiration Date: XX/XX/XXXX

STOMACH AND DUODENAL CONDITIONS (NOT INCLUDING GERD OR
ESOPHAGEAL DISORDERS) 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. 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 STOMACH OR DUODENUM CONDITIONS?
YES

NO

(If "Yes," complete Item 1B)

NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed below. If there is no diagnosis, if the diagnosis is different
from a previous diagnosis for this condition, or if there is a diagnosis of a complication due to the claimed condition, explain your findings and reasons in the Remarks
section. Date of diagnosis can be the date of the evaluation if the clinician is making the initial diagnosis, or an approximate date is determined through record review or
reported history.
1B. SELECT THE VETERAN'S CONDITION (check all that apply):
GASTRIC ULCER

ICD code:

Date of diagnosis:

DUODENAL ULCER

ICD code:

Date of diagnosis:

STENOSIS OF THE STOMACH

ICD code:

Date of diagnosis:

MARGINAL (GASTROJEJUNAL) ULCER

ICD code:

Date of diagnosis:

HYPERTROPHIC GASTRITIS

ICD code:

Date of diagnosis:

POSTGASTRECTOMY SYNDROME

ICD code:

Date of diagnosis:

STATUS POST VAGOTOMY WITH PYLOROPLASTY

ICD code:

Date of diagnosis:

GASTROENTEROSTOMY
PERITONEAL ADHESIONS FOLLOWING INJURY OR
SURGERY OF THE STOMACH

ICD code:

Date of diagnosis:

ICD code:

Date of diagnosis:

HELICOBACTER PYLORI

ICD code:

Date of diagnosis:

OTHER STOMACH OR DUODENAL CONDITIONS
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 STOMACH OR DUODENUM CONDITIONS, LIST USING ABOVE FORMAT:

NOTE: The diagnosis of gastric or duodenal ulcer or stenosis can be made by upper gastrointestinal imaging series or endoscopy. The diagnosis of gastritis requires
endoscopic confirmation. If testing is of record and is consistent with veteran's current condition, repeat testing is not required.
SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S STOMACH OR DUODENUM CONDITIONS (brief summary):

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

NO

IF YES, LIST ONLY THOSE MEDICATIONS USED FOR THE DIAGNOSED CONDITION:

VA FORM
XXX XXXX

21-0960G-7

SUPERSEDES VA FORM 21-0960G-7, OCT 2012,
WHICH WILL NOT BE USED.

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SECTION III - SIGNS AND SYMPTOMS
3. DOES THE VETERAN HAVE ANY OF THE FOLLOWING SIGNS OR SYMPTOMS DUE TO ANY STOMACH OR DUODENUM CONDITIONS?
YES

NO

IF YES, (check all that apply):
Recurring episodes of symptoms that are not severe
If checked, indicate frequency of episodes of symptom recurrence per year:
0

1

2

3

4 or more

If checked, indicate average duration of episodes of symptoms:
1-9 days

Less than 1 day

10 days or more

Recurring episodes of severe symptoms
If checked, indicate frequency of episodes of symptom recurrence per year:
0

1

2

3

4 or more

If checked, indicate average duration of episodes of symptoms:
Less than 1 day

1-9 days

10 days or more

Abdominal Pain
If checked, indicate severity and frequency (check all that apply):
SEVERITY:

Relieved by standard ulcer therapy

FREQUENCY:

Occurs less than monthly

Only partially relieved by standard ulcer therapy
Occurs at least monthly

Pronounced

Periodic

Unrelieved by standard ulcer therapy
Continuous

Anemia
If checked, provide hemoglobin/hematocrit in diagnostic testing section.
Weight loss
If checked, provide baseline weight:

and current weight:

(For VA purposes, baseline weight is the average weight for 2-year period preceding onset of disease).
Nausea
If checked, indicate severity:
Mild

Transient

Recurrent

Periodic

If checked, indicate frequency of episodes of nausea per year:
0

1

2

3

4 or more

If checked, indicate average duration of episodes of nausea:
Less than 1 day

1-9 days

10 days or more

Vomiting
If checked, indicate severity:
Mild

Transient

Recurrent

Periodic

If checked, indicate frequency of episodes of vomiting per year:
0

1

2

3

4 or more

If checked, indicate average duration of episodes of vomiting:
Less than 1 day

1-9 days

10 days or more

Hematemesis
If checked, indicate severity:
Mild

Transient

Recurrent

Periodic

If checked, indicate frequency of episodes of hematemesis per year:
0

1

2

3

4 or more

If checked, indicate average duration of episodes of hematemesis:
Less than 1 day

1-9 days

10 days or more

Melena
If checked, indicate severity:
Mild

Transient

Recurrent

Periodic

If checked, indicate frequency of episodes of melena per year:
0

1

2

3

4 or more

If checked, indicate average duration of episodes of melena:
Less than 1 day

VA FORM 21-0960G-7, XXX XXXX

1-9 days

10 days or more

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SECTION IV - INCAPACITATING EPISODES
4. DOES THE VETERAN HAVE INCAPACITATING EPISODES DUE TO SIGNS OR SYMPTOMS OF ANY STOMACH OR DUODENUM CONDITION?
YES

NO

IF YES, DESCRIBE INCAPACITATING EPISODES:
Indicate frequency of incapacitating episodes per year:
0

1

2

3

4 or more

Indicate average duration of incapacitating episodes:
Less than 1 day

1-9 days

10 days or more

SECTION V - OTHER CONDITIONS
5. DOES THE VETERAN HAVE ANY OF THE FOLLOWING CONDITIONS?
YES

NO

IF YES, INDICATE CONDITIONS AND COMPLETE APPROPRIATE SECTIONS (check all that apply):
Hypertrophic gastritis
If checked, indicate severity:
No symptoms or findings
Chronic, with small nodular lesions, and symptoms
Chronic, with multiple small eroded or ulcerated areas, and symptoms
Chronic, with severe hemorrhages, or large ulcerated or eroded areas
NOTE: If atrophic gastritis is present, state the underlying cause:
Postgastrectomy syndrome
If checked, indicate severity:
No symptoms or findings
Mild; infrequent episodes of epigastric distress with characteristic mild circulatory symptoms or
continuous mild manifestations.
Moderate; less frequent episodes of epigastric disorders with characteristic mild circulatory
symptoms after meals but with diarrhea and weight loss
Severe; associated with nausea, sweating, circulatory disturbance after meals, diarrhea,
hypoglycemic symptoms, and weight loss with malnutrition and anemia
Vagotomy with pyloroplasty or gastroenterostomy
If checked, indicate the severity of residuals following vagotomy with pyloroplasty or gastroenterostomy:
No symptoms or findings
Recurrent ulcer with incomplete vagotomy
Symptoms and confirmed diagnosis of alkaline gastritis, or of confirmed persisting diarrhea
Demonstrably confirmative postoperative complications of stricture or continuing gastric retention
Peritoneal adhesions following an injury or surgical procedure of the stomach or duodenum
If checked, ALSO complete the VA Form 21-0960G-6, Peritoneal Adhesions Disability Benefits Questionnaire.

SECTION VI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
6A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN THE
DIAGNOSIS SECTION?
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.
IF NO, PROVIDE LOCATION AND MEASURMENTS OF SCAR IN CENTIMETERS.
LOCATION: ______________________
MEASUREMENTS: Length_______________ cm X width_______________cm.
NOTE: An "unstable scar" is one where, for any reason, there is frequent loss of covering of the skin over the scar. If there are multiple scars, enter additional locations and measurements
in the Remarks section below. It is not necessary to also complete a Scars DBQ.
6B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO
ANY CONDITIONS LISTED IN THE DIAGNOSIS SECTION?
YES

NO

IF YES, DESCRIBE (brief summary):

VA FORM 21-0960G-7, XXX XXXX

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SECTION VII - DIAGNOSTIC TESTING
NOTE: If testing has been performed and reflects veteran's current condition, no further testing is required for this examination report.
The diagnosis of gastric or duodenal ulcer or stenosis can be made by upper gastrointestinal imaging series or endoscopy.
7A. HAVE DIAGNOSTIC IMAGING STUDIES OR OTHER DIAGNOSTIC PROCEDURES BEEN PERFORMED?
YES

NO

IF YES, CHECK ALL THAT APPLY:
Upper endoscopy

Date:

Results:

Upper GI radiographic studies

Date:

Results:

MRI

Date:

Results:

CT

Date:

Results:

Biopsy, specify site:

Date:

Results:

Other, specify:

Date:

Results:

7B. HAS LABORATORY TESTING BEEN PERFORMED?
YES

NO

IF YES, CHECK ALL THAT APPLY:
CBC

Date of test:

Hemoglobin:

Hematocrit:

Helicobacter pylori

Date of test:

Other, specify:

White blood cell count:

Platelets:

Results:
Date of test:

Results:

7C. 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):

SECTION VIII - FUNCTIONAL IMPACT
8. DO ANY OF THE VETERAN'S STOMACH OR DUODENUM CONDITIONS IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

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

VA FORM 21-0960G-7, XXX XXXX

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SECTION IX - REMARKS
9. REMARKS (If any)

SECTION X - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
10A. PHYSICIAN'S SIGNATURE

10D. PHYSICIAN'S PHONE AND FAX NUMBER

10B. PHYSICIAN'S PRINTED NAME

10E. PHYSICIAN'S MEDICAL LICENSE NUMBER

10C. DATE SIGNED

10F. 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, 58VA21/22/28, 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 a 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-7, XXX XXXX

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