VA Form 21-0960g-1 Esophageal Conditions (Including Gastroesophageal Reflux Disease (GERD), Hiatal Hernia and Other Esophageal Disorders) Disability Benefits Questionnaire

VA Form 21-0960g-1 or the "Esophageal Conditions (including Gastroesophageal Reflux Disease (gerd), Hiatal Hernia And Other Esophageal Disorders) Disability Benefits Questionnaire" is a form issued by the United States Department of Veterans Affairs.

The form was last revised on September 1, 2016 - an up-to-date fillable PDF VA Form 21-0960g-1 down below or find it on the Veterans Affairs Forms website.

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OMB Control No. 2900-0778
Respondent Burden: 15 Minutes
Expiration Date: 09/30/2019
ESOPHAGEAL CONDITIONS (Including gastroesophageal reflux disease (GERD),
hiatal hernia and other 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 THIS FORM.
(First, Middle Initial, Last)
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
NOTE: The diagnosis of gastroesophageal reflux disease (GERD) can be made clinically by evidence of relief of typical symptoms of reflux, epigastric discomfort and/or burning, by treatment
with proton pump inhibitors, histamine 2 receptor antagonists and/or antacids. If upper endoscopy was indicated or performed, the findings of erythema, ulcers and/or strictures are consistent
with the diagnosis of GERD.
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH AN ESOPHAGEAL CONDITION?
(If "Yes," complete Item 1B)
YES
NO
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.
(Check all that apply)
1B. DIAGNOSIS
GERD
ICD CODE:
DATE OF DIAGNOSIS:
HIATAL HERNIA
ICD CODE:
DATE OF DIAGNOSIS:
ESOPHAGEAL STRICTURE
ICD CODE:
DATE OF DIAGNOSIS:
ESOPHAGEAL SPASM
ICD CODE:
DATE OF DIAGNOSIS:
ESOPHAGEAL DIVERTICULUM
ICD CODE:
DATE OF DIAGNOSIS:
OTHER ESOPHAGEAL CONDITION(S), specify:
(such as eosinophilic esophagitis, Barrett's
esophagitis, etc.)
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 ESOPHAGEAL DISORDERS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
(brief summary)
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S ESOPHAGEAL CONDITIONS
:
2B. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING CONTINUOUS MEDICATION FOR THE DIAGNOSED CONDITION?
(If, "Yes," list only those medications used for the diagnosed condition):
YES
NO
SECTION III - SIGNS AND SYMPTOMS
(including
)
3. DOES THE VETERAN HAVE ANY OF THE FOLLOWING SIGNS OR SYMPTOMS DUE TO ANY ESOPHAGEAL CONDITIONS
GERD
?
YES
NO
(If "Yes," check all that apply)
PERSISTENTLY RECURRENT EPIGASTRIC DISTRESS
If checked, indicate frequency of symptom recurrence per year:
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
INFREQUENT EPISODES OF EPIGASTRIC DISTRESS
If checked, indicate frequency of symptom recurrence per year:
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
DYSPHAGIA
If checked, indicate frequency of symptom recurrence per year:
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
PYROSIS (Heartburn)
If checked, indicate frequency of symptom recurrence per year:
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
SUPERSEDES VA FORM 21-0960G-1, OCT 2012,
21-0960G-1
VA FORM
Page 1
WHICH WILL NOT BE USED.
SEP 2016
OMB Control No. 2900-0778
Respondent Burden: 15 Minutes
Expiration Date: 09/30/2019
ESOPHAGEAL CONDITIONS (Including gastroesophageal reflux disease (GERD),
hiatal hernia and other 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 THIS FORM.
(First, Middle Initial, Last)
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
NOTE: The diagnosis of gastroesophageal reflux disease (GERD) can be made clinically by evidence of relief of typical symptoms of reflux, epigastric discomfort and/or burning, by treatment
with proton pump inhibitors, histamine 2 receptor antagonists and/or antacids. If upper endoscopy was indicated or performed, the findings of erythema, ulcers and/or strictures are consistent
with the diagnosis of GERD.
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH AN ESOPHAGEAL CONDITION?
(If "Yes," complete Item 1B)
YES
NO
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.
(Check all that apply)
1B. DIAGNOSIS
GERD
ICD CODE:
DATE OF DIAGNOSIS:
HIATAL HERNIA
ICD CODE:
DATE OF DIAGNOSIS:
ESOPHAGEAL STRICTURE
ICD CODE:
DATE OF DIAGNOSIS:
ESOPHAGEAL SPASM
ICD CODE:
DATE OF DIAGNOSIS:
ESOPHAGEAL DIVERTICULUM
ICD CODE:
DATE OF DIAGNOSIS:
OTHER ESOPHAGEAL CONDITION(S), specify:
(such as eosinophilic esophagitis, Barrett's
esophagitis, etc.)
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 ESOPHAGEAL DISORDERS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset and course)
(brief summary)
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S ESOPHAGEAL CONDITIONS
:
2B. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING CONTINUOUS MEDICATION FOR THE DIAGNOSED CONDITION?
(If, "Yes," list only those medications used for the diagnosed condition):
YES
NO
SECTION III - SIGNS AND SYMPTOMS
(including
)
3. DOES THE VETERAN HAVE ANY OF THE FOLLOWING SIGNS OR SYMPTOMS DUE TO ANY ESOPHAGEAL CONDITIONS
GERD
?
YES
NO
(If "Yes," check all that apply)
PERSISTENTLY RECURRENT EPIGASTRIC DISTRESS
If checked, indicate frequency of symptom recurrence per year:
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
INFREQUENT EPISODES OF EPIGASTRIC DISTRESS
If checked, indicate frequency of symptom recurrence per year:
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
DYSPHAGIA
If checked, indicate frequency of symptom recurrence per year:
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
PYROSIS (Heartburn)
If checked, indicate frequency of symptom recurrence per year:
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
SUPERSEDES VA FORM 21-0960G-1, OCT 2012,
21-0960G-1
VA FORM
Page 1
WHICH WILL NOT BE USED.
SEP 2016
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION III - SIGNS AND SYMPTOMS (Continued)
REFLUX
If checked, indicate frequency of symptom recurrence per year:
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
REGURGITATION
If checked, indicate frequency of symptom recurrence per year:
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
SUBSTERNAL ARM OR SHOULDER PAIN
If checked, indicate frequency of symptom recurrence per year:
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
SLEEP DISTURBANCE CAUSE BY ESOPHAGEAL REFLUX
If checked, indicate frequency of symptom recurrence per year:
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
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:
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:
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 vomiting per year:
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
MELENA
If checked, indicate severity:
Mild
Transient
Recurrent
Periodic
If checked, indicate frequency of episodes of vomiting per year:
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
VA FORM 21-0960G-1, SEP 2016
Page 2
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION IV - ESOPHAGEAL STRICTURE, SPASM AND DIVERTICULA
4. DOES THE VETERAN HAVE AN ESOPHAGEAL STRICTURE, SPASM OF ESOPHAGUS (CARDIOSPASM OR ACHALASIA), OR AN ACQUIRED DIVERTICULUM OF
THE ESOPHAGUS?
YES
NO
If Yes, indicate severity of condition:
ASYMPTOMATIC
NOT AMENABLE TO DILATION
MILD If checked, describe:
MODERATE If checked, describe:
SEVERE, PERMITTING PASSAGE OF LIQUIDS ONLY
If checked, describe:
SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, SIGNS AND/OR SYMPTOMS
5A. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS? IF YES, DESCRIBE
(brief summary)
:
5B. 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 THESE 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?
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.
SECTION VI - DIAGNOSTIC TESTING
Note: If testing has been performed and reflects veteran's current condition, no further testing is required for this examination report.
6A. 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:
ESOPHAGRAM (barium swallow)
Date:
Results:
MRI
Date:
Results:
CT
Date:
Results:
BIOPSY, SPECIFY SITE:
Date:
Results:
OTHER, SPECIFY:
Date:
Results:
Page 3
VA FORM 21-0960G-1, SEP 2016
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION VI - DIAGNOSTIC TESTING (Continued)
6B. HAS LABORATORY TESTING BEEN PERFORMED?
YES
NO
If Yes, check all that apply:
CBC
Date of testing:
Hemoglobin:
Hematocrit:
White blood cell count:
Platelets:
HELICOBACTER PYLORI
Date of test:
Results:
OTHER, SPECIFY:
Date of test:
Results:
6C. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES
NO
(brief summary
If Yes, provide type of test or procedure, date and results
):
SECTION VII - FUNCTIONAL IMPACT
7. DO ANY OF THE VETERAN"S ESOPHAGEAL CONDITIONS IMPACT HIS OR HER ABILITY TO WORK?
YES
NO
If Yes, describe impact of each of the veteran's esophageal conditions, providing one ore more examples:
SECTION VIII - REMARKS
(If any)
8. REMARKS
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
9B. PHYSICIAN'S PRINTED NAME
9C. DATE SIGNED
9D. PHYSICIAN'S PHONE AND FAX NUMBER
9E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER
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 21-0960G-1, SEP 2016
Page 4
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