Fillable Printable Vba 21 0960J 2 Are
Fillable Printable Vba 21 0960J 2 Are
Vba 21 0960J 2 Are
VA FORM
FEB 2015
21-0960J-2
MALE REPRODUCTIVE ORGAN CONDITIONS
DISABILITY BENEFITS QUESTIONNAIRE
1A. DOES THE VETERAN NOW HAVE OR HAS HE EVER BEEN DIAGNOSED WITH ANY CONDITIONS OF THE MALE REPRODUCTIVE SYSTEM?
OMB Control No. 2900-0779
Respondent Burden: 15 Minutes
Expiration Date: 01/31/2018
SECTION I - DIAGNOSIS
NOYES
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.
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.
2C. HAS THE VETERAN HAD AN ORCHIECTOMY?
Indicate testicle removed:
Indicate reason for removal:
YES
Right
Undescended
Congenitally underdeveloped
Other, provide reason for removal:
Left Both
NO
2A. DESCRIBE THE HISTORY
(including onset and course) OF THE VETERAN'S MALE REPRODUCTIVE ORGAN CONDITION(S) (brief summary):
2B. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING CONTINUOUS MEDICATION FOR THE DIAGNOSED CONDITION?
YES NO
Page 1
SUPERSEDES VA FORM 21-0960J-2, OCT 2012,
WHICH WILL NOT BE USED.
ICD code:
1B. INDICATE DIAGNOSES: (check all that apply)
Erectile dysfunction Date of diagnosis:
Penis, deformity (e.g., Peyronie's)
ICD code: Date of diagnosis:
Testis, atrophy, one or both ICD code: Date of diagnosis:
Testis, removal, one or both ICD code: Date of diagnosis:
Epididymitis, chronic ICD code: Date of diagnosis:
Epididymo-orchitis, chronic ICD code: Date of diagnosis:
Prostate injury ICD code: Date of diagnosis:
Prostate hypertrophy (BPH)
ICD code: Date of diagnosis:
Prostatitis, chronic ICD code: Date of diagnosis:
Prostate surgical residuals (as addressed in items 3–6)
ICD code: Date of diagnosis:
Neoplasms of the male reproductive system ICD code:
ICD code: Date of diagnosis:
Date of diagnosis:ICD code:
Date of diagnosis:
Other male reproductive system condition (specify
diagnosis, providing only diagnoses that pertain to the
male reproductive system)
Other diagnosis #1:
Other diagnosis #2:
1C. IF THERE ARE ANY ADDITIONAL DIAGNOSES THAT PERTAIN TO THE MALE REPRODUCTIVE ORGAN CONDITIONS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
List medications taken for the male reproductive organ condition:
(If "Yes," complete Item 1B)
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
NAME OF PATIENT/VETERAN
(If yes, provide etiology of recurrent urinary tract or kidney infections):
Other, describe:
Requires absorbent material which must be changed more than 4 times per day
Page 2
SECTION III - VOIDING DYSFUNCTION
YES NO
3A. DOES THE VETERAN HAVE A VOIDING DYSFUNCTION?
(If yes, complete Items 3B thru 3E)
(If yes, provide etiology of voiding dysfunction):
Requires absorbent material which must be changed 2 to 4 times per day
Requires absorbent material which must be changed less than 2 times per day
Does not require the wearing of absorbent material
Indicate severity (check one):
NO
3B. DOES THE VOIDING DYSFUNCTION CAUSE URINE LEAKAGE?
YES
(If yes, describe the appliance):
NOYES
3C. DOES THE VOIDING DYSFUNCTION REQUIRE THE USE OF AN APPLIANCE?
Nighttime awakening to void 2 times
Daytime voiding interval less than 1 hour
Daytime voiding interval between 1 and 2 hours
Daytime voiding interval between 2 and 3 hours
(If yes, check all that apply):
NOYES
3D. DOES THE VOIDING DYSFUNCTION CAUSE INCREASED URINARY FREQUENCY?
Nighttime awakening to void 3 to 4 times
Nighttime awakening to void 5 or more times
Hesitancy
(If yes, check all that apply):
NOYES
3E. DOES THE VOIDING DYSFUNCTION CAUSE SIGNS OR SYMPTOMS OF OBSTRUCTED VOIDING?
NOYES
If checked, is hesitancy marked?
NO
YES
If checked, is stream markedly slow or weak?
Slow or weak stream
NOYES
If checked, is force of stream markedly decreased?
Decreased force of stream
Stricture disease requiring dilatation 1 to 2 times per year
Stricture disease requiring periodic dilatation every 2 to 3 months
Recurrent urinary tract infections secondary to obstruction
Uroflowmetry peak flow rate less than 10 cc/sec
Urinary retention requiring intermittent catheterization
Post void residuals greater than 150 cc
Other, describe:
Urinary retention requiring continuous catheterization
(If yes, complete Item 4B)
NOYES
4A. DOES THE VETERAN HAVE A HISTORY OF RECURRENT SYMPTOMATIC URINARY TRACT OR KIDNEY INFECTIONS?
SECTION IV - URINARY TRACT/KIDNEY INFECTION
No treatment
4B. INDICATE ALL TREATMENT MODALITIES USED FOR RECURRENT URINARY TRACT OR KIDNEY INFECTIONS (check all that apply):
Long-term drug therapy
If checked, list medications used and indicate dates for courses of treatment over the past 12 months:
VA FORM 21-0960J-2, FEB 2015
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION VII - MALE REPRODUCTIVE ORGAN INFECTIONS
SECTION IV - URINARY TRACT/KIDNEY INFECTION
(Continued)
SECTION VI - RETROGRADE EJACULATION
Page 3
Drainage
Hospitalization
If checked, indicate frequency of hospitalization:
>2 per year
1 or 2 per year
If checked, indicate dates when drainage performed over past 12 months:
If checked, indicate types of treatment and medications used over past 12 months:
Continuous intensive management
Intermittent intensive management
If checked, indicate types of treatment and medications used over past 12 months:
Other, describe:
SECTION V - ERECTILE DYSFUNCTION
(If yes, provide etiology of erectile dysfunction):
(If yes, complete Items 5B and 5C)
NOYES
5A. DOES THE VETERAN HAVE ERECTILE DYSFUNCTION?
NOYES
5B. IF THE VETERAN HAS ERECTILE DYSFUNCTION, IS IT AS LIKELY AS NOT
(at least a 50% probability) ATTRIBUTABLE TO ONE OF THE DIAGNOSES IN
SECTION I, INCLUDING RESIDUALS OF TREATMENT FOR THIS DIAGNOSIS?
(If yes, specify the diagnosis to which the erectile dysfunction is as likely as not attributable):
NOYES
5C. IF THE VETERAN HAS ERECTILE DYSFUNCTION, IS HE ABLE TO ACHIEVE AN ERECTION SUFFICIENT FOR PENETRATION AND EJACULATION
(without medication)?
IF NO, IS THE VETERAN ABLE TO ACHIEVE AN ERECTION SUFFICIENT FOR PENETRATION AND EJACULATION (with medication)?
NO
YES
(If yes, specify the diagnosis to which the erectile dysfunction is as likely as not attributable):
NOYES
6B. IF THE VETERAN HAS RETROGRADE EJACULATION, IS IT AS LIKELY AS NOT
(at least a 50% probability) ATTRIBUTABLE TO ONE OF THE DIAGNOSES IN
SECTION I, INCLUDING RESIDUALS OF TREATMENT FOR THIS DIAGNOSIS?
(If yes, provide etiology of retrograde ejaculation):
(If yes, complete Item 6B and provide etiology of retrograde ejaculation)
NOYES
6A. DOES THE VETERAN HAVE RETROGRADE EJACULATION?
7. DOES THE VETERAN HAVE A HISTORY OF CHRONIC EPIDIDYMITIS, EPIDIDYMO-ORCHITIS OR PROSTATITIS?
NO
YES
Other, describe:
Intermittent intensive management
If checked, indicate types of treatment and medications used over past 12 months:
If checked, indicate types of treatment and medications used over past 12 months:
Continuous intensive management
>2 per year
1 or 2 per year
If checked, indicate frequency of hospitalization:
Hospitalization
If checked, list medications used and indicate dates for courses of treatment over the past 12 months:
Long-term drug therapy
No treatment
(If yes, indicate all treatment modalities used for chronic epididymitis, epididymo-orchitis or prostatitis (check all that apply)):
4B. INDICATE ALL TREATMENT MODALITIES USED FOR RECURRENT URINARY TRACT OR KIDNEY INFECTIONS (check all that apply) (Continued):
VA FORM 21-0960J-2, FEB 2015
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION VIII - PHYSICAL EXAM
Page 4
Penis deformity (such as Peyronie's disease)
Loss/removal of glans penis
Loss/removal of half or more of penis
If abnormal, indicate severity:
Not examined per veteran's request; Veteran reports normal anatomy with no penile deformity or abnormality
Not examined per veteran's request
Normal
8A. PENIS
Abnormal
Not examined; penis exam not relevant to condition
If checked, describe:
If abnormal, check all that apply:
Abnormal
Not examined; testicular exam not relevant to condition
Not examined per veteran's request; Veteran reports normal anatomy with no testicular deformity or abnormality
Not examined per veteran's request
Normal
8B. TESTES
Size 1/3 or less of normal
Size 1/2 to 1/3 of normal
Right testicle
Considerably softer than normal
Considerably harder than normal
Other abnormality
Absent
Describe:
Left testicle
Size 1/3 or less of normal
Size 1/2 to 1/3 of normal
Considerably harder than normal
Considerably softer than normal
Absent
Other abnormality
Describe:
8C. EPIDIDYMIS
Normal
Not examined per veteran's request
Not examined per veteran's request; veteran reports normal anatomy of epididymis with no deformity or abnormality
Not examined; epididymis exam not relevant to condition
Abnormal
If abnormal, check all that apply:
Right epididymis
Tender to palpation
Other, describe:
Left epididymis
Tender to palpation
Other, describe:
Abnormal
Not examined; prostate exam not relevant to condition
Not examined per veteran's request
Normal
8D. PROSTATE
If abnormal, describe:
VA FORM 21-0960J-2, FEB 2015
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION IX - TUMORS AND NEOPLASMS
Page 5
(If yes, complete Items 9B thru 9E)
NOYES
9A. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DIAGNOSIS?
9B. IS THE NEOPLASM:
MALIGNANTBENIGN
(If yes, indicate type of treatment the veteran is currently undergoing or has completed (check all that apply)):
9C. HAS THE VETERAN COMPLETED TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT NEOPLASM
OR METASTASES?
NO; WATCHFUL WAITINGYES
SECTION X - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
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. When appropriate, provide most recent results. No specific studies are required for this examination.
SECTION XI - DIAGNOSTIC TESTING
Other, describe:
Spermatozoa present
Date of biopsy:
NOYES
11A. HAS A TESTICULAR BIOPSY BEEN PERFORMED?
Results:
Treatment completed; currently in watchful waiting status
If checked, describe:
Surgery
Date(s) of surgery:
Date of most recent treatment:
Radiation therapy
Date of completion of treatment or anticipated date of completion:
Date of most recent treatment:
Antineoplastic chemotherapy
Date of completion of treatment or anticipated date of completion:
If checked, describe procedure:
Other therapeutic procedure
Date of most recent procedure:
If checked, describe treatment:
Other therapeutic treatment
Date of completion of treatment or anticipated date of completion:
9D. 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?
9E. IF THERE ARE ADDITIONAL BENIGN OR MALIGNANT NEOPLASMS OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DIAGNOSIS,
DESCRIBE USING THE ABOVE FORMAT:
NO
YES
(If yes, list residual conditions and complications (brief summary)):
10A. DOES THE VETERAN HAVE ANY SCARS (SURGICAL OR OTHERWISE) RELATED TO ANY CONDITION OR TO THE TREATMENT OF ANY CONDITIONS LISTED
IN SECTION I, DIAGNOSIS?
10B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS?
NO
YES
(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)?)
NO
YES
(If yes, also complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire.)
NO
YES
(If yes, describe (brief summary)):
VA FORM 21-0960J-2, FEB 2015
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION XII - FUNCTIONAL IMPACT
SECTION XI - DIAGNOSTIC TESTING (Continued)
(If yes, provide type of test or procedure, date and results (brief summary)):
NO
YES
11B. HAVE ANY OTHER IMAGING STUDIES, DIAGNOSTIC PROCEDURES OR LABORATORY TESTING BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
14C. DATE SIGNED
14F. PHYSICIAN'S ADDRESS
14B. PHYSICIAN'S PRINTED NAME
14A. PHYSICIAN'S SIGNATURE
(Sign in ink)
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
SECTION XIV - PHYSICIAN'S CERTIFICATION AND SIGNATURE
14D. PHYSICIAN'S PHONE AND FAX NUMBER
NOTE - VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.
(If yes, describe impact of each of the veteran's male reproductive system conditions, providing one or more examples):
NO
YES
12. DOES THE VETERAN'S MALE REPRODUCTIVE SYSTEM CONDITION(S), INCLUDING NEOPLASMS, IF ANY, IMPACT HIS ABILITY TO WORK?
SECTION XIII- REMARKS
13. REMARKS (if any)
(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.
IMPORTANT - Physician please fax the completed form to:
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 21-0960J-2, FEB 2015
Page 6
14E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER
PATIENT/VETERAN'S SOCIAL SECURITY NO.
