VA Form 21-0960A-3 Hypertension DBQ

Disability Benefits Questionnaires - Group 2

21-0960A-3

DBQs

OMB: 2900-0776

Document [pdf]
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OMB Approved No. 2900-XXXX
Respondent Burden: 15 minutes

HYPERTENSION 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 consider the information you
provide on this questionnaire as part of their evaluation in processing the Veteran's claim.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN HAVE A DIAGNOSIS OF HYPERTENSION?
YES

NO

(If "No," complete Item 1B)

(If "Yes," complete Item 1C)

1B. PROVIDE RATIONALE

NOTE: For VA disability rating purposes, the term hypertension means that the diastolic blood pressure is predominantly 90mm or greater, and isolated systolic
hypertension means that the systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm.
1C. Provide only diagnoses that pertain to hypertension:
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 HYPERTENSION LIST USING ABOVE FORMAT

SECTION II - MEDICAL HISTORY
2A. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING CONTINUOUS MEDICATION FOR HYPERTENSION?
YES

NO

2B. LIST MEDICATIONS PRESCRIBED FOR HYPERTENSION:

2C. WAS THE VETERAN'S INITIAL DIAGNOSIS OF HYPERTENSION OR ISOLATED SYSTOLIC HYPERTENSION CONFIRMED BY READINGS TAKEN 2 OR MORE
TIMES ON AT LEAST 3 DIFFERENT DAYS?
YES

NO

UNKNOWN

(If, "Yes," complete Item 2D)

2D. PROVIDE ANY BLOOD PRESSURE READINGS USED TO CONFIRM INITIAL DIAGNOSIS, IF KNOWN:
READING # 1:

READING # 2:

DATE OF READING:

READING # 1:

READING # 2:

DATE OF READING:

READING # 1:

READING # 2:

DATE OF READING:

2E. DOES THE VETERAN HAVE A HISTORY OF A DIASTOLIC PRESSURE PREDOMINANTLY 100 OR MORE?
YES

NO

2F. DOES THE VETERAN CURRENTLY HAVE DIASTOLIC PRESSURE PREDOMINANTLY 100 OR MORE, OR SYSTOLIC PRESSURE PREDOMINANTLY 160 OR MORE?
NO

YES

2G. CURRENT BLOOD PRESSURE READINGS
READING # 1:

READING # 2:

DATE OF READING:

READING # 1:

READING # 2:

DATE OF READING:

READING # 1:

READING # 2:

DATE OF READING:

VA FORM
JAN 2011

21-0960A-3

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SECTION III - FUNCTIONAL IMPACT AND REMARKS
3. DOES THE VETERAN'S HYPERTENSION IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

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

4. REMARKS (If any)

SECTION IV - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
5A. PHYSICIAN'S SIGNATURE

5D. PHYSICIAN'S PHONE NUMBER

5B. PHYSICIAN'S PRINTED NAME

5E. PHYSICIAN'S MEDICAL LICENSE NUMBER

5C. DATE SIGNED

5F. 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 21-0960A-3, JAN 2011

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File Typeapplication/pdf
File TitleVA Form 21-0960A-4
SubjectHypertension - Disability Benefits Questionnaire
AuthorN. Kessinger
File Modified2011-02-24
File Created2011-02-24

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