VA Form 21-0960G-7 Stomach and Duodenal Conditions (Not including GERD or E

OMB Control No. 2900-0778
Respondent Burden: 15 minutes

STOMACH AND DUODENAL CONDITIONS (NOT INCLUDING GERD OR
ESOPHAGEAL DISORDERS) 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 NOW HAVE OR HAS HE/SHE EVER HAD ANY STOMACH OR DUODENUM CONDITIONS?
YES

NO

1B. IF YES, SELECT THE VETERAN'S CONDITION (check all that apply):
GASTRIC ULCER

ICD code:

Date of diagnosis:

DUODENAL ULCER

ICD code:

Date of diagnosis:

STENOSIS OF THE STOMACH

ICD code:

Date of diagnosis:

MARGINAL (GASTROJEJUNAL) ULCER

ICD code:

Date of diagnosis:

HYPERTROPHIC GASTRITIS

ICD code:

Date of diagnosis:

POSTGASTRECTOMY SYNDROME

ICD code:

Date of diagnosis:

STATUS POST VAGOTOMY WITH PYLOROPLASTY

ICD code:

Date of diagnosis:

GASTROENTEROSTOMY
PERITONEAL ADHESIONS FOLLOWING INJURY OR
SURGERY OF THE STOMACH

ICD code:

Date of diagnosis:

ICD code:

Date of diagnosis:

HELICOBACTER PYLORI

ICD code:

Date of diagnosis:

OTHER STOMACH OR DUODENAL CONDITIONS
Other diagnosis #1:

ICD code:

Date of diagnosis:

Other diagnosis #2:

ICD code:

Date of diagnosis:

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO STOMACH OR DUODENAL CONDITIONS, LIST USING ABOVE FORMAT:

NOTE: The diagnosis of gastric or duodenal ulcer or stenosis can be made by upper gastrointestinal imaging series or endoscopy. The diagnosis of gastritis requires
endoscopic confirmation. If testing is of record and is consistent with Veteran's current condition, repeat testing is not required.
SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S STOMACH OR DUODENUM CONDITIONS (brief summary):

2B. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING CONTINUOUS MEDICATION FOR THE DIAGNOSED CONDITION?
YES

NO

IF YES, LIST ONLY THOSE MEDICATIONS USED FOR THE DIAGNOSED CONDITION:

VA FORM
FEB 2011

21-0960G-7

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SECTION III - SIGNS AND SYMPTOMS
3A. DOES THE VETERAN HAVE ANY OF THE FOLLOWING SIGNS OR SYMPTOMS DUE TO ANY STOMACH OR DUODENUM CONDITIONS?
YES

NO

IF YES, (check all that apply):
Recurring episodes of symptoms that are not severe
If checked, indicate frequency of episodes of symptom recurrence per year:
0

2

1

3

4 or more

If checked, indicate average duration of episodes of symptoms:
Less than 1 day

1-9 days

10 days or more

Recurring episodes of severe symptoms
If checked, indicate frequency of episodes of symptom recurrence per year:
0

1

2

3

4 or more

If checked, indicate average duration of episodes of symptoms:
Less than 1 day

1-9 days

10 days or more

Abdominal Pain
If checked, indicate severity and frequency (check all that apply):
Occurs less than monthly
Occurs at least monthly
Pronounced
Periodic
Continuous
Relieved by standard ulcer therapy
Only partially relieved by standard ulcer therapy
Unrelieved by standard ulcer therapy
Anemia
If checked, provide hemoglobin/hematocrit in diagnostic testing section.
Weight loss
If checked, provide baseline weight:

and current weight:

(For VA purposes, baseline weight is the average weight for 2-year period preceding onset of disease).
Nausea
If checked, indicate severity:
Mild

Transient

Recurrent

Periodic

If checked, indicate frequency of episodes of nausea per year:
0

1

2

3

4 or more

If checked, indicate average duration of episodes of nausea:
Less than 1 day

1-9 days

10 days or more

Vomiting
If checked, indicate severity:
Mild

Transient

Recurrent

Periodic

If checked, indicate frequency of episodes of vomiting per year:
0

1

2

3

4 or more

If checked, indicate average duration of episodes of vomiting:
Less than 1 day

1-9 days

10 days or more

Hematemesis
If checked, indicate severity:
Mild

Transient

Recurrent

Periodic

If checked, indicate frequency of episodes of hematemesis per year:
0

1

2

3

4 or more

If checked, indicate average duration of episodes of hematemesis:
Less than 1 day

1-9 days

10 days or more

Melena
If checked, indicate severity:
Mild

Transient

Recurrent

Periodic

If checked, indicate frequency of episodes of melena per year:
0

1

2

3

4 or more

If checked, indicate average duration of episodes of melena:
Less than 1 day
VA FORM 21-0960G-7, FEB 2011

1-9 days

10 days or more

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SECTION IV - INCAPACITATING EPISODES
4A. DOES THE VETERAN HAVE INCAPACITATING EPISODES DUE TO SIGNS OR SYMPTOMS OF ANY STOMACH OR DUODENUM CONDITION?
NO

YES

IF YES, DESCRIBE INCAPACITATING EPISODES:
Indicate frequency of incapacitating episodes per year:
0

1

2

3

4 or more

Indicate average duration of incapacitating episodes:
Less than 1 day

1-9 days

10 days or more

SECTION V - OTHER CONDITIONS
5A. DOES THE VETERAN HAVE ANY OF THE FOLLOWING CONDITIONS?
YES

NO

IF YES, INDICATE CONDITIONS AND COMPLETE APPROPRIATE SECTIONS (check all that apply):
Hypertrophic gastritis
If checked, indicate severity:
No symptoms or findings
Chronic, with small nodular lesions, and symptoms
Chronic, with multiple small eroded or ulcerated areas, and symptoms
Chronic, with severe hemorrhages, or large ulcerated or eroded areas
NOTE: If atrophic gastritis is present, state the underlying cause:
Postgastrectomy syndrome
If checked, indicate severity:
No symptoms or findings
Mild; infrequent episodes of epigastric distress with characteristic mild circulatory symptoms after
meals but with diarrhea and weight loss
Moderate; less frequent episodes of epigastric disorders with characteristic mild circulatory
symptoms after meals but with diarrhea and weight loss
Severe; associated with nausea, sweating, circulatory disturbance after meals, diarrhea,
hypoglycemic symptoms, and weight loss with malnutrition and anemia
Vagotomy with pyloroplasty or gastroenterostomy
If checked, indicate the severity of residuals following vagotomy with pyloroplasty or gastroenterostomy:
No symptoms or findings
Recurrent ulcer with incomplete vagotomy
Symptoms and confirmed diagnosis of alkaline gastritis, or of confirmed persisting diarrhea
Demonstrably confirmative postoperative complications of stricture or continuing gastric retention
Peritoneal adhesions following an injury or surgical procedure of the stomach or duodenum
If checked, ALSO complete the VA Form 21-0960G-6, Peritoneal Adhesions Disability Benefits Questionnaire.

SECTION VI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
6A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS OR TO THE
TREATMENT OF ANY CONDITIONS LISTED IN THE DIAGNOSIS SECTION ABOVE?
YES

NO

(IF YES, ARE ANY OF THE SCARS PAINFUL AND/OR UNSTABLE, OR IS THE TOTAL AREA OF ALL RELATED SCARS GREATER THAN 39 SQUARE CM (6 square
inches)?
YES

NO

(If "Yes," ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)
6A. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN THE DIAGNOSIS SECTION ABOVE?
YES

NO

IF YES, DESCRIBE (brief summary):

VA FORM 21-0960G-7, FEB 2011

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SECTION VII - DIAGNOSTIC TESTING
NOTE: If testing has been performed and reflects Veteran's current condition, no further testing is required for this examination report.
The diagnosis of gastric or duodenal ulcer or stenosis can be made by upper gastrointestinal imaging series or endoscopy.
7A. HAVE DIAGNOSTIC IMAGING STUDIES OR OTHER DIAGNOSTIC PROCEDURES BEEN PERFORMED?
YES

NO

IF YES, CHECK ALL THAT APPLY:
Upper endoscopy

Date:

Results:

Upper GI radiographic studies

Date:

Results:

MRI

Date:

Results:

CT

Date:

Results:

Biopsy, specify site:

Date:

Results:

Other, specify:

Date:

Results:

7B. HAS LABORATORY TESTING BEEN PERFORMED?
YES

NO

IF YES, CHECK ALL THAT APPLY:
CBC

Date of test:

Hemoglobin:

Hematocrit:

Helicobacter pylori

Date of test:

Other, specify:

Results:
White blood cell count:

Platelets:

Results:
Date of test:

Results:

7C. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
YES

NO

IF YES, PROVIDE TYPE OF TEST OR PROCEDURE, DATE AND RESULTS (brief summary):

SECTION VIII - FUNCTIONAL IMPACT
8. DO ANY OF THE VETERAN'S STOMACH OR DUODENUM CONDITIONS IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

IF YES, DESCRIBE IMPACT OF EACH OF THE VETERAN'S STOMACH OR DUODENUM CONDITIONS, PROVIDING ONE OR MORE EXAMPLES:

VA FORM 21-0960G-7, FEB 2011

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SECTION IX - REMARKS
9. REMARKS (If any)

SECTION X - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
10A. PHYSICIAN'S SIGNATURE

10B. PHYSICIAN'S PRINTED NAME

10D. PHYSICIAN'S PHONE AND FAX NUMBER 10E. PHYSICIAN'S MEDICAL LICENSE NUMBER

10C. DATE SIGNED

10F. 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, 58VA21/22/28, 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 a 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 21-0960G-7, FEB 2011

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