VA Form 21-0960J-4 "Urinary Tract (Including Bladder and Urethra) Conditions (Excluding Male Reproductive System) Disability Benefits Questionnaire"

What Is VA Form 21-0960J-4?

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 VA Form 21-0960J-4 "Urinary Tract (Including Bladder and Urethra) Conditions (Excluding Male Reproductive System) Disability Benefits Questionnaire"

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OMB Approved No. 2900-0781
Respondent Burden: 15 Minutes
Expiration Date: 09/30/2019
URINARY TRACT (INCLUDING BLADDER AND URETHRA) CONDITIONS
(EXCLUDING MALE REPRODUCTIVE SYSTEM) 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.
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 A CONDITION OF THE BLADDER OR URETHRA OF THE URINARY
(This is the condition the veteran is claiming or for which an exam has been requested)
TRACT?
(If "Yes," complete Item 1B)
YES
NO
NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed above. 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 appropriate date determined through record review or reported history.
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO URINARY TRACT CONDITIONS OF THE BLADDER OR URETHRA:
Diagnosis # 1 -
ICD code -
Date of diagnosis -
Diagnosis # 2 -
ICD code -
Date of diagnosis -
Diagnosis # 3 -
ICD code -
Date of diagnosis -
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO URINARY TRACT CONDITIONS OF THE BLADDER OR URETHRA, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL RECORD REVIEW
2. INDICATE MEDICAL RECORDS REVIEWED IN PREPARATION OF THIS REPORT:
C-FILE (VA ONLY)
OTHER, DESCRIBE:
SECTION III - MEDICAL HISTORY
(including onset and course)
(brief summary):
3A. DESCRIBE THE HISTORY
OF THE VETERAN'S URINARY TRACT CONDITION
3B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF THE VETERAN'S URINARY TRACT CONDITION?
(If "Yes," list only those medications required for the veteran's urinary tract condition):
YES
NO
SECTION IV - VOIDING DYSFUNCTION
4. DOES THE VETERAN HAVE A VOIDING DYSFUNCTION?
(If "Yes," complete Items 4A thru 4E):
YES
NO
(i.e., relationship of voiding dysfunction to any condition in Section I, Diagnosis):
A. ETIOLOGY OF VOIDING DYSFUNCTION
B. DOES THE VOIDING DYSFUNCTION CAUSE URINE LEAKAGE?
YES
NO
(If "Yes," indicate severity)
Does not require the wearing of absorbent material
Requires absorbent material which must be changed less than 2 times per day
Requires absorbent material which must be changed 2 to 4 times per day
Requires absorbent material which must be changed more than 4 times per day
Other, describe:
C. DOES THE VOIDING DYSFUNCTION REQUIRE THE USE OF AN APPLIANCE?
(If "Yes," describe the appliance):
YES
NO
D. DOES THE VOIDING DYSFUNCTION CAUSE INCREASED URINARY FREQUENCY?
YES
NO
(If "Yes," check all that apply):
Daytime voiding interval between 2 and 3 hours
Daytime voiding interval between 1 and 2 hours
Daytime voiding interval less than 1 hour
Nighttime awakening to void 2 times
Nighttime awakening to void 3 to 4 times
Nighttime awakening to void 5 or more times
21-0960J-4
SUPERSEDES VA FORM 21-0960J-4, OCT 2012,
Page 1
VA FORM
WHICH WILL NOT BE USED.
SEP 2016
OMB Approved No. 2900-0781
Respondent Burden: 15 Minutes
Expiration Date: 09/30/2019
URINARY TRACT (INCLUDING BLADDER AND URETHRA) CONDITIONS
(EXCLUDING MALE REPRODUCTIVE SYSTEM) 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.
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 A CONDITION OF THE BLADDER OR URETHRA OF THE URINARY
(This is the condition the veteran is claiming or for which an exam has been requested)
TRACT?
(If "Yes," complete Item 1B)
YES
NO
NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed above. 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 appropriate date determined through record review or reported history.
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO URINARY TRACT CONDITIONS OF THE BLADDER OR URETHRA:
Diagnosis # 1 -
ICD code -
Date of diagnosis -
Diagnosis # 2 -
ICD code -
Date of diagnosis -
Diagnosis # 3 -
ICD code -
Date of diagnosis -
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO URINARY TRACT CONDITIONS OF THE BLADDER OR URETHRA, LIST USING ABOVE FORMAT:
SECTION II - MEDICAL RECORD REVIEW
2. INDICATE MEDICAL RECORDS REVIEWED IN PREPARATION OF THIS REPORT:
C-FILE (VA ONLY)
OTHER, DESCRIBE:
SECTION III - MEDICAL HISTORY
(including onset and course)
(brief summary):
3A. DESCRIBE THE HISTORY
OF THE VETERAN'S URINARY TRACT CONDITION
3B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF THE VETERAN'S URINARY TRACT CONDITION?
(If "Yes," list only those medications required for the veteran's urinary tract condition):
YES
NO
SECTION IV - VOIDING DYSFUNCTION
4. DOES THE VETERAN HAVE A VOIDING DYSFUNCTION?
(If "Yes," complete Items 4A thru 4E):
YES
NO
(i.e., relationship of voiding dysfunction to any condition in Section I, Diagnosis):
A. ETIOLOGY OF VOIDING DYSFUNCTION
B. DOES THE VOIDING DYSFUNCTION CAUSE URINE LEAKAGE?
YES
NO
(If "Yes," indicate severity)
Does not require the wearing of absorbent material
Requires absorbent material which must be changed less than 2 times per day
Requires absorbent material which must be changed 2 to 4 times per day
Requires absorbent material which must be changed more than 4 times per day
Other, describe:
C. DOES THE VOIDING DYSFUNCTION REQUIRE THE USE OF AN APPLIANCE?
(If "Yes," describe the appliance):
YES
NO
D. DOES THE VOIDING DYSFUNCTION CAUSE INCREASED URINARY FREQUENCY?
YES
NO
(If "Yes," check all that apply):
Daytime voiding interval between 2 and 3 hours
Daytime voiding interval between 1 and 2 hours
Daytime voiding interval less than 1 hour
Nighttime awakening to void 2 times
Nighttime awakening to void 3 to 4 times
Nighttime awakening to void 5 or more times
21-0960J-4
SUPERSEDES VA FORM 21-0960J-4, OCT 2012,
Page 1
VA FORM
WHICH WILL NOT BE USED.
SEP 2016
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
(Continued)
SECTION IV - VOIDING DYSFUNCTION
E. DOES THE VOIDING DYSFUNCTION CAUSE SIGNS OR SYMPTOMS OF OBSTRUCTED VOIDING?
(If "Yes," check all that apply):
YES
NO
(If checked, is hesitancy marked?):
Hesitancy
Yes
No
(If checked, is stream markedly slow or weak?):
Slow or weak stream
Yes
No
(If checked, is force of stream markedly decreased?):
Decreased force of stream
Yes
No
(If checked, indicate frequency of periodic dilation):
Stricture disease requiring dilatation
1 to 2 times per year
Every 2 to 3 months
Other, specify:
Recurrent urinary tract infections secondary to obstruction
Uroflowmetry peak flow rate less than 10 cc/sec
Post void residuals greater than 150 cc
Urinary retention requiring intermittent catheterization
Urinary retention requiring continuous catheterization
Other, describe:
SECTION V - UROLITHIASIS
(cysto or urethrolithiasis)
5. DOES THE VETERAN HAVE A HISTORY OF URETHRAL OR BLADDER CALCULI
?
(If "Yes," complete Items 5A thru 5C):
YES
NO
(check all that apply):
A. INDICATE LOCATION OF CALCULI
Urethra
Bladder
B. HAS THE VETERAN HAD TREATMENT FOR RECURRENT STONE FORMATION IN THE URETHRA OR BLADDER?
(If "Yes," indicate treatment (check all that apply)):
YES
NO
(If checked, specify diet:
and dates of use:
)
Diet therapy
(If checked, list medication:
and dates of use:
)
Drug therapy
(If checked, indicate average number of times per year invasive or non-invasive procedures were required):
Invasive or non-invasive procedures
0 to 1 per year
2 per year
> 2 per year
Provide name of facility and dates of most recent invasive or noninvasive procedure:
C. DOES THE VETERAN HAVE SIGNS OR SYMPTOMS DUE TO URETHROLITHIASIS?
(If "Yes," indicate type/severity (check all that apply)):
YES
NO
Bladder pain
Dysuria
Hematuria
Voiding dysfunction
Requirement for catheter drainage
Sudden painful interruption of urinary stream
Other, describe:
SECTION VI - BLADDER OR URETHRAL INFECTION
6. DOES THE VETERAN HAVE A HISTORY OF RECURRENT SYMPTOMATIC BLADDER OR URETHRAL INFECTIONS?
(If "Yes," complete Items 6A & 6B)
YES
NO
(i.e., relationship of recurrent symptomatic bladder or urethral infections to any condition in Section I, Diagnosis):
A. PROVIDE ETIOLOGY
B. IF THE VETERAN HAS HAD RECURRENT SYMPTOMATIC URETHRAL OR BLADDER INFECTIONS, INDICATE ALL TREATMENT MODALITIES THAT APPLY:
No treatment
(If checked, list medications used and indicate dates for courses of treatment over the past 12 months):
Long-term drug therapy
(If checked, indicate frequency of hospitalization):
Hospitalization
1 or 2 per year
> 2 per year
(If checked, indicate dates when drainage performed over past 12 months):
Drainage
(If checked, indicate types of treatment and medications used over past 12 months):
Continuous intensive management
(If checked, indicate types of treatment and medications used over past 12 months):
Intermittent intensive management
Other, describe:
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VA FORM 21-0960J-4, SEP 2016
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
SECTION VII - OTHER BLADDER/URETHRAL CONDITIONS
7. DOES THE VETERAN NOW HAVE OR HAS THE VETERAN EVER HAD A BLADDER OR URETHRAL FISTULA, STRICTURE, NEUROGENIC BLADDER, BLADDER
INJURY OR OTHER BLADDER SURGERY?
(If "Yes," complete Items 7A thru 7E):
YES
NO
A. DOES THE VETERAN HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO A BLADDER OR URETHRAL FISTULA?
YES
NO
(If "Yes," check all that apply):
(urine leakage, obstructed voiding)
Voiding dysfunction
Requirement for catheter drainage
(cystitis or urethritis)
Infection
Impaired kidney function
(NOTE: If veteran has impaired kidney function, also complete VA Form 21-0960J-1, Kidney Conditions (Nephrology) Disability Benefits Questionnaire)
Other, describe:
B. HAS THE VETERAN HAD SURGERY FOR A BLADDER OR URETHRAL FISTULA?
YES
NO
(If "Yes," indicate surgical treatment):
None
(If checked, provide date of treatment and name of treatment facility:
)
Resection or closure of fistula
(If checked, provide date of treatment and name of treatment facility:
)
Urinary diversion
(If checked, provide date of treatment and name of treatment facility:
)
Partial bladder resection
(If checked, provide date of treatment and name of treatment facility:
)
Other, describe:
C. DOES THE VETERAN HAVE A NEUROGENIC OR A SEVERELY DYSFUNCTIONAL BLADDER?
(If "Yes," describe):
YES
NO
D. DOES THE VETERAN HAVE A BLADDER INJURY?
(If "Yes," describe):
YES
NO
E. HAS THE VETERAN HAD OTHER BLADDER SURGERY?
(If "Yes," describe):
YES
NO
SECTION VIII - TUMORS AND NEOPLASMS
8. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DIAGNOSIS?
(If "Yes," complete Items 8A through 8D)
YES
NO
A. IS THE NEOPLASM
BENIGN
MALIGNANT
B. HAS THE VETERAN COMPLETED TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT NEOPLASM OR
METASTASES?
YES
NO; WATCHFUL WAITING
(If "Yes," indicate type of treatment the veteran is currently undergoing or has completed (check all that apply)):
Treatment completed; currently in watchful waiting status
(If checked, describe:
and provide date(s) of surgery:
Surgery
(If checked, provide date of most recent treatment:
and provide date of completion of treatment or anticipated date of
Radiation therapy
completion:
)
(If checked, provide date of most recent treatment:
and provide date of completion of treatment or
Antineoplastic chemotherapy
anticipated date of completion:
)
(If checked, describe procedure:
and provide date of most recent
Other therapeutic procedure
procedure:
)
(If checked, describe treatment:
and provide date
Other therapeutic treatment
of completion of treatment or anticipated date of completion:
)
(including metastases)
C. DOES THE VETERAN CURRENTLY HAVE ANY RESIDUAL CONDITIONS OR COMPLICATIONS DUE TO THE NEOPLASM
OR ITS
TREATMENT, OTHER THAN THOSE ALREADY DOCUMENTED ON THIS QUESTIONNAIRE?
(If "Yes," list residual conditions and complications (brief summary)):
YES
NO
D. 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:
Page 3
VA FORM 21-0960J-4, SEP 2016
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
SECTION IX - OTHER PERTINENT PHYSICAL FINDINGS, SCARS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
(surgical or otherwise)
9A. DOES THE VETERAN HAVE ANY SCARS
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 AND/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
YES
IF "YES," ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT DISABILITY BENEFITS QUESTIONNAIRE (DBQ).
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. It is not necessary to also complete a Scars/Disfigurement DBQ.
9B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS?
(If "Yes," describe (brief summary)):
YES
NO
SECTION X - DIAGNOSTIC TESTING
NOTE: If diagnostic test results are in the medical record and reflect the veteran's current urinary tract condition, repeat testing is not required.
10. HAS THE VETERAN HAD 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):
YES
NO
SECTION XI - FUNCTIONAL IMPACT
11. DOES THE VETERAN'S CONDITION(S) OF THE BLADDER OR URETHRA IMPACT HIS OR HER ABILITY TO WORK?
(If "Yes," describe the impact of each of the veteran's bladder or urethra condition(s), providing one or more examples):
YES
NO
SECTION XII - REMARKS
(If any):
12. REMARKS
SECTION XIII - PHYSICIAN'S CERTIFICATION AND SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
13A. PHYSICIAN'S SIGNATURE
13B. PHYSICIAN'S PRINTED NAME
13C. DATE SIGNED
13E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER 13F. PHYSICIAN'S ADDRESS
13D. PHYSICIAN'S PHONE/FAX NUMBERS
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.
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VA FORM 21-0960J-4, SEP 2016
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