VA Form 21-0960J-1 Kidney Conditions (Nephrology) Disability Benefits Quesi

OMB Approved No. 2900-0779
Respondent Burden: 30 Minutes
Expiration Date: XX/XX/XXXX

KIDNEY CONDITIONS (NEPHROLOGY) 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. VA reserves the right to confirm the authenticity of ALL DBQs completed by
private health care providers.
SECTION I - DIAGNOSIS
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH A KIDNEY CONDITION?
YES

NO

(If "Yes," complete Item 1B)

1B. INDICATE DIAGNOSIS (check all that apply):
Diabetic nephropathy

ICD CODE:

DATE OF DIAGNOSIS:

Glomerulonephritis

ICD CODE:

DATE OF DIAGNOSIS:

Hydronephrosis

ICD CODE:

DATE OF DIAGNOSIS:

Interstitial nephritis

ICD CODE:

DATE OF DIAGNOSIS:

Kidney transplant

ICD CODE:

DATE OF DIAGNOSIS:

Nephrosclerosis

ICD CODE:

DATE OF DIAGNOSIS:

Nephrolithiasis

ICD CODE:

DATE OF DIAGNOSIS:

Renal artery stenosis

ICD CODE:

DATE OF DIAGNOSIS:

Ureterolithiasis

ICD CODE:

DATE OF DIAGNOSIS:

Neoplasm of the kidney

ICD CODE:

DATE OF DIAGNOSIS:

Cholesterol emboli

ICD CODE:

DATE OF DIAGNOSIS:

Cystic kidney disease

ICD CODE:

DATE OF DIAGNOSIS:

Congenital kidney disorder

ICD CODE:

DATE OF DIAGNOSIS:

Other inherited kidney disorder

ICD CODE:

DATE OF DIAGNOSIS:

ICD CODE:

DATE OF DIAGNOSIS:

ICD CODE:

DATE OF DIAGNOSIS:

Specify:
Other kidney condition (Specify

diagnosis, providing only diagnoses
that pertain to kidney conditions)

Other diagnosis #1:

Other diagnosis #2:

1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO KIDNEY CONDITION(S), LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including cause, onset and course) OF THE VETERAN'S CURRENT KIDNEY CONDITION(S) (Give a brief summary):

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

NO

List medications taken for the diagnosed condition:

SECTION III - RENAL DYSFUNCTION
3A. DOES THE VETERAN HAVE RENAL DYSFUNCTION? (Evidence of renal dysfunction includes either persistent proteinuria, hematuria or GFR < 60 cc/min/1.73m2)
YES

NO

(If yes complete questions 3B - 3D)

3B. DOES THE VETERAN REQUIRE REGULAR DIALYSIS?
YES
VA FORM
XXX XXXX

NO

21-0960J-1

SUPERSEDES VA FORM 21-0960J-1, FEB 2015,
WHICH WILL NOT BE USED.

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION III - RENAL DYSFUNCTION (Continued)
3C. DOES THE VETERAN HAVE ANY SIGNS OR SYMPTOMS DUE TO RENAL DYSFUNCTION?
YES

NO

(If yes check all that apply):
Proteinuria (albuminuria)
(If checked, indicate frequency: (check all that apply)
Recurring

Persistent

Constant

Edema (due to renal dysfunction)

(If checked, indicate frequency: (check all that apply)
Some

Transient

Persistent

Slight

Anorexia (due to renal dysfunction)
Weight loss (due to renal dysfunction)
If checked, provide baseline weight (average weight for 2-year period preceding onset of disease):

Provide current weight:

Generalized poor health (due to renal dysfunction)
Lethargy (due to renal dysfunction)
Weakness (due to renal dysfunction)
Limitation of exertion (due to renal dysfunction)
Able to perform only sedentary activity, due to persistent edema caused by renal dysfunction
Markedly decreased function of other organ systems, especially the cardiovascular system, caused by renal dysfunction (If checked, describe):

Other (If checked, describe):

3D. DOES THE VETERAN HAVE HYPERTENSION AND/OR HEART DISEASE DUE TO RENAL DYSFUNCTION OR CAUSED BY ANY KIDNEY CONDITION?
YES

NO

(If Yes, also complete VA Form 21-0960A-3, Hypertension Disability Benefits Questionnaire and/or VA Form 21-0960A-4, Heart Conditions (Including Ischemic and
Non-Ischemic Heart Disease, Arrhythmias, Valvular Disease and Cardiac Surgery) Disability Benefits Questionnaire, as appropriate.))
SECTION IV - UROLITHIASIS
4A. DOES THE VETERAN NOW HAVE OR HAS HE/SHE EVER HAD KIDNEY, URETAL OR BLADDER CALCULI (UROLITHIASIS)?
YES

NO

(If yes, complete questions 4B - 4D)
4B. INDICATE CURRENT/PAST LOCATION OF CALCULI
KIDNEY

URETER

BLADDER

4C. HAS THE VETERAN HAD TREATMENT FOR RECURRENT STONE FORMATION IN THE KIDNEY, URETER OR BLADDER?
YES

NO

(If yes, indicate treatment (Check all that apply)):
Diet therapy
If checked, specify diet and dates of use:
Drug therapy
If checked, list medication and dates of use:
Invasive or non-invasive procedures
If checked, indicate average number of times per year invasive or non-invasive procedures were required:
0 to 1/year

2/year

more than 2/year

Date and facility of most recent invasive or non-invasive procedure:
4D. DOES THE VETERAN HAVE ANY SIGNS OR SYMPTOMS DUE TO UROLITHIASIS?
YES

NO

(If yes, indicate severity (Check all that apply)):
No symptoms or attacks of colic

Causing infection (pyonephrosis)

Occasional attacks of colic

Causing hydronephrosis

Frequent attacks of colic

Causing impaired kidney function

Causing voiding dysfunction

Other, describe:

Requires catheter drainage
VA FORM 21-0960J-1, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION V - INFECTIONS OF THE KIDNEY AND/OR URINARY TRACT
5A. DOES THE VETERAN HAVE A HISTORY OF RECURRENT SYMPTOMATIC URINARY TRACT OR KIDNEY INFECTIONS?
YES

NO

(If yes, complete questions 5B - 5C)
5B. ETIOLOGY OF RECURRENT URINARY TRACT OR KIDNEY INFECTIONS:
5C. INDICATE ALL TREATMENT MODALITIES USED FOR RECURRENT URINARY TRACT OR KIDNEY INFECTIONS (check all that apply):
No treatment
Long-term drug therapy
If checked, list medications used and indicate dates for courses of treatment over the past 12 months:

Hospitalization
If checked, indicate frequency of hospitalization:
1 or 2 per year

More than 2 per year

Drainage
If checked, indicate dates when drainage was performed over the past 12 months:
Continuous intensive management
If checked, indicate types of treatment and medications used over the past 12 months:
Intermittent intensive management
If checked, indicate types of treatment and medications used over the past 12 months:
Other, describe:

SECTION VI - KIDNEY TRANSPLANT OR REMOVAL
6A. HAS THE VETERAN HAD A KIDNEY TRANSPLANT OR REMOVAL?
YES

NO

(If yes, complete questions 6B - 6C)
6B. HAS THE VETERAN HAD A KIDNEY REMOVED?
YES

NO

(If yes, provide reason):
Kidney donation
Due to disease
Due to trauma or injury
Other, describe:
6C. HAS THE VETERAN HAD A KIDNEY TRANSPLANT?
YES

NO

If yes, date of transplant:
Name of treatment facility, date of admission and date of discharge for transplant:

SECTION VII - TUMORS AND NEOPLASMS
7A. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DIAGNOSIS?
YES

NO

(If yes, complete questions 7B - 7E)
7B. IS THE NEOPLASM
BENIGN

MALIGNANT

7C. HAS THE VETERAN COMPLETED TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT NEOPLASM
OR METASTASES?
YES

NO; WATCHFUL WAITING

VA FORM 21-0960J-1, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION VII - TUMORS AND NEOPLASMS (Continued)
7C. HAS THE VETERAN COMPLETED TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT NEOPLASM
OR METASTASES? (Continued)
If "Yes," indicate type of treatment the Veteran is currently undergoing or has completed (check all that apply):
Treatment completed; currently in watchful waiting status
Surgery
If checked, describe:
Date(s) of surgery:
Radiation therapy
Date of completion of treatment or anticipated date of completion:

Date of most recent treatment:
Antineoplastic chemotherapy

Date of completion of treatment or anticipated date of completion:

Date of most recent treatment:
Other therapeutic procedure
If checked, describe procedure:
Date of most recent procedure:
Other therapeutic treatment
If checked, describe treatment:

Date of completion of treatment or anticipated date of completion:
7D. DOES THE VETERAN CURRENTLY HAVE ANY RESIDUAL CONDITIONS OR COMPLICATIONS DUE TO THE NEOPLASM (INCLUDING METASTASES) OR ITS
TREATMENT, OTHER THAN THOSE ALREADY DOCUMENTED IN THE REPORT ABOVE?
YES

NO

(If yes, list residual conditions and complications (brief summary)):

7E. IF THERE ARE ADDITIONAL BENIGN OR MALIGNANT NEOPLASMS OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DIAGNOSIS,
DESCRIBE USING THE ABOVE FORMAT:

SECTION VIII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
8A. DOES THE VETERAN HAVE ANY SCARS (SURGICAL OR OTHERWISE) RELATED TO ANY CONDITION 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.)
8B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS?
YES

NO

(If yes, describe (brief summary)):

SECTION IX - DIAGNOSTIC TESTING
NOTE: If laboratory test results are in the medical record and reflect the veteran's current renal function, repeat testing is not required. Provide testing completed
appropriate to veteran's condition; testing indicated below is not indicated for every kidney condition.
9A. HAS THE VETERAN HAD LABORATORY OR OTHER DIAGNOSTIC STUDIES PERFORMED?
YES

NO

(If yes, provide most recent results (if available)):

9B. LABORATORY STUDIES
BUN

Date:

Result:

Creatinine

Date:

Result:

EGFR

Date:

Result:

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION IX - DIAGNOSTIC TESTING (Continued)
9C. URINALYSIS
Hyaline casts

Date:

Result:

Granular casts

Date:

Result:

RBC's/HPF

Date:

Result:

Proteinuria (albumin)
Spot urine for
protein/creatinine ratio

Date:

Result:

Date:

Result:

24 hour protein (mg/day)

Date:

Result:

9D. SPOT URINE MICROALBUMIN/CREATININE
Date:

Result:

9E. 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 X - FUNCTIONAL IMPACT
10. DOES THE VETERAN'S KIDNEY CONDITION(S), INCLUDING NEOPLASMS, IF ANY, IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

(If yes, describe impact of each of the veteran's kidney conditions, providing one or more examples):

SECTION XI - REMARKS
11. REMARKS

SECTION XII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
12A. PHYSICIAN'S SIGNATURE

12D. PHYSICIAN'S PHONE AND FAX NUMBER

12B. PHYSICIAN'S PRINTED NAME

15E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER

12C. DATE SIGNED

12F. 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 21-0960J-1, XXX XXXX

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