VA Form 21-0960A-2 Artery and Vein Conditions (Vascular Diseases including

OMB Approved No. 2900-0776
Respondent Burden: 30 minutes

ARTERY AND VEIN CONDITIONS (VASCULAR DISEASES INCLUDING VARICOSE VEINS)
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 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 NOW HAVE VASCULAR DISEASE(S) (ARTERIAL OR VENOUS)?
YES

NO

(If "Yes," complete Item 1B)

1B. Provide only diagnoses that pertain to vascular condition(s):
DIAGNOSIS # 1 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 2 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 3 -

ICD CODE -

DATE OF DIAGNOSIS -

1C. IF ADDITIONAL DIAGNOSES THAT PERTAIN TO VASCULAR DISEASES, LIST USING ABOVE FORMAT

SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE CAUSE/ONSET OF THE VETERAN'S CURRENT VASCULAR CONDITION(S) (Provide a brief summary)

2B. TYPE OF VASCULAR DISEASE CONDITION (Check all that apply and then complete the corresponding Section(s) III-VIII)
Section III: Varicose veins and/or post-phlebitic syndrome
Section IV: Peripheral vascular disease, aneurysm of any large artery (other than aorta),
arteriosclerosis obliterans or thrombo-angitis obliterans (Buerger's Disease)
Section V: Aortic aneurysm
Section VI: Aneurysm of a small artery
Section VII: Raynaud's syndrome
Section VIII: Arteriovenous (AV) fistula, angioneurotic edema or erythromelalgia

SECTION III - VARICOSE VEINS AND/OR POST- PHLEBITIC SYNDROME
3A. DOES THE VETERAN HAVE VARICOSE VEINS OR POST-PHLEBITIC SYNDROME OF ANY ETIOLOGY?
YES

NO

(If "Yes," complete Items 3B and 3C)

3B. CHECK ALL SYMPTOMS THAT APPLY AND INDICATE EXTREMITY AFFECTED:
Asymptomatic palpable varicose veins

Right

Left

Both

Asymptomatic visible varicose veins

Right

Left

Both

Aching and fatigue in leg after prolonged standing or walking

Right

Left

Both

Symptoms relieved by elevation of extremity

Right

Left

Both

Symptoms relieved by compression hosiery

Right

Left

Both

3C. CHECK ALL SYMPTOMS THAT APPLY AND INDICATE EXTREMITY AFFECTED:
Incipient stasis pigmentation or eczema

Right

Left

Persistent stasis pigmentation or eczema

Right

Left

Both

Intermittent ulceration

Right

Left

Both

Intermittent edema of extremity

Right

Left

Both

Persistent edema that is incompletely
relieved by elevation of extremity

Right

Left

Both

Persistent edema

Right

Left

Both

Persistent subcutaneous induration

Right

Left

Both

Massive board-like edema

Right

Left

Both

Constant pain at rest

Right

Left

Both

VA FORM
JAN 2011

21-0960A-2

Both

Page 1

SECTION IV - PERIPHERAL VASCULAR DISEASE, ANEURYSM OF ANY LARGE ARTERY (OTHER THAN AORTA) ARTERIOSCLEROSIS
OBLITERANS OR THROMBO-ANGIITIS OBLITERANS (BUERGER'S DISEASE)
4A. HAS THE VETERAN BEEN DIAGNOSED WITH PERIPHERAL VASCULAR DISEASE, ANEURYSM OF ANY LARGE ARTERY (OTHER THAN AORTA)
ARTERIOSCLEROSIS OBLITERANS OR THROMBO-ANGIITIS OBLITERANS (BUERGER'S DISEASE)?
YES

NO

(If "Yes," complete Items 4B through 4D)

4B. HAS THE VETERAN UNDERGONE SURGERY FOR ANY OF THESE LISTED CONDITIONS?
YES

NO

(If "Yes," list type of surgery:

Date of surgery:

)

4C. HAS THE VETERAN UNDERGONE ANY PROCEDURE (OTHER THAN SURGERY) FOR REVASCULARIZATION?
YES

NO

(If "Yes," list type of procedure:

Date of procedure:

)

4D. INDICATE SEVERITY OF CURRENT SIGNS AND SYMPTOMS AND INDICATE EXTREMITY AFFECTED: (Check all that apply)
Claudication on walking more than 100 yards

Right

Left

Both

Claudication on walking between 25 and 100 yards on a level grade at 2 miles per hour

Right

Left

Both

Claudication on walking less than 25 yards on a level grade at 2 miles per hour

Right

Left

Both

Persistent coldness of the extremity

Right

Left

Both

Diminished peripheral pulses

Right

Left

Both

Ischemic limb pain at rest

Right

Left

Trophic changes (thin skin, absence of hair, dystrophic nails)
1 or more deep ischemic ulcers

Right

Right

Both
Left

Left

Both
Both

SECTION V - AORTIC ANEURYSM
5A. HAS THE VETERAN EVER BEEN DIAGNOSED WITH AN AORTIC ANEURYSM?
YES

NO

(If "Yes," complete Item 5B)

5B. HAS THE VETERAN HAD A SURGICAL PROCEDURE FOR AN AORTIC ANEURYSM?
YES

NO

Date of surgery:

(If "Yes," indicate type of surgery:

)

5C. DOES THE VETERAN CURRENTLY HAVE AN AORTIC ANEURYSM?
YES

NO

(If "Yes," indicate severity)
5 centimeters or larger in diameter
Symptomatic
Precludes exertion

6. REMARKS (If any)

SECTION VII - 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 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-2, JAN 2011

Page 2