VA FORM FEB 2011 dept of veterans affairs OMB Control No. 2900-XXXX OMB Respondent Burden: 15 minutes
21-0960G-3

INTESTINAL DISORDERS (OTHER THAN SURGICAL OR INFECTIOUS) (INCLUDING IRRITABLE BOWEL SYNDROME, CROHN'S DISEASE, ULCERATIVE COLITIS, AND DIVERTICULITIS) DISABILITY BENEFITS QUESTIONNAIRE

NAME OF PATIENT/VETERAN

PATIENT/VETERAN'S SOCIAL SECURITY NUMBER

If yes, list only those medications required for the intestinal condition:

1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH AN INTESTINAL CONDITION (Other than surgical or infectious)?

If no, provide rationale (e.g., Veteran does not currently have any known non-surgical or non-infectious intestinal conditions):

IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO INTESTINAL CONDITION(S) (OTHER THAN SURGICAL OR INFECTIOUS), LIST USING ABOVE FORMAT

OMB Control No. 2900-XXXX Respondent Burden: 15 minutes

SECTION I - DIAGNOSIS

2A. DESCRIBE THE HISTORY (INCLUDING ONSET AND COURSE) OF THE VETERAN'S INTESTINAL CONDITION (brief summary):

SECTION II - MEDICAL HISTORY

NO YES

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.

If yes, select the Veteran's condition (check all that apply);

ICD Code:

Ulcerative colitis

Date of Diagnosis:

ICD Code:

Celiac disease

Date of Diagnosis:

ICD Code:

Diverticulitis

Date of Diagnosis:

ICD Code:

Chronic enterocolitis

Date of Diagnosis:

ICD Code:

ICD Code:

Irritable bowel syndrome

Chronic diarrhea

Date of Diagnosis:

Date of Diagnosis:

ICD Code:

Spastic colitis

Date of Diagnosis:

ICD Code:

Mucous colitis

Date of Diagnosis:

ICD Code:

Crohn's disease

Date of Diagnosis:

ICD Code:

Chronic enteritis

Date of Diagnosis:

Intestinal neoplasm (If checked, ALSO complete the Tumors and Neoplasms Questionaire.)

Date of Diagnosis:

ICD Code:

Other non-surgical or non-infectous intestinal conditions:

Date of Diagnosis:

ICD Code:

Other diagnosis #1:

Date of Diagnosis:

ICD Code:

Other diagnosis #2:

2B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF THE VETERAN'S INTESTINAL CONDITION?

If yes, ALSO complete the Intestinal Surgery Questionaire.

YES NO

2C. HAS THE VETERAN HAD SURGICAL TREATMENT FOR AN INTESTINAL CONDITION?

Peritoneal adhesions attributable to diverticulitis (If checked,ALSO complete the Peritoneal Adhesions Questionaire.)

Date of Diagnosis:

ICD Code:

IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR COST INCURRED IN THE

Other non-surgical or non-infectous intestinal conditions:

Date of Diagnosis:

ICD Code:

Other diagnosis #1:

Date of Diagnosis:

ICD Code:

Other diagnosis #2:

IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO INTESTINAL CONDITION(S) (OTHER THAN SURGICAL OR INFECTIOUS), LIST USING ABOVE FORMAT

SECTION II - MEDICAL HISTORY

2A. DESCRIBE THE HISTORY (INCLUDING ONSET AND COURSE) OF THE VETERAN'S INTESTINAL CONDITION (brief summary):

2B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF THE VETERAN'S INTESTINAL CONDITION?

Yes or no

If yes, list only those medications required for the intestinal condition

2C. HAS THE VETERAN HAD SURGICAL TREATMENT FOR AN INTESTINAL CONDITION?

Yes or no

If yes, ALSO complete the Intestinal Surgery Questionaire.

SECTION III - SIGNS AND SYMPTOMS

3. DOES THE VETERAN HAVE ANY SIGNS OR SYMPTOMS ATTRIBUTABLE TO ANY NON-SURGICAL NON-INFECTIOUS INTESTINAL CONDITIONS?

Yes or no

If yes, check all that apply:

Diarrhea If checked, describe:

Alternating diarrhea and constipation If checked, describe:

Abdominal distension If checked, describe:

Anemia If checked, describe:

Nausea If checked, describe:

Vomiting If checked, describe:

Other, describe:

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

If Yes, indicate severity and frequency: (check all that apply)

Episodes of bowel disturbance with abdominal distress If checked, indicate frequency:

Occasional episodes

Frequent episodes

More or less constant abdominal distress

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:

0 1 2 3 4 5 6 7 or more

SECTION V - WEIGHT LOSS

5. DOES THE VETERAN HAVE WEIGHT LOSS ATTRIBUTABLE TO A SURGICAL INTESTINAL CONDITION?

NO YES

If yes, provide veteran's baseline weight:

and current weight:

(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?

NO YES

If Yes, indicate severity: (check all that apply)

Health only fair during remissions

Resulting in general debility

Resulting in serious complication such as liver abscess

Malnutrition If checked, is malnutrition marked?

Other, describe:

SECTION VII - OTHER PERTINENT FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS?

7A. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS?

NO

YES

If "Yes," describe (brief summary):

7B. 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 ABOVE?

NO

YES

If yes, are any of the scars painful and/or unstable, or is the total area of all related scars greater than 39 square cm (6 square inches)?

Yes

no

If yes, also complete a Scars Questionnaire?

SECTION VIII - DIAGNOSTIC TESTING

NOTE: If imaging studies, diagnostic procedures or laboratory testing has been performed and reflects the veteran's current condition, provide the most recent results; no further studies or testing are required for this examination.

NO

YES

If Yes, check all that apply:

8A. HAS LABORATORY TESTING BEEN PERFORMED?

NO

YES

If Yes, check all that apply:

CBC (if anemia due to any intestinal condition is suspected or present)

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?

NO YES

If Yes, provide type of test or procedure, date and results (brief summary):

8C. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?

NO YES

If Yes, provide type of test or procedure, date and results (brief summary):

SECTION IX - FUNCTIONAL IMPACT

9. DOES THE VETERAN'S INTESTINAL CONDITION IMPACT HIS OR HER ABILITY TO WORK?

Yes no

If Yes, describe the impact of each of the veteran's intestinal conditions, providing one or more examples:

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 NUMBER 11E. PHYSICIAN'S MEDICAL LICENSE 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.vba.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 required to obtain or retain benefits. 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-3, FEB 2011 Page 3 (may want to see va form 21-0960g-4 also)

From katrine(kathrine)elizabeth sackett 32463 whitelady (5’3)(5’2 ½)(3030)

Spring terrace apts 7101 n ih 35 austin texas apt 214 old building donated for apt use for needy

Date sept 16 2020 wed

Information found in internet website hope it helps ya all out good luck

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