VA Form 21-0960-G- ESOPHAGEAL CONDITIONS (Including gastroesophageal reflux

OMB Control No. 2900-0778
Respondent Burden: 15 Minutes
Expiration Date: XX/XX/XXXX

ESOPHAGEAL CONDITIONS (Including gastroesophageal reflux disease (GERD),
hiatal hernia and other 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 THIS 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. VA reserves the right to confirm the authenticity of ALL DBQs completed by
private health care providers.
SECTION I - DIAGNOSIS
NOTE: The diagnosis of gastroesophageal reflux disease (GERD) can be made clinically by evidence of relief of typical symptoms of reflux, epigastric discomfort and/or burning, by treatment
with proton pump inhibitors, histamine 2 receptor antagonists and/or antacids. If upper endoscopy was indicated or performed, the findings of erythema, ulcers and/or strictures are consistent
with the diagnosis of GERD.
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH AN ESOPHAGEAL CONDITION?
YES
NO (If "Yes," complete Item 1B)
NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed below. If there is no diagnosis, if the diagnosis is different
from a previous diagnosis for this condition, or if there is a diagnosis of a complication due to the claimed condition, explain your findings and reasons in the Remarks
section. Date of diagnosis can be the date of the evaluation if the clinician is making the initial diagnosis, or an approximate date is determined through record review or
reported history.
1B. DIAGNOSIS (Check all that apply)
DATE OF DIAGNOSIS:

GERD

ICD CODE:

HIATAL HERNIA

ICD CODE:

DATE OF DIAGNOSIS:

ESOPHAGEAL STRICTURE

ICD CODE:

DATE OF DIAGNOSIS:

ESOPHAGEAL SPASM

ICD CODE:

DATE OF DIAGNOSIS:

ESOPHAGEAL DIVERTICULUM

ICD CODE:

DATE OF DIAGNOSIS:

OTHER DIAGNOSIS #1:

ICD CODE:

DATE OF DIAGNOSIS:

OTHER DIAGNOSIS #2:

ICD CODE:

DATE OF DIAGNOSIS:

OTHER ESOPHAGEAL CONDITION(S), specify:

(such as eosinophilic esophagitis, Barrett's
esophagitis, etc.)

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO ESOPHAGEAL DISORDERS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY

2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S ESOPHAGEAL 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):

SECTION III - SIGNS AND SYMPTOMS

3. DOES THE VETERAN HAVE ANY OF THE FOLLOWING SIGNS OR SYMPTOMS DUE TO ANY ESOPHAGEAL CONDITIONS (including GERD)?
YES
NO

(If "Yes," check all that apply)
PERSISTENTLY RECURRENT EPIGASTRIC DISTRESS
If checked, indicate frequency of symptom recurrence per year:
4 or more
1
2
3
If checked, indicate average duration of episodes of symptoms:
1-9 days
10 days or more
Less than 1 day
INFREQUENT EPISODES OF EPIGASTRIC DISTRESS
If checked, indicate frequency of symptom recurrence per year:
1
2
3
4 or more
If checked, indicate average duration of episodes of symptoms:
1-9 days
10 days or more
Less than 1 day
DYSPHAGIA
If checked, indicate frequency of symptom recurrence per year:
1
2
3
4 or more
If checked, indicate average duration of episodes of symptoms:
1-9 days
10 days or more
Less than 1 day
PYROSIS (Heartburn)
If checked, indicate frequency of symptom recurrence per year:
4 or more
1
2
3
If checked, indicate average duration of episodes of symptoms:
1-9 days
10 days or more
Less than 1 day
VA FORM
XXX XXXX

21-0960G-1

SUPERSEDES VA FORM 21-0960G-1, OCT 2012,
WHICH WILL NOT BE USED.

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SECTION III - SIGNS AND SYMPTOMS (Continued)
REFLUX
If checked, indicate frequency of symptom recurrence per year:
1

2

3

4 or more

If checked, indicate average duration of episodes of symptoms:
1-9 days

Less than 1 day

10 days or more

REGURGITATION
If checked, indicate frequency of symptom recurrence per year:
1

2

3

4 or more

If checked, indicate average duration of episodes of symptoms:
1-9 days

Less than 1 day

10 days or more

SUBSTERNAL ARM OR SHOULDER PAIN
If checked, indicate frequency of symptom recurrence per year:
1

2

4 or more

3

If checked, indicate average duration of episodes of symptoms:
1-9 days

Less than 1 day

10 days or more

SLEEP DISTURBANCE CAUSE BY ESOPHAGEAL REFLUX
If checked, indicate frequency of symptom recurrence per year:
1

2

4 or more

3

If checked, indicate average duration of episodes of symptoms:
1-9 days

Less than 1 day

10 days or more

ANEMIA
If checked, provide hemoglobin/hematocrit in diagnostic testing section.
WEIGHT LOSS
and current weight:

If checked, provide baseline 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:
1

2

4 or more

3

If checked, indicate average duration of episodes of nausea:
1-9 days

Less than 1 day

10 days or more

VOMITING
If checked, indicate severity:
Mild

Transient

Recurrent

Periodic

If checked, indicate frequency of episodes of vomiting per year:
1

2

3

4 or more

If checked, indicate average duration of episodes of vomiting:
1-9 days

Less than 1 day

10 days or more

HEMATEMESIS
If checked, indicate severity:
Mild

Transient

Recurrent

Periodic

If checked, indicate frequency of episodes of vomiting per year:
1

2

3

4 or more

If checked, indicate average duration of episodes of vomiting:
1-9 days

Less than 1 day

10 days or more

MELENA
If checked, indicate severity:
Mild

Transient

Recurrent

Periodic

If checked, indicate frequency of episodes of vomiting per year:
1

2

3

4 or more

If checked, indicate average duration of episodes of vomiting:
Less than 1 day
VA FORM 21-0960G-1, XXX XXXX

1-9 days

10 days or more

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SECTION IV - ESOPHAGEAL STRICTURE, SPASM AND DIVERTICULA
4. DOES THE VETERAN HAVE AN ESOPHAGEAL STRICTURE, SPASM OF ESOPHAGUS (CARDIOSPASM OR ACHALASIA), OR AN ACQUIRED DIVERTICULUM OF
THE ESOPHAGUS?
YES

NO

If Yes, indicate severity of condition:
ASYMPTOMATIC
NOT AMENABLE TO DILATION
MILD If checked, describe:
MODERATE If checked, describe:
SEVERE, PERMITTING PASSAGE OF LIQUIDS ONLY

If checked, describe:

SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, SIGNS AND/OR SYMPTOMS
5A. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS? IF YES, DESCRIBE
(brief summary):

5B. DOES THE VETERAN HAVE ANY SCARS (SURGICAL OR OTHERWISE) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS
LISTED IN THE DIAGNOSIS SECTION?
NO

YES

IF YES, ARE ANY OF THESE SCARS PAINFUL OR UNSTABLE; HAVE A TOTAL AREA EQUAL TO OR GREATER THAN 39 SQUARE CM (6 square inches); OR
ARE LOCATED ON THE HEAD, FACE OR NECK?
YES

NO

IF YES, ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT DISABILITY BENEFITS QUESTIONNAIRE.
IF NO, PROVIDE LOCATION AND MEASURMENTS OF SCAR IN CENTIMETERS
LOCATION:
MEASUREMENTS: Length

cm X width

cm.

NOTE: An "unstable scar" is one where, for any reason, there is frequent loss of covering of the skin over the scar. If there are multiple scars, enter additional locations and measurements
in the Remarks section below. It is not necessary to also complete a Scars DBQ.

SECTION VI - DIAGNOSTIC TESTING

Note: If testing has been performed and reflects veteran's current condition, no further testing is required for this examination report.
6A. 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:

ESOPHAGRAM (barium swallow)
Date:

Results:

MRI
Date:

Results:

CT
Date:

Results:

BIOPSY, SPECIFY SITE:
Date:

Results:

OTHER, SPECIFY:
Date:
VA FORM 21-0960G-1, XXX XXXX

Results:

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SECTION VI - DIAGNOSTIC TESTING (Continued)
6B. HAS LABORATORY TESTING BEEN PERFORMED?
YES

NO

If Yes, check all that apply:
CBC

Date of testing:

Hemoglobin:

Hematocrit:

HELICOBACTER PYLORI

Date of test:

OTHER, SPECIFY:

White blood cell count:

Platelets:

Results:
Date of test:

Results:

6C. 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 VII - FUNCTIONAL IMPACT
7. DO ANY OF THE VETERAN"S ESOPHAGEAL CONDITIONS IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

If Yes, describe impact of each of the veteran's esophageal conditions, providing one ore more examples:

SECTION VIII - REMARKS

8. REMARKS (If any)

SECTION IX - 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 AND FAX 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.benefits.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 voluntary. 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 21-0960G-1, XXX XXXX

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