VA Form 21-0960A-4 Heart Conditions (Including Ischemic and Non-Ischemic He

OMB Approved No. 2900-0776
Respondent Burden: 30 minutes
Expiration Date: XX/XX/XXXX

HEART CONDITIONS (INCLUDING ISCHEMIC AND NON-ISCHEMIC HEART DISEASE,
ARRHYTHMIAS, VALVULAR DISEASE AND CARDIAC 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
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 OR SHE EVER BEEN DIAGNOSED WITH A HEART CONDITION?
YES

NO

(If "Yes," complete Item 1B)

1B. SELECT THE VETERAN'S HEART CONDITION(S) (Check all that apply):
Acute, subacute, or old myocardial infarction

ICD Code:

Date of diagnosis:

Atherosclerotic cardiovascular disease

ICD Code:

Date of diagnosis:

Coronary artery disease

ICD Code:

Date of diagnosis:

Stable angina

ICD Code:

Date of diagnosis:

Unstable angina

ICD Code:

Date of diagnosis:

Coronary spasm, including Prinzmetal's angina

ICD Code:

Date of diagnosis:

Congestive heart failure

ICD Code:

Date of diagnosis:

Supraventricular arrhythmia

ICD Code:

Date of diagnosis:

Ventricular arrhythmia

ICD Code:

Date of diagnosis:

Heart block

ICD Code:

Date of diagnosis:

Valvular heart disease

ICD Code:

Date of diagnosis:

Heart valve replacement

ICD Code:

Date of diagnosis:

Cardiomyopathy

ICD Code:

Date of diagnosis:

Hypertensive heart disease

ICD Code:

Date of diagnosis:

Heart transplant

ICD Code:

Date of diagnosis:

Implanted cardiac pacemaker

ICD Code:

Date of diagnosis:

Implanted automatic implantable cardioverter defibrillator (AICD)

ICD Code:

Date of diagnosis:

Infectious heart conditions (including active valvular infection, rheumatic heart
disease, endocarditis, pericarditis or syphilitic heart disease)
Pericardial adhesions

ICD Code:

Date of diagnosis:

ICD Code:

Date of diagnosis:

Diagnosis #1:

ICD Code:

Date of diagnosis:

Diagnosis #2:

ICD Code:

Date of diagnosis:

Other heart condition, specify below

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

SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S HEART CONDITION(S) (brief summary):

2B. DO ANY OF THE VETERAN'S HEART CONDITIONS QUALIFY WITHIN THE GENERALLY ACCEPTED MEDICAL DEFINITION OF ISCHEMIC HEART DISEASE (IHD)?
YES

VA FORM
MAR 2014

NO

(If "Yes," list the conditions that qualify):

21-0960A-4

SUPERSEDES VA FORM 21-0960A-4, OCT 2012,
WHICH WILL NOT BE USED.

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SECTION II - MEDICAL HISTORY (Continued)
2C. PROVIDE THE ETIOLOGY, IF KNOWN, OF EACH OF THE VETERAN'S HEART CONDITIONS, INCLUDING THE RELATIONSHIP/CAUSALITY TO OTHER HEART
CONDITIONS, PARTICULARLY THE RELATIONSHIP/CAUSALITY TO THE VETERAN'S IHD CONDITIONS, IF ANY:
Heart condition #1 (provide etiology):
Heart condition #2 (provide etiology):
2D. IF THERE ARE ADDITIONAL HEART CONDITIONS, PROVIDE ETIOLOGY AND LIST USING THE ABOVE FORMAT:

2E. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF THE VETERAN'S HEART CONDITION?
YES

NO

(If, "Yes," list medications required for the veteran's heart condition (include name of medication and heart condition it is used for, such as atenolol for myocardial
infarction or atrial fibrillation):

SECTION III - MYOCARDIAL INFARCTION (MI)
3A. HAS THE VETERAN HAD A MYOCARDIAL INFARCTION (MI)?
YES

NO

(If, "Yes," complete the following):

MI #1: Date and treatment facility:
MI #2: Date and treatment facility:
3B. IF THE VETERAN HAS HAD ADDITIONAL MIs, LIST USING ABOVE FORMAT:

SECTION IV - CONGESTIVE HEART FAILURE (CHF)
4A. HAS THE VETERAN HAD CONGESTIVE HEART FAILURE (CHF)?
NO (If "Yes," complete Item 4B)

YES

4B. DOES THE VETERAN HAVE CHRONIC CHF?
YES

NO

4C. HAS THE VETERAN HAD ANY EPISODES OF ACUTE CHF IN THE PAST YEAR?
YES

NO

(If, "Yes," specify the number of episodes of acute CHF the veteran has had in the past year):
0

1

More than 1

Provide date of most recent episode of acute CHF:

4D. WAS THE VETERAN ADMITTED FOR TREATMENT OF ACUTE CHF?
YES

NO

(If, "Yes," indicate name of treatment facility):
SECTION V - ARRHYTHMIA

5A. HAS THE VETERAN HAD A CARDIAC ARRHYTHMIA?
YES

NO

(If "Yes," complete Item 5B)

5B. SELECT TYPE OF ARRHYTHMIA (Check all that apply):
Atrial fibrillation
Constant
Intermittent (paroxysmal)
(If checked, indicate frequency):
0
(If "Intermittent," indicate number of episodes in the past 12 months):
(Indicate how these episodes were documented.) (Check all that apply):

1-4

More than 4

0

1-4

More than 4

Constant
Intermittent (paroxysmal)
(If checked, indicate frequency):
0
(If "Intermittent," indicate number of episodes in the past 12 months):
(Indicate how these episodes were documented.) (Check all that apply):

1-4

More than 4

EKG

Holter

Other, specify:

Atrial flutter

(If checked, indicate frequency):

Constant

Intermittent (paroxysmal)

(If "Intermittent," indicate number of episodes in the past 12 months):
(Indicate how these episodes were documented.) (Check all that apply):
EKG

Holter

Other, specify:

Supraventricular tachycardia

EKG

Holter

Other, specify:

VA FORM 21-0960A-4, MAR 2014

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SECTION V - ARRHYTHMIA (Continued)
5B. SELECT TYPE OF ARRHYTHMIA (Check all that apply) (Continued)
Atrioventricular block
I degree

II degree

III degree

Ventricular arrhythmia (sustained)

(Indicate date of hospital admission for initial evaluation and medical treatment in Section IX, Procedures)
Other cardiac arrhythmia, specify:
Constant
Intermittent (paroxysmal)
(If checked, indicate frequency):
0
(If "Intermittent," indicate number of episodes in the past 12 months):
(Indicate how these episodes were documented.) (Check all that apply):
EKG

Holter

1-4

More than 4

Other, specify:

SECTION VI - HEART VALVE CONDITIONS
6A. HAS THE VETERAN HAD A HEART VALVE CONDITION?
YES

NO

(If "Yes," complete Item 6B)

6B. SELECT HEART VALVES AFFECTED (Check all that apply):
Mitral

Tricuspid

Aortic

Pulmonary

6C. DESCRIBE TYPE OF HEART VALVE CONDITION FOR EACH CHECKED VALVE:

SECTION VII - INFECTIOUS HEART CONDITIONS
7A. HAS THE VETERAN HAD ANY INFECTIOUS CARDIAC CONDITIONS, INCLUDING ACTIVE VALVULAR INFECTION (INCLUDING RHEUMATIC HEART DISEASE),
ENDOCARDITIS, PERICARDITIS OR SYPHILITIC HEART DISEASE?
YES

NO

(If "Yes," complete Item 7B)

7B. HAS THE VETERAN UNDERGONE OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR ANY ACTIVE INFECTION?
YES

NO

(If, "Yes," describe treatment and site of infection being treated):
7C. HAS TREATMENT FOR AN ACTIVE INFECTION BEEN COMPLETED?
YES

NO

(If, "Yes," provide date completed):
7D. HAS THE VETERAN HAD A SYPHILITIC AORTIC ANEURYSM?
YES

NO

(If "Yes," ALSO complete VA Form 21-0960A-2, Artery and Vein Conditions Disability Benefits Questionnaire)
SECTION VIII - PERICARDIAL ADHESIONS

8A. HAS THE VETERAN HAD PERICARDIAL ADHESIONS?
YES

NO

(If "Yes," complete Item 8B)

8B. SELECT ETIOLOGY OF PERICARDIAL ADHESIONS:
Pericarditis

Cardiac surgery/bypass

Other, describe:

SECTION IX - PROCEDURES
9A. HAS THE VETERAN HAD ANY NON-SURGICAL OR SURGICAL PROCEDURES FOR THE TREATMENT OF A HEART CONDITION?
YES

NO

(If "Yes," complete Item 9B)

9B. INDICATE THE NON-SURGICAL OR SURGICAL PROCEDURES THE VETERAN HAS HAD FOR THE TREATMENT OF HEART CONDITIONS (Check all that apply):
Percutaneous coronary intervention (PCI) (angioplasty)
Indicate date of treatment or date of admission if admitted for treatment and name of treatment facility:

Coronary artery bypass surgery
Indicate date of admission for treatment and name of treatment facility:
Heart valve replacement
Specify valve(s) replaced and type of valve(s):
Indicate date of admission for treatment and name of treatment facility:
Heart transplants
Indicate date of admission for treatment and name of treatment facility:
Implanted cardiac pacemaker
Indicate date of admission for treatment and name of treatment facility:
VA FORM 21-0960A-4, MAR 2014

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SECTION IX - PROCEDURES (Continued)
9B. INDICATE THE NON-SURGICAL OR SURGICAL PROCEDURES THE VETERAN HAS HAD FOR THE TREATMENT OF HEART CONDITIONS (Continued)

(Check all that apply):

Implanted automatic implantable cardioverter defibrillator (AICD)
Indicate date of admission for treatment and name of treatment facility:
Valve replacement
If checked indicate valve(s) that have been replaced (check all that apply):
Mitral

Tricuspid

Aortic

Pulmonary

Indicate date of admission for treatment and name of treatment facility for each checked valve:

Ventricular aneurysmectomy
Indicate date of admission for treatment and name of treatment facility:
Other surgical and/or non-surgical procedures for the treatment of a heart condition, describe:
Indicate date of admission for treatment and name of treatment facility:
Indicate the condition that resulted in the need for this procedure/treatment:

SECTION X - HOSPITALIZATIONS
10. HAS THE VETERAN HAD ANY OTHER HOSPITALIZATIONS FOR THE TREATMENT OF HEART CONDITIONS (OTHER THAN FOR NON-SURGICAL AND SURGICAL
PROCEDURES DESCRIBED ABOVE)?
YES

NO

(If "Yes," provide the following):

Date of admission for treatment and name of treatment facility:
Condition that resulted in the need for hospitalization:

SECTION XI - PHYSICAL EXAM
11. PHYSICAL EXAM:
Heart rate:
Rhythm:

Regular

Point of maximal impact:

Not palpable

4th intercostal space

Heart sounds:

Normal

Abnormal, specify:

Jugular-venous distension:

Yes

No

Auscultation of the lungs:

Clear

Bibasilar rales

Other, describe:

Dorsalis pedis:

Normal

Diminished

Absent

Posterior tibial:

Normal

Diminished

Absent

Irregular
5th intercostal space

Other, specify:

Peripheral pulses:

Peripheral edema:
Right lower extremity:

None

Trace

1+

2+

3+

4+

Left lower extremity:

None

Trace

1+

2+

3+

4+

Blood pressure:

SECTION XII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
12A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
SECTION I, DIAGNOSIS?
YES

NO

(If "Yes," are any of the scars painful and/or unstable, or is the total area of all related scars greater than or equal to 39 square cm (6 square inches)?)
YES

NO

(If "Yes," ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire)

12B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN SECTION I, DIAGNOSIS?
YES

NO

(If "Yes," describe - brief summary):

VA FORM 21-0960A-4, MAR 2014

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SECTION XIII - DIAGNOSTIC TESTING
NOTE: For VA purposes, exams for all heart conditions require a determination of whether or not cardiac hypertrophy or dilatation is present. The suggested order of
testing for cardiac hypertrophy/dilatation is EKG, then chest x-ray (PA and lateral), then echocardiogram. An echocardiogram to determine heart size is only necessary
if the other two tests are negative. Also for VA purposes, if LVEF testing is not of record, but available medical information sufficiently reflects the severity of the
veteran's cardiovascular condition, LVEF testing is not required.
13A. IS THERE EVIDENCE OF CARDIAC HYPERTROPHY?
YES

NO

(If "Yes," indicate how this condition was documented):
EKG

Chest x-ray

Echocardiogram

Date of test:

13B. IS THERE EVIDENCE OF CARDIAC DILATATION?
YES

NO

(If "Yes," indicate how this condition was documented):
Chest x-ray

Echocardiogram

Date of test:

13C. SELECT ALL TESTING COMPLETED AND PROVIDE MOST RECENT RESULTS WHICH REFLECT THE VETERAN'S CURRENT FUNCTIONAL STATUS

(Check all that apply):
EKG

Date of EKG:
Result of EKG:
Normal
Arrhythmia, describe:
Hypertrophy, describe:
Ischemic, describe:
Other, describe:

Chest x-ray

Date of CXR:
Result of CXR:
Normal
Abnormal, describe:

Echocardiogram

Date of echocardiogram:
Left ventricular ejection fraction (LVEF):

Holter monitor

%

Wall motion:

Normal

Abnormal, describe:

Wall thickness:

Normal

Abnormal, describe:

Date of holter monitor test:
Result:
Normal
Abnormal, describe:

MUGA

Date of MUGA:
Left ventricular ejection fraction (LVEF):

%

Result:
Normal
Abnormal, describe:
Coronary artery
angiogram

Date of angiogram:
Result:
Normal
Abnormal, describe:

CT angiography

Date of CT angiography:
Result:
Normal
Abnormal, describe:

Other test, specify:

Date of test:
Result:

VA FORM 21-0960A-4, MAR 2014

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SECTION XIV - METs TESTING
NOTE: For VA purposes, all heart exams require METs testing (either exercise-based or interview-based) to determine the activity level at which symptoms such as
dyspnea, fatigue, angina, dizziness, or syncope develop (except exams for supraventricular arrhythmias.)
If a laboratory determination of METs by exercise testing cannot be done for medical reasons (e.g. chronic CHF or multiple episodes of acute CHF within the past 12
months), or if exercise-based METs test was not completed because it is not required as part of the veteran's treatment plan, or if exercise stress test results do no reflect
veteran's current cardiac function, perform an interview-based METs test based on the veteran's responses to a cardiac activity questionnaire and provide the results
below.
14A. INDICATE ALL TESTING COMPLETED PROVIDING ONLY MOST RECENT RESULTS WHICH REFLECT THE VETERAN'S CURRENT FUNCTIONAL STATUS.

(Check all that apply):
Exercise stress test

Date of most recent exercise stress test:
Results:
METs level the veteran performed, if provided:

Interview-based METs test

Date of interview-based METs test:
Symptoms during activity:
The METs level checked below reflects the lowest activity level at which the veteran reports any of the
following symptoms (check all symptoms that the veteran reports at the indicated METs level of activity):
Dyspnea

Fatigue

Angina

Dizziness

Syncope

Other, describe:
Results:
METs level on most recent interview-based METs test:
(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
14B. IF THE VETERAN HAS HAD BOTH AN EXERCISE STRESS TEST AND INTERVIEW-BASED METs TEST, INDICATE WHICH RESULTS MOST ACCURATELY
REFLECT THE VETERAN'S CURRENT CARDIAC FUNCTIONAL LEVEL:
Exercise stress test

Interview-based METs test

N/A

14C. IS THE METs LEVEL LIMITATION DUE SOLELY TO THE HEART CONDITIONS?
YES

NO

(If "No," estimate the percentage of the METs level limitation that is due solely to the heart condition(s)):
0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

The limitation in METs level is due to multiple factors; it is not possible to accurately estimate this percentage.
14D. IN ADDITION TO THE HEART CONDITION(S), DOES THE VETERAN HAVE OTHER NON-CARDIAC MEDICAL CONDITIONS (such as musculoskeletal or
pulmonary conditions) LIMITING THE METs LEVEL?
YES

NO

(If "Yes," identify each condition and describe how each non-cardiac medical condition limits the veteran's METs level):
Other medical condition #1:

Effect on METs level:

Other medical condition #2:

Effect on METs level:

14E. IF THERE ARE ADDITIONAL MEDICAL CONDITIONS AFFECTING METs LEVEL, LIST USING ABOVE FORMAT:

VA FORM 21-0960A-4, MAR 2014

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SECTION XV - FUNCTIONAL IMPACT
15. DOES THE VETERAN'S HEART CONDITION(S) IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If "Yes," describe impact of each of the veteran's heart conditions, providing one or more examples)

SECTION XVI - REMARKS
16. REMARKS (If any)

SECTION XVII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
17A. PHYSICIAN'S SIGNATURE
17D. PHYSICIAN'S PHONE NUMBER

17B. PHYSICIAN'S PRINTED NAME
17E. PHYSICIAN'S MEDICAL LICENSE NUMBER

17C. DATE SIGNED
17F. PHYSICIAN'S ADDRESS

NOTE: VA may obtain additional medical information, including an examination, 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.
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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
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VA FORM 21-0960A-4, MAR 2014

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