VA Form 21-0960g-8 "Infectious Intestinal Disorders, Including Bacterial and Parasitic Infections Disability Benefits Questionnaire"

What Is VA Form 21-0960g-8?

This is a legal form that was released by the U.S. Department of Veterans Affairs on September 1, 2016 and used country-wide. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2016;
  • The latest available edition released by the U.S. Department of Veterans Affairs;
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Download a fillable version of VA Form 21-0960g-8 by clicking the link below or browse more documents and templates provided by the U.S. Department of Veterans Affairs.

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Download VA Form 21-0960g-8 "Infectious Intestinal Disorders, Including Bacterial and Parasitic Infections Disability Benefits Questionnaire"

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OMB Approved No. 2900-0778
Respondent Burden: 15 Minutes
Expiration Date: 09/30/2019
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.
(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
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH AN INFECTIOUS INTESTINAL 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. SELECT THE VETERAN'S CONDITION
:
BACILLARY DYSENTERY
ICD code:
Date of diagnosis:
(intestinal fluke)
INTESTINAL DISTOMIASIS
ICD code:
Date of diagnosis:
PARASITIC INFECTION OF THE INTESTINES
ICD code:
Date of diagnosis:
AMEBIASIS
ICD code:
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.
OTHER INFECTIOUS INTESTINAL CONDITION
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 INFECTIOUS INTESTINAL CONDITIONS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset, course, and past treatment)
(brief summary)
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S INFECTIOUS INTESTINAL CONDITIONS
:
2B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF THE VETERAN'S INTESTINAL CONDITIONS?
YES
NO
IF YES, LIST ONLY THOSE MEDICATIONS REQUIRED FOR THE INTESTINAL CONDITIONS:
2C. HAS THE VETERAN HAD SURGICAL TREATMENT FOR AN INTESTINAL CONDITION?
YES
NO
(If "Yes," ALSO complete VA Form 21-0960G-4, Intestinal Surgery (Bowel Resection, Colostomy, Ileostomy) Disability Benefits Questionnaire)
SECTION III - SIGNS AND SYMPTOMS
3. DOES THE VETERAN HAVE ANY SIGNS OR SYMPTOMS ATTRIBUTABLE TO ANY INFECTIOUS INTESTINAL CONDITIONS?
YES
NO
IF YES, CHECK ALL THAT APPLY
(If checked, describe)
MILD SYMPTOMS ATTRIBUTABLE TO DISTOMIASIS, INTESTINAL OR HEPATIC
:
(If checked, describe)
MODERATE SYMPTOMS ATTRIBUTABLE TO DISTOMIASIS, INTESTINAL OR HEPATIC
:
(If checked, describe)
SEVERE SYMPTOMS ATTRIBUTABLE TO DISTOMIASIS, INTESTINAL OR HEPATIC
:
(If checked, describe)
MILD GASTROINTESTINAL DISTURBANCES
:
If checked, describe
LOWER ABDOMINAL CRAMPS.
:
(If checked, describe)
GASEOUS DISTENTION
:
(If checked, describe)
CHRONIC CONSTIPATION INTERRUPTED BY DIARRHEA
:
ANEMIA (If checked, provide hemoglobin/hematocrit in Section 8, Diagnostic Testing)
(If checked, describe)
NAUSEA
:
(If checked, describe)
VOMITING
:
(describe)
OTHER,
:
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).
VA FORM
21-0960G-8
SUPERSEDES VA FORM 21-0960G-8, OCT 2012,
Page 1
SEP 2016
WHICH WILL NOT BE USED.
OMB Approved No. 2900-0778
Respondent Burden: 15 Minutes
Expiration Date: 09/30/2019
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.
(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
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH AN INFECTIOUS INTESTINAL 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. SELECT THE VETERAN'S CONDITION
:
BACILLARY DYSENTERY
ICD code:
Date of diagnosis:
(intestinal fluke)
INTESTINAL DISTOMIASIS
ICD code:
Date of diagnosis:
PARASITIC INFECTION OF THE INTESTINES
ICD code:
Date of diagnosis:
AMEBIASIS
ICD code:
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.
OTHER INFECTIOUS INTESTINAL CONDITION
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 INFECTIOUS INTESTINAL CONDITIONS, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL HISTORY
(including onset, course, and past treatment)
(brief summary)
2A. DESCRIBE THE HISTORY
OF THE VETERAN'S INFECTIOUS INTESTINAL CONDITIONS
:
2B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF THE VETERAN'S INTESTINAL CONDITIONS?
YES
NO
IF YES, LIST ONLY THOSE MEDICATIONS REQUIRED FOR THE INTESTINAL CONDITIONS:
2C. HAS THE VETERAN HAD SURGICAL TREATMENT FOR AN INTESTINAL CONDITION?
YES
NO
(If "Yes," ALSO complete VA Form 21-0960G-4, Intestinal Surgery (Bowel Resection, Colostomy, Ileostomy) Disability Benefits Questionnaire)
SECTION III - SIGNS AND SYMPTOMS
3. DOES THE VETERAN HAVE ANY SIGNS OR SYMPTOMS ATTRIBUTABLE TO ANY INFECTIOUS INTESTINAL CONDITIONS?
YES
NO
IF YES, CHECK ALL THAT APPLY
(If checked, describe)
MILD SYMPTOMS ATTRIBUTABLE TO DISTOMIASIS, INTESTINAL OR HEPATIC
:
(If checked, describe)
MODERATE SYMPTOMS ATTRIBUTABLE TO DISTOMIASIS, INTESTINAL OR HEPATIC
:
(If checked, describe)
SEVERE SYMPTOMS ATTRIBUTABLE TO DISTOMIASIS, INTESTINAL OR HEPATIC
:
(If checked, describe)
MILD GASTROINTESTINAL DISTURBANCES
:
If checked, describe
LOWER ABDOMINAL CRAMPS.
:
(If checked, describe)
GASEOUS DISTENTION
:
(If checked, describe)
CHRONIC CONSTIPATION INTERRUPTED BY DIARRHEA
:
ANEMIA (If checked, provide hemoglobin/hematocrit in Section 8, Diagnostic Testing)
(If checked, describe)
NAUSEA
:
(If checked, describe)
VOMITING
:
(describe)
OTHER,
:
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).
VA FORM
21-0960G-8
SUPERSEDES VA FORM 21-0960G-8, OCT 2012,
Page 1
SEP 2016
WHICH WILL NOT BE USED.
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION IV - SYMPTOM EPISODES, ATTACKS AND EXACERBATIONS
4. DOES THE VETERAN HAVE EPISODES OF BOWEL DISTURBANCE WITH ABDOMINAL DISTRESS, OR EXACERBATIONS OR ATTACKS OF THE
INTESTINAL CONDITION?
YES
NO
(check all that apply)
IF YES, INDICATE SEVERITY AND FREQUENCY
EPISODES OF BOWEL DISTURBANCE WITH ABDOMINAL DISTRESS. IF CHECKED, INDICATE FREQUENCY:
Occasional episodes
More or less constant abdominal distress
Frequent episodes
EPISODES OF EXACERBATIONS AND/OR ATTACKS OF THE INTESTINAL CONDITION
IF CHECKED, DESCRIBE TYPICAL EXACERBATION OR ATTACK:
INDICATE NUMBER OF EXACERBATIONS AND/OR ATTACKS IN PAST 12 MONTHS:
7 or more
1
2
3
4
5
6
SECTION V - WEIGHT LOSS
5. DOES THE VETERAN HAVE WEIGHT LOSS ATTRIBUTABLE TO AN INFECTIOUS INTESTINAL CONDITION?
YES
NO
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)
SECTION VI - MALNUTRITION, COMPLICATIONS AND OTHER GENERAL HEALTH EFFECTS
6. DOES THE VETERAN HAVE MALNUTRITION, SERIOUS COMPLICATIONS OR OTHER GENERAL HEALTH EFFECTS ATTRIBUTABLE TO THE INTESTINAL
CONDITION?
YES
NO
(check all that apply)
IF YES, INDICATE SEVERITY
Health only fair during remissions
Resulting in general debility
Serious complication such as liver abscess (Describe)
Malnutrition. If checked, is malnutrition marked?
Yes
No
Other (Describe):
SECTION VII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
(surgical or otherwise)
7A. DOES THE VETERAN HAVE ANY SCARS
RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
THE DIAGNOSIS SECTION?
YES
NO
(6 square inches
IF YES, ARE ANY OF THE SCARS PAINFUL OR UNSTABLE; HAVE A TOTAL AREA EQUAL TO OR GREATER THAN 39 SQUARE CM
) 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.
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?
(brief summary)
YES
NO IF YES, DESCRIBE
:
SECTION VIII - DIAGNOSTIC TESTING
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?
YES
NO
IF YES, CHECK ALL THAT APPLY:
(if anemia due to any intestinal condition is suspected or present)
CBC
Date of test:
Hemoglobin:
Hematocrit:
White blood cell count:
Platelets:
Other, specify:
Date of test:
Results:
8B. HAVE IMAGING STUDIES OR DIAGNOSTIC PROCEDURES BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
(brief summary)
YES
NO
IF YES, PROVIDE TYPE OF TEST OR PROCEDURE, DATE AND RESULTS
:
8C. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
(brief summary)
YES
NO IF YES, PROVIDE TYPE OF TEST OR PROCEDURE, DATE AND RESULTS
:
VA FORM 21-0960G-8, SEP 2016
Page 2
PATIENT/VETERAN'S SOCIAL SECURITY NO.
SECTION IX - FUNCTIONAL IMPACT
9. DO ANY OF THE VETERAN'S INFECTIOUS INTESTINAL CONDITIONS IMPACT HIS OR HER ABILITY TO WORK?
YES
NO
IF YES, DESCRIBE THE IMPACT OF EACH OF THE VETERAN'S INFECTIOUS INTESTINAL CONDITIONS, PROVIDING ONE OR MORE EXAMPLES:
SECTION X - REMARKS
10. REMARKS, IF ANY:
SECTION XI - PHYSICIAN'S CERTIFICATION AND SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
11A. PHYSICIAN'S SIGNATURE
11B. PHYSICIAN'S PRINTED NAME
11C. DATE SIGNED
11D. PHYSICIAN'S PHONE AND FAX NUMBER
11E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER
11F. 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-8, SEP 2016
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