Fillable Printable Vba 21 0960G 8 Are

Vba 21 0960G 8 Are

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).

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.

VA FORM

SEP 2016

21-0960G-8

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

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.

1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH AN INFECTIOUS INTESTINAL CONDITION?

SECTION III - SIGNS AND SYMPTOMS

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

OMB Approved No. 2900-0778

Respondent Burden: 15 Minutes

Expiration Date: 09/30/2019

SECTION I - DIAGNOSIS

3. DOES THE VETERAN HAVE ANY SIGNS OR SYMPTOMS ATTRIBUTABLE TO ANY INFECTIOUS INTESTINAL CONDITIONS?

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

SECTION II - MEDICAL HISTORY

YES

VOMITING (If checked, describe):

GASEOUS DISTENTION (If checked, describe):

LOWER ABDOMINAL CRAMPS.

If checked, describe:

2A. DESCRIBE THE HISTORY

(including onset, course, and past treatment) OF THE VETERAN'S INFECTIOUS INTESTINAL CONDITIONS (brief summary):

AMEBIASIS

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

MILD GASTROINTESTINAL DISTURBANCES (If checked, describe):

MILD SYMPTOMS ATTRIBUTABLE TO DISTOMIASIS, INTESTINAL OR HEPATIC

(If checked, describe):

ANEMIA (If checked, provide hemoglobin/hematocrit in Section 8, Diagnostic Testing)

MODERATE SYMPTOMS ATTRIBUTABLE TO DISTOMIASIS, INTESTINAL OR HEPATIC

(If checked, describe):

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PARASITIC INFECTION OF THE INTESTINES

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.

ICD code:

Date of diagnosis:

ICD code:

Date of diagnosis:

ICD code:

INTESTINAL DISTOMIASIS

(intestinal fluke)

BACILLARY DYSENTERY

NAUSEA

(If checked, describe):

SEVERE SYMPTOMS ATTRIBUTABLE TO DISTOMIASIS, INTESTINAL OR HEPATIC

(If checked, describe):

CHRONIC CONSTIPATION INTERRUPTED BY DIARRHEA

(If checked, describe):

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

OTHER,

(describe):

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

OTHER INFECTIOUS INTESTINAL CONDITION

OTHER DIAGNOSIS #2:

OTHER DIAGNOSIS #1:

ICD code:

Date of diagnosis:

Date of diagnosis:ICD code:

YES

YESNO

IF YES, CHECK ALL THAT APPLY

(If "Yes," complete Item 1B)

SUPERSEDES VA FORM 21-0960G-8, OCT 2012,

WHICH WILL NOT BE USED.

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.

NAME OF PATIENT/VETERAN

(First, Middle Initial, Last)

PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

7B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY

CONDITIONS LISTED IN THE DIAGNOSIS SECTION?

4. DOES THE VETERAN HAVE EPISODES OF BOWEL DISTURBANCE WITH ABDOMINAL DISTRESS, OR EXACERBATIONS OR ATTACKS OF THE

INTESTINAL CONDITION?

VA FORM 21-0960G-8, SEP 2016

7A. 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?

IF YES, INDICATE SEVERITY (check all that apply)

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

SECTION IV - SYMPTOM EPISODES, ATTACKS AND EXACERBATIONS

SECTION VIII - DIAGNOSTIC TESTING

IF YES, CHECK ALL THAT APPLY:

SECTION VI - MALNUTRITION, COMPLICATIONS AND OTHER GENERAL HEALTH EFFECTS

8C. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?

Occasional episodes

EPISODES OF BOWEL DISTURBANCE WITH ABDOMINAL DISTRESS. IF CHECKED, INDICATE FREQUENCY:

INDICATE NUMBER OF EXACERBATIONS AND/OR ATTACKS IN PAST 12 MONTHS:

Frequent episodes

EPISODES OF EXACERBATIONS AND/OR ATTACKS OF THE INTESTINAL CONDITION

IF CHECKED, DESCRIBE TYPICAL EXACERBATION OR ATTACK:

More or less constant abdominal distress

6. DOES THE VETERAN HAVE MALNUTRITION, SERIOUS COMPLICATIONS OR OTHER GENERAL HEALTH EFFECTS ATTRIBUTABLE TO THE INTESTINAL

CONDITION?

SECTION V - WEIGHT LOSS

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5. DOES THE VETERAN HAVE WEIGHT LOSS ATTRIBUTABLE TO AN INFECTIOUS INTESTINAL CONDITION?

NOTE: If imaging studies, diagnostic procedures or laboratory testing have been performed and reflect 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?

IF YES, ARE ANY OF THE SCARS PAINFUL OR UNSTABLE; HAVE A TOTAL AREA EQUAL TO OR GREATER THAN 39 SQUARE CM (6 square inches) OR ARE LOCATED

ON THE HEAD, FACE OR NECK?

8B. HAVE IMAGING STUDIES OR DIAGNOSTIC PROCEDURES BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?

Malnutrition. If checked, is malnutrition marked?

Other (Describe):

Resulting in general debility

Serious complication such as liver abscess (Describe)

Health only fair during remissions

Yes

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

YESNO

5 6

7 or more

3421

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)

YESNO

IF YES, DESCRIBE (brief summary):

YESNO

Other, specify:

CBC

(if anemia due to any intestinal condition is suspected or present)

Results:

Date of test:

Hemoglobin:Hematocrit:White blood cell count:Platelets:

Date of test:

YESNO

IF YES, PROVIDE TYPE OF TEST OR PROCEDURE, DATE AND RESULTS (brief summary):

YESNO

IF YES, PROVIDE TYPE OF TEST OR PROCEDURE, DATE AND RESULTS (brief summary):

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.

PATIENT/VETERAN'S SOCIAL SECURITY NO.

VA FORM 21-0960G-8, SEP 2016

10. REMARKS, IF ANY:

SECTION XI - PHYSICIAN'S CERTIFICATION AND SIGNATURE

SECTION IX - FUNCTIONAL IMPACT

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

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

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YESNO

SECTION X - REMARKS

11C. DATE SIGNED

11E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER11F. PHYSICIAN'S ADDRESS

11B. PHYSICIAN'S PRINTED NAME

(VA Regional Office FAX No.)

11A. PHYSICIAN'S SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.

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.

IMPORTANT - Physician please fax the completed form to:

11D. PHYSICIAN'S PHONE AND FAX NUMBER

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.

NOTE - VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.

PATIENT/VETERAN'S SOCIAL SECURITY NO.