Fillable Printable Vba 21 0960K 2 Are
Fillable Printable Vba 21 0960K 2 Are
Vba 21 0960K 2 Are
SECTION IV - TREATMENT
VA FORM
SEP 2016
21-0960K-2
GYNECOLOGICAL CONDITIONS DISABILITY BENEFITS QUESTIONNAIRE
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO GYNECOLOGICAL CONDITION(S):
OMB Approved No. 2900-0778
Respondent Burden: 30 Minutes
Expiration Date: 09/30/2019
SECTION I - DIAGNOSIS
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.
SECTION III - SYMPTOMS
SECTION II - MEDICAL HISTORY
Page 1
SUPERSEDES VA FORM 21-0960K-2, OCT 2012,
WHICH WILL NOT BE USED.
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.
3. DOES THE VETERAN CURRENTLY HAVE SYMPTOMS RELATED TO A GYNECOLOGICAL CONDITION, INCLUDING ANY DISEASES, INJURIES OR ADHESIONS
OF THE FEMALE REPRODUCTIVE ORGANS?
1A. DOES THE VETERAN NOW HAVE OR HAS SHE EVER HAD A GYNECOLOGICAL CONDITION?
(If "Yes," complete Item 1B)
1C. IF THERE ARE ADDITIONAL GYNECOLOGICAL DIAGNOSES, LIST USING ABOVE FORMAT:
2. DESCRIBE THE HISTORY
(including cause, onset and course) OF EACH OF THE VETERAN'S GYNECOLOGICAL CONDITION(S):
NOYES
NO
YESNO
YESNO
YES
(If yes, indicate current symptoms including frequency and severity of pain, if any - check all that apply):
DATE OF DIAGNOSIS -
DATE OF DIAGNOSIS -
DATE OF DIAGNOSIS -
ICD CODE -
ICD CODE -
ICD CODE -
DIAGNOSIS # 3 -
DIAGNOSIS # 2 -
DIAGNOSIS # 1 -
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:
4A. HAS THE VETERAN HAD TREATMENT FOR SYMPTOMS/FINDINGS FOR ANY DISEASES, INJURIES AND/OR ADHESIONS OF THE REPRODUCTIVE ORGANS?
(If yes, specify condition(s), organ(s) affected and treatment):
Date(s) of treatment:
4B. DOES THE VETERAN CURRENTLY REQUIRE TREATMENT OR MEDICATIONS FOR SYMPTOMS RELATED TO REPRODUCTIVE TRACT CONDITIONS?
(If yes, list current treatment/medications and the reproductive organ conditions being treated):
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
Page 2
4C. IF YES, INDICATE EFFECTIVENESS OF TREATMENT IN CONTROLLING SYMPTOMS:
SECTION IV - SYMPTOMS (Continued)
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)?
(If yes, describe):
(If yes, describe):
YESNO
YES
NOYES
NOYES
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?
SECTION VII - CONDITIONS OF THE CERVIX
7. HAS THE VETERAN BEEN DIAGNOSED WITH ANY DISEASES, INJURIES, ADHESIONS OR OTHER CONDITIONS OF THE CERVIX?
SECTION VIII - CONDITIONS OF THE UTERUS
8A. HAS THE VETERAN BEEN DIAGNOSED WITH ANY DISEASES, INJURIES, ADHESIONS OR OTHER CONDITIONS OF THE UTERUS?
8B. HAS THE VETERAN HAD A HYSTERECTOMY?
(If yes, provide date(s) of surgery, facility(ies) where performed and cause):
8C. DOES THE VETERAN HAVE UTERINE PROLAPSE?
(If yes, indicate severity):
Incomplete
Complete(through vagina and introitus)
(If yes, does the condition currently cause symptoms?)
YESNO
YESNO
YESNO
(If yes, describe):
8D. DOES THE VETERAN HAVE UTERINE FIBROIDS, ENLARGEMENT OF THE UTERUS AND/OR DISPLACEMENT OF THE UTERUS?
(If yes, are there signs and symptoms?):
(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:
VA FORM 21-0960K-2, SEP 2016
NO
YESNO
YES
PATIENT/VETERAN'S SOCIAL SECURITY NO.
8E. HAS THE VETERAN BEEN DIAGNOSED WITH ANY OTHER DISEASES, INJURIES, ADHESIONS OR OTHER CONDITIONS OF THE UTERUS?
SECTION VIII - CONDITIONS OF THE UTERUS(Continued)
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)?
SECTION X - CONDITIONS OF THE OVARIES
10A. HAS THE VETERAN UNDERGONE MENOPAUSE?
Natural menopause
Premature menopause
Surgical menopause
Chemical-induced menopause
Radiation-induced menopause
10B. HAS THE VETERAN UNDERGONE PARTIAL OR COMPLETE OOPHORECTOMY?
(If "Yes," check all that apply):
(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?
(If yes, etiology):
Partial atrophy of 1 or both ovaries
Complete atrophy of 1 ovary
Complete atrophy of both ovaries (excluding natural menopause)
UNKNOWN
(If yes, indicate severity):
10D. HAS THE VETERAN BEEN DIAGNOSED WITH ANY OTHER DISEASES, INJURIES, ADHESIONS AND/OR OTHER CONDITIONS OF THE OVARIES?
(If yes, describe):
SECTION XI - INCONTINENCE
11. DOES THE VETERAN HAVE URINARY INCONTINENCE/LEAKAGE?
(If yes, is the urinary incontinence/leakage due to a gynecologic condition?):
(If yes, check all that apply):
Requires absorbent material that is changed less than 2 times per day
Stress incontinence
Does not require/does not use absorbent material
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:
(If yes, condition causing it):
VA FORM 21-0960K-2, SEP 2016
Page 3
(If yes, describe):
YES
NO
YES
Partial removal of an ovary
Complete removal of an ovary
NO
YESNO
YESNO
YESNO
YESNO
YES
NO
(If yes, describe):
(If yes, indicate):
NOYES
RightLeftBoth
Both
LeftRight
(If "No,", complete 10C.)
PATIENT/VETERAN'S SOCIAL SECURITY NO.
12A. DOES THE VETERAN HAVE A RECTOVAGINAL FISTULA?
SECTION XII - FISTULAE
NOYES
NO
YESNO
YESNO
YES
NO
YES
NOYES
NO
YES
NO
YES
(If yes, does the veteran have vaginal-fecal leakage?):
(If yes, indicate frequency (check all that apply)):
1-3 times per week
Less than once a 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?
(If yes, does the veteran have urine leakage?):
(If yes, check all that apply):
Requires absorbent material that is changed less than 2 times per day
Does not require/does not use absorbent material
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
13. HAS THE VETERAN BEEN DIAGNOSED WITH ENDOMETRIOSIS?
NOTE - A diagnosis of endometriosis must be substantiated by laparoscopy.
(If yes, does the veteran currently have any findings, signs or symptoms due to endometriosis?)
(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?
(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?
(If yes, describe):
NOTE - If obstetrical or gynecologic complications impact other body systems, also complete the additional appropriate Questionnaire(s)
(If yes, cause):
(If yes, cause):
VA FORM 21-0960K-2, SEP 2016
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PATIENT/VETERAN'S SOCIAL SECURITY NO.
Page 5
(If "Yes," also complete Items 15B through 15E)
15A. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DIAGNOSIS?
SECTION XV - TUMORS AND NEOPLASMS
15B. IS THE NEOPLASM
(If "Yes," indicate type of treatment the veteran is currently undergoing or has completed) (Check all that apply):
YES
Treatment completed; currently in watchful waiting status
15C. HAS THE VETERAN COMPLETED TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT NEOPLASM
OR METASTASES?
NO
YES
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 ITEM 15C?
15E. IF THERE ARE ADDITIONAL BENIGN OR MALIGNANT NEOPLASMS OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DESCRIBE
USING THE FORMAT IN ITEM 15C:
SECTION XVI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
16B. DOES THE VETERAN HAVE ANY OTHER PERTINENT FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN THE DIAGNOSIS SECTION?
(If yes, describe - brief summary):
(If "Yes," list residual conditions and complications - brief summary):
NOYES
NO
YESNO
YES
16A. 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," 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?)
NO
NO, WATCHFUL WAITING
YES
BENIGNMALIGNANT
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
Other therapeutic procedure
Other therapeutic treatment
Date of most recent treatment:
If checked, describe procedure:
If checked, describe treatment:
Date of most recent procedure:
Date of completion of treatment or anticipated date of completion:
Date of completion of treatment or anticipated date of completion:
VA FORM 21-0960K-2, SEP 2016
(If "Yes," ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire.)
(If "No,' provide location and measurements 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.
SECTION XVIII - FUNCTIONAL IMPACT
18. DOES THE VETERAN'S GYNECOLOGICAL CONDITION(S) IMPACT HER ABILITY TO WORK?
(If yes, describe impact of each of the veteran's gynecological conditions, providing one or more examples):
SECTION XIX - REMARKS
19. REMARKS (If any)
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
SECTION XX - PHYSICIAN'S CERTIFICATION AND SIGNATURE
Page 6
NOYES
20C. DATE SIGNED
20E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER
20F. PHYSICIAN'S ADDRESS
20B. PHYSICIAN'S PRINTED NAME
(VA Regional Office FAX No.)
20A. PHYSICIAN'S SIGNATURE
IMPORTANT - Physician please fax the completed form to:
20D. PHYSICIAN'S PHONE AND FAX NUMBERS
NOTE - VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.
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
VA FORM 21-0960K-2, SEP 2016
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?
(If yes, provide date(s), facility where performed, and results):
NOYES
NOYES
NOYES
SECTION XVII - DIAGNOSTIC TESTING
(If yes, provide most recent test results):
17B. HAS THE VETERAN BEEN DIAGNOSED WITH ANEMIA? (If due to a gynecological condition noted in Section I.)
17C. HAS THE VETERAN HAD ANY OTHER DIAGNOSTIC TESTING AND IF SO, ARE THERE SIGNIFICANT FINDINGS AND/OR RESULTS?
(If yes, provide type of test or procedure, date and results (brief summary)):
Hgb:Hct:Date of test:
PATIENT/VETERAN'S SOCIAL SECURITY NO.
NOTE - A list of VA Regional Office FAX Numbers can be found at www.benefits.va.gov/disabilityexamsor obtained by calling 1-800-827-1000.
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.
