VA Form 29-8160 Supplemental Physical Examination Report (Diabetes - Phy

OMB Control No. 2900-0324
Respondent Burden: 45 Mins.

SUPPLEMENTAL PHYSICAL EXAMINATION REPORT
(DIABETES - PHYSICIAN’S REPORT)
PRIVACY ACT INFORMATION: This report is authorized by law (38 CFR 8.8, 8.9, and 8.22). The information is required to help us make a decision on the
veteran’s claim for the insurance benefits under consideration. Responses may be disclosed outside VA only if the disclosure is authorized by the Privacy Act,
including the routine uses identified in the VA system of records, 36VA00, Veterans and Armed Forces Personnel U.S. Government Life Insurance Records - VA,
published in the Federal Register.
RESPONDENT BURDEN: VA may not conduct or sponsor, and respondent is not required to respond to this collection of information unless it displays a valid OMB
Control Number. Public reporting burden for this collection of information is estimated to average 45 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. If you have
comments regarding this burden estimate or any other aspect of this collection of information, call 1-800-827-1000 for mailing information on where to send your
comments.
1. NAME OF APPLICANT (Type or print)
2. INSURANCE FILE NUMBER
NOTICE TO APPLICANT
Any examinations required in connection with V, RS, W, RH or K insurance or in
connection with reinstatement or change of plan of "J" insurance may be made by
medical officers in active service or physicians of the U.S. Public Health Service, for
those entitled, or may be made free of charge by a physician of the VA Regional
Office or Medical Center. The examination may also be made at the applicant’s own
expense by a physician duly licensed for practice of medicine by a State, Territory or
Possession of the United States, or District of Columbia, who is not related to the
applicant, by blood or marriage, associated with his/her business, or financially
interested in the granting of this insurance. Any medical examination required in
connection with the issuance of the Total Disability Income Provision to "J"
insurance must be made at the applicant’s own expense.
3. REASON APPLICANT CONSULTED PHYSICIAN

NOTICE TO PHYSICIAN
Please furnish all pertinent information. If more space is needed, you may use
the reverse of this form. The completed form should be sent to the office
checked below. Please do not return it to the applicant. Thank you.
RETURN TO:

Department of Veterans Affairs
Regional Office and Insurance Center
P.O. Box 7208
Philadelphia, PA 19101

4. IS APPLICANT RECEIVING TREATMENT
5. DATE FIRST TREATMENT WAS
OR UNDER MEDICAL SUPERVISION NOW?
INSTITUTED

YES
NO
6. DATE DIABETES FIRST DIAGNOSED 7. NAME OF PHYSICIAN DIAGNOSING DIABETES
(Month and year)

8. ADDRESS OF PHYSICIAN (City and State)

9. DRUGS AND/OR DIET USED IN TREATMENT

10. IS TREATMENT REGIME STRICTLY FOLLOWED?
YES

NO

11. DETAILS REGARDING HEIGHT OF BLOOD SUGAR BEFORE AND DURING TREATMENT
12. HAS APPLICANT EVER HAD HISTORY OF DIABETIC COMA?
YES

NO

(If "Yes," give dates)

ITEM

YES NO

INFECTIONS (Bolts, etc.)

ITEM
HIGH BLOOD

EYE TROUBLE
HEART TROUBLE
17. RESULTS OF CURRENT EKG

13. HAS APPLICANT EVER HAD HISTORY OF INSULIN SHOCK?
YES
NO
(If "Yes," give dates)
15A. NUMBER OF TIMES
16A. IS URINE SUGAR FREE?
APPLICANT VISITED YOU
YES
NO
YES NO
NOW?
IN PAST YEAR
YES
NO
ALWAYS?
15B. DATE OF LAST VISIT
16B. DATE OF LAST TEST

KIDNEY TROUBLE

18. REPORT OF CURRENT CHEST X-RAY

19. RESULTS OF CURRENT GLUCOSE TOLERANCE TEST
DATE

BLOOD SUGAR

URINE SPEC. GRAVITY

FASTING

MG%

1/2 HOUR

MG%

1 HOUR

MG%

2 HOURS

MG%

URINE ALBUMIN

URINE SUGAR

MICROSCOPIC

20. REPORT OF ANY POST PRANDIAL OR OTHER BLOOD SUGAR TESTS
21. NAME OF EXAMINING PHYSICIAN (Type or print)

22. DATE EXAMINED

24. SIGNATURE OF PHYSICIAN (Do no print)

25. ADDRESS OF PHYSICIAN (City, county, State and ZIP Code)

VA FORM
MAR 2002

29-8160

SUPERSEDES VA FORM 29-8160, MAY 1989,
WHICH WILL NOT BE USED.

23. STATE IN WHICH LICENSED TO
PRACTICE