VA Form 21-0960J-3 Prostate Cancer Disability Benefits Questionnaire

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

PROSTATE CANCER 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
ON REVERSE BEFORE COMPLETING 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 use the information you provide
on this questionnaire to process the Veteran's claim.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER BEEN DIAGNOSED WITH PROSTATE CANCER?
YES

(If "No," complete Item 1B) (If "Yes," complete Item 1C)

NO

1B. PROVIDE RATIONALE
1C. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO PROSTATE CANCER
DIAGNOSIS # 1 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 2 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 3 -

ICD CODE -

DATE OF DIAGNOSIS -

1D. IF ADDITIONAL DIAGNOSES THAT PERTAIN TO PROSTATE CANCER, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY
2. INDICATE STATUS OF THE DISEASE
ACTIVE

REMISSION

SECTION III - TREATMENT FOR PROSTATE CANCER
3. HAS THE VETERAN COMPLETED ANY TYPE OF TREATMENT FOR PROSTATE CANCER OR IS THE VETERAN CURRENTLY UNDERGOING ANY
TYPE OF TREATMENT FOR PROSTATE CANCER (INCLUDING WATCHFUL WAITING)?
YES

(If "Yes," specify treatment type)

NO

NO TREATMENT OTHER THAN WATCHFUL WAITING
SURGERY
PROSTATECTOMY
(DATE OF SURGERY):

OTHER SURGICAL PROCEDURE (DESCRIBE):

RADIATION THERAPY (DATE OF COMPLETION OF TREATMENT OR ANTICIPATED DATE OF COMPLETION):
BRACHYTHERAPY (DATE OF TREATMENT):
ANTINEOPLASTIC CHEMOTHERAPY (DATES OF MOST RECENT TREATMENT):
ANDROGEN DEPRIVATION THERAPY (HORMONAL THERAPY) (DATES OF MOST RECENT TREATMENT):
OTHER THERAPEUTIC PROCEDURE AND/OR TREATMENT (DESCRIBE):
(DATE OF PROCEDURE):
(DATE OF COMPLETION OF TREATMENT OR ANTICIPATED DATE OF COMPLETION):

SECTION IV - RESIDUALS
4. DOES THE VETERAN HAVE ANY RESIDUALS DUE TO PROSTATE CANCER OR TREATMENT FOR PROSTATE CANCER?
YES

NO

(If "Yes," complete the following Items 4A through 4G)

A. VOIDING DYSFUNCTION/INCONTINENCE
DOES THE VETERAN HAVE VOIDING DYSFUNCTION SECONDARY TO TREATMENT FOR PROSTATE CANCER (Continual urine leakage post-surgical urinary

diversion, urinary incontinence or stress incontinence)?
YES

NO

(If "Yes," indicate veteran's use of absorbent material)

ABSORBENT MATERIAL NOT NECESSARY
ABSORBENT MATERIAL CHANGED LESS THAN 2 TIMES PER DAY
ABSORBENT MATERIAL CHANGED 2 TO 4 TIMES PER DAY
ABSORBENT MATERIAL CHANGED MORE THAN 4 TIMES PER DAY
Is the use of an appliance required?
YES
VA FORM
DEC 2010

NO

21-0960J-3

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SECTION IV - RESIDUALS (Continued)
B. URINARY FREQUENCY

DOES THE VETERAN HAVE URINARY FREQUENCY?
YES
NO (If "Yes," indicate daytime and nighttime voiding intervals)
DAYTIME VOIDING INTERVALS:
DAYTIME VOIDING INTERVAL GREATER THAN 3 HOURS

NIGHTTIME VOIDING INTERVALS:
NIGHTTIME AWAKENING TO VOID LESS THAN 2 TIMES

DAYTIME VOIDING INTERVAL BETWEEN 2 AND 3 HOURS

NIGHTTIME AWAKENING TO VOID 2 TIMES

DAYTIME VOIDING INTERVAL BETWEEN 1 AND 2 HOURS

NIGHTTIME AWAKENING TO VOID 3 TO 4 TIMES

DAYTIME VOIDING INTERVAL LESS THAN 1 HOUR

NIGHTTIME AWAKENING TO VOID 5 OR MORE TIMES

C. OBSTRUCTED VOIDING
DOES THE VETERAN HAVE OBSTRUCTED VOIDING?
YES
NO (If "Yes," check all that apply)
OBSTRUCTIVE SYMPTOMATOLOGY WITH OR WITHOUT
STRICTUREDISEASE REQUIRING DILATATION 1 TO 2 TIMES
PER YEAR
MARKED OBSTRUCTIVE SYMPTOMATOLOGY
MARKED HESITANCY

POST VOID RESIDUALS GREATER THAN 150cc
MARKEDLY DIMINISHED PEAK FLOW RATE ON UROFLOWMETRY (less than 10cc/sec)
RECURRENT URINARY TRACT INFECTIONS SECONDARY TO OBSTRUCTION
STRICTURE DISEASE REQUIRING PERIODIC DILATATION EVERY 2 TO 3 MONTHS
URINARY RETENTION REQUIRING INTERMITTENT OR CONTINUOUS
CATHETERIZATION

MARKEDLY SLOW OR WEAK STREAM
MARKEDLY DECREASED FORCE OF STREAM

D. URINARY TRACT INFECTIONS
DOES THE VETERAN HAVE A HISTORY OF URINARY TRACT INFECTIONS?
YES

(If "Yes," does the veteran have a history of recurrent symptomatic infections requiring any of the following?) (Check all that apply)

NO

NONE

LONG-TERM DRUG THERAPY

DRAINAGE

1-2 HOSPITALIZATIONS PER YEAR

FREQUENT HOSPITALIZATION (greater than 2 times per year)

INTERMITTENT INTENSIVE MANAGEMENT

CONTINUOUS INTENSIVE MANAGEMENT

E. ERECTILE DYSFUNCTION
DOES THE VETERAN HAVE ERECTILE DYSFUNCTION?
YES

NO

(If "Yes," is the erectile dysfunction as likely as not (at least a 51% probability)
NO (If "No," provide the etiology of the erectile dysfunction):
YES
attributable to prostate cancer (including treatment or residuals)?
(If "Yes," is the veteran able to achieve an erection (without the use of medication) sufficient for penetration and ejaculation)
YES
NO

F. RENAL DYSFUNCTION
DOES THE VETERAN HAVE RENAL DYSFUNCTION ATTRIBUTABLE TO PROSTATE CANCER OR TREATMENT FOR PROSTATE CANCER?
YES

NO

(If "Yes," complete Genitourinary/Renal Dysfunction Questionnaire)

G. OTHER COMPLICATIONS

DOES THE VETERAN HAVE ANY OTHER RESIDUAL COMPLICATIONS?
YES

NO

(If "Yes," describe):
SECTION V - FUNCTIONAL IMPACT AND REMARKS

5. DOES THE VETERAN'S PROSTATE CANCER IMPACT HIS ABILITY TO WORK?
YES

NO

(If "Yes," describe impact, providing one or more examples)

6. REMARKS (If any)

SECTION V - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
7A. PHYSICIAN'S SIGNATURE
7D. PHYSICIAN'S PHONE NUMBER

7B. PHYSICIAN'S PRINTED NAME
7E. PHYSICIAN'S MEDICAL LICENSE NUMBER

7C. DATE SIGNED
7F. PHYSICIAN'S ADDRESS

NOTE - VA may obtain additional medical information, including an examination, 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 DEC 2010, 21-0960J-3

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