VA Form 21-0960A-4 Non-Ischemic Heart Disease (Including Arrhythmias and Su

OMB Approved No. 2900-XXXX
Respondent Burden: 30 minutes

NON-ISCHEMIC HEART DISEASE (INCLUDING ARRHYTHMIAS AND SURGERY)
DISABILITY BENEFITS QUESTIONNAIRE
NOTE - For coronary artery disease, myocardial infarction, or hypertensive disease, complete VA Form 21-0960A-1, Ischemic Heart Disease 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 NOW HAVE A NON-ISCHEMIC HEART DISEASE, ARRHYTHMIA, OR UNDERGONE CARDIAC SURGERY?
YES

NO

(If "No," complete Item 1B)

(If "Yes," complete Item 1C)

1B. PROVIDE RATIONALE (e.g., veteran does not currently have any known heart condition(s)):

1C. Provide only diagnoses that pertain to cardiac conditions:
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 CARDIAC CONDITIONS, LIST USING ABOVE FORMAT

SECTION II - MEDICAL HISTORY
2A. DOES THE VETERAN HAVE HEART DISEASE?
YES

NO

(If, "Yes," check all that apply):
Diseases of the heart (check all that apply)
Valvular heart disease

Rheumatic heart disease

Endocarditis

(If, checked, is there active infection with valvular heart damage?)
YES

NO

(If, "Yes," is the veteran currently undergoing therapy (treatment) for heart valve infection?)
YES

NO

(If, "No," provide date therapy ceased):
(If, therapy ceased more than 3 months ago, is there any residual valvular heart disease?)
YES

NO

2B. DOES THE VETERAN HAVE ANY OF THE FOLLOWING CONDITIONS?
Pericarditis

Pericardial adhesions

(If, checked, is there active disease with pericardial involvement?) (Does this CFR category include inflammatory pericarditis?)
YES

NO

(If, "Yes," is the veteran currently undergoing therapy?)
YES

NO

(If, "No," provide date therapy ceased):
Syphilitic heart disease (Note - If syphilitic aortic aneurysm is present, complete VA Form 21-0960A-2, Artery and
Vein Conditions Disability Benefits Questionnaire)
2C. DESCRIBE CAUSE/ONSET OF THE VETERAN'S HEART CONDITION (brief summary):

VA FORM
JAN 2011

21-0960A-4

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SECTION II - MEDICAL HISTORY (Continued)
2D. DOES THE VETERAN HAVE A CARDIAC ARRHYTHMIA?
YES

NO

(If, "Yes," check all that apply):
Atrioventricular block (II and III degree)

ICD CODE :

DATE OF DIAGNOSIS:

Hyperthyroid heart disease

ICD CODE :

DATE OF DIAGNOSIS:

Supraventricular arrhythmias

ICD CODE :

DATE OF DIAGNOSIS:

Ventricular arrhythmias (sustained)

ICD CODE :

DATE OF DIAGNOSIS:

(If, checked, has the veteran been admitted to a hospital?)
YES

NO

(If, "Yes," provide date of most recent admission):
Other cardiac arrhythmias (specify diagnoses):

DATE OF DIAGNOSIS:

ICD CODE :

2E. HAS THE VETERAN UNDERGONE CARDIAC SURGERY(IES)?
YES

NO

(If, "Yes," check all that apply):
Heart valve replacement (prosthesis)

ICD CODE :

DATE OF SURGERY:

Coronary bypass surgery

ICD CODE :

DATE OF SURGERY:

Implantable cardiac pacemakers

ICD CODE :

DATE OF SURGERY:

Transplant, cardiac

ICD CODE :

DATE OF SURGERY:

Other cardiac surgery(ies) (specify):

ICD CODE :

DATE OF SURGERY:

SECTION III - MEDICAL HISTORY TREATMENT
3A. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING CONTINUOUS MEDICATION FOR THE DIAGNOSED CONDITION?
YES

NO

(If, "Yes," list medications):

3B. IS THERE A HISTORY OF:
Percutaneous coronary intervention (PCI)

YES

NO

Treatment facility/date:

Myocardial infarction

YES

NO

Treatment facility/date:

Coronary bypass surgery

YES

NO

Treatment facility/date:

Heart transplant

YES

NO

Treatment facility/date:

(If, "Yes," what condition(s) resulted in the heart transplant):
implanted cardiac pacemaker

YES

NO

(If, "Yes," what condition(s) resulted in the need for a cardiac pacemaker):
implanted automatic implantable
cardioverter defibrillator (AICD)

YES

NO

(If, "Yes," what condition(s) resulted in the need for a automatic implantable cardioverter):

SECTION IV - CONGESTIVE HEART FAILURE (CHF)
4A. DOES THE VETERAN HAVE CHF?
YES

NO

4B. IS THE VETERAN'S CHF CHRONIC?
YES

NO

4C. IF THE VETERAN'S CHF IS NOT CHRONIC, HAS THE VETERAN HAD MORE THAN ONE EPISODE OF ACUTE CHF IN THE PAST YEAR?
YES

NO

(If, "Yes," provide the treatment facility and date of the most recent episode of CHF):

VA FORM 21-0960A-4, JAN 2011

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SECTION V - CARDIAC FUNCTIONAL ASSESSMENT
5A. HAS A DIAGNOSTIC EXERCISE TEST BEEN CONDUCTED?
YES

NO

(If "Yes," provide level of METs the veteran can perform as shown by the most recent diagnostic exercise testing):
(Date of most recent diagnostic exercise test):
(If "No," complete Item 5B)
5B. COMPLETE THE FOLLOWING METs TEST BASED ON THE VETERAN'S RESPONSES:

(Lowest level of activity at which the veteran reports symptoms (check all symptoms that apply)):
Dyspnea

Angina

Fatigue

Dizziness

Syncope

(1-3 METs)

This METs level has been found to be consistent with activities such as eating, dressing,
taking a shower, slow walking (2 mph) for 1-2 blocks

(>3-5 METs)

This METs level has been found to be consistent with activities such as light yard work (weeding),
mowing lawn (power mower), brisk walking (4 mph)

(>5-7 METs)

This METs level has been found to be consistent with activities such as walking 1 flight of stairs,
golfing (without cart), mowing lawn (push mower), heavy yard work (digging)

(>7-10 METs)

This METs level has been found to be consistent with activities such as climbing stairs quickly,
moderate bicycling, sawing wood, jogging (6 mph)

The veteran denies experiencing above symptoms with any level of physical activity

SECTION VI - DIAGNOSTIC TESTING
NOTE - Determination of cardiac hypertrophy/dilatation is required; the suggested order of testing for cardiac hypertrophy/dilatation is EKG, then chest x-ray (PA and
lateral), then echocardiogram. Echocardiogram is only necessary if the other two tests are negative. A limited echocardiogram, if available is appropriate to determine if
cardiac hypertrophy/dilatation is present by measuring only left ventricular dimension, wall thickness and ejection fraction.
6A. IS THERE EVIDENCE OF CARDIAC HYPERTROPHY OR DILATATION?
YES

NO

6B. DIAGNOSTIC TEST (provide most recent test only):
EKG

Date of EKG:

Chest x-ray

Date of CXR:

Echocardiogram

Date of echocardiogram:

Holter monitor?
YES

NO

Other study (specify):
LEFT VENTRICULAR EJECTION FRACTION (LVEF), if known:

Date:
%

Date of test:

6C. IS ATRIAL FIBRILLATION PRESENT?
NO

YES

(If "Yes," check all that apply)
Is it paroxysmal atrial fibrillation or other supraventricular tachycardia?
YES

NO

Is it permanent atrial fibrillation?
YES

NO

Is the frequency more than 4 episodes per year?
YES

NO

Is the frequency 4 or less episodes per year?
YES

NO

Has the frequency been documented by a Holter monitor?
YES

NO

Has the frequency been documented by a electrocardiogram?
YES

NO

VA FORM 21-0960A-4, JAN 2011

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SECTION VII - FUNCTIONAL IMPACT AND REMARKS
7. DOES THE VETERAN'S HEART DISEASE IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

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

8. REMARKS (If any)

SECTION VIII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
9A. PHYSICIAN'S SIGNATURE

9D. PHYSICIAN'S PHONE NUMBER

9B. PHYSICIAN'S PRINTED NAME

9E. PHYSICIAN'S MEDICAL LICENSE NUMBER

9C. DATE SIGNED

9F. 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 30 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-4, JAN 2011

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