Va Form 21 0960L 1 PDF Details

In the realm of assisting veterans with respiratory conditions other than tuberculosis and sleep apnea in navigating the complexities of claiming disability benefits, the Department of Veterans Affairs (VA) form VA 21-0960L-1 plays a pivotal role. Designed as a Disability Benefits Questionnaire, this form serves as a vital tool for physicians to record detailed information about a veteran's respiratory condition, which is an essential step in the VA's evaluation process for disability claims. The form comprehensively covers a wide array of respiratory conditions including, but not limited to, asthma, emphysema, chronic obstructive pulmonary disease (COPD), and interstitial lung disease, among others. Physicians are required to document diagnoses, treatment details, and the impact on the veteran's health, while the form also emphasizes that the VA will not reimburse any costs incurred in its completion. Importantly, it guides the completion process with a note on the importance of thorough documentation for the claims evaluation process and the potential need for supplementary forms for related conditions, such as sleep apnea or narcolepsy. The detailed structure of the form, from diagnosis through medical history to specific pulmonary conditions, underscores its significance in ensuring veterans receive the benefits commensurate with the extent of their service-related health issues.

QuestionAnswer
Form NameVa Form 21 0960L 1
Form Length7 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 45 sec
Other namesva form for sleep apnea, va form 21 0960l 2, vba 21 0960l 2 are pdf, va dbq form sleep apnea

Form Preview Example

OMB Approved No. 2900-0781

Respondent Burden: 30 minutes

RESPIRATORY CONDITIONS (OTHER THAN TUBERCULOSIS AND SLEEP APNEA)

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.

SECTION I - DIAGNOSIS

1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH A RESPIRATORY CONDITION? (This is the condition the veteran is

 

 

claiming or for which an exam has been requested.)

 

 

 

 

 

 

 

 

 

 

NO (If "Yes," complete Item 1B)

 

 

 

 

 

 

 

 

YES

 

 

 

 

 

 

 

 

 

 

 

 

1B. SELECT THE VETERAN'S CONDITION (Check all that apply):

 

 

 

 

 

 

 

 

ASTHMA

 

ICD code:

 

Date of diagnosis:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPHYSEMA

ICD code:

 

Date of diagnosis:

 

 

 

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

ICD code:

 

 

 

 

 

 

 

 

Date of diagnosis:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CHRONIC BRONCHITIS

ICD code:

 

Date of diagnosis:

 

 

 

 

 

 

ICD code:

 

 

 

 

 

 

 

CONSTRICTIVE BRONCHIOLITIS

 

Date of diagnosis:

 

 

 

INTERSTITIAL LUNG DISEASE (If checked, specify):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ICD code:

 

Date of diagnosis:

 

 

NOTE - Interstitial lung diseases include but are not limited to asbestosis, diffuse interstitial fibrosis, interstitial pneumonitis, fibrosing alveolitis, desquamative interstitial pneumonitis, pulmonary alveolar proteinosis, eosinophilic granuloma of lung, drug-induced pulmonary pneumonitis and fibrosis, radiation-induced pulmonary pneumonitis and fibrosis, hypersensitivity pneumonitis (extrinsic allergic alveolitis) and pneumoconiosis such as silicosis, anthracosis, etc.)

RESTRICTIVE LUNG DISEASE (If checked, specify):

ICD code:

 

Date of diagnosis:

NOTE - Restrictive lung diseases include but are not limited to diaphragm paralysis or paresis, spinal cord injury with respiratory insufficiency, kyphoscoliosis, pectus excavatum, pectus carinatum, traumatic chest wall defect, pneumothorax, hernia, etc., post-surgical residual (lobectomy, pneumonectomy, etc.), chronic pleural effusion or fibrosis.

 

 

SCARCOIDOSIS

ICD code:

 

Date of diagnosis:

 

 

BENIGN OR MALIGNANT NEOPLASM OR METASTASES OF

 

 

 

 

 

 

 

 

RESPIRATORY SYSTEM (If checked, specify):

 

 

 

 

 

 

ICD code:

 

Date of diagnosis:

 

 

PULMONARY VASCULAR DISEASE (Including pulmonary

 

 

 

 

 

thromboembolism) (If checked, specify):

 

 

 

 

 

 

ICD code:

 

Date of diagnosis:

 

 

OTHER DIAGNOSIS (If checked, specify):

 

 

 

 

 

 

 

 

 

 

 

ICD code:

 

Date of diagnosis:

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

NOTE - If diagnosed with Sleep Apnea complete VA Form 21-0960L-2, Sleep Apnea Disability Benefits Questionnaire. If diagnosed with Narcolepsy complete VA Form 21-0960C-6, Narcolepsy Disability Benefits Questionnaire.

VA FORM

21-0960L-1

SUPERSEDES VA FORM 21-0960L-1, MAR 2011,

Page 1

OCT 2012

WHICH WILL NOT BE USED.

 

SECTION II - MEDICAL RECORD REVIEW

2. INDICATE MEDICAL RECORDS REVIEWED IN PREPARATION OF THIS REPORT:

C-FILE (VA ONLY)

OTHER, DESCRIBE:

SECTION III - MEDICAL HISTORY

3A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S RESPIRATORY CONDITION (brief summary):

3B. DOES THE VETERAN'S RESPIRATORY CONDITION REQUIRE THE USE OF ORAL OR PARENTERAL CORTICOSTEROID MEDICATIONS?

 

YES

 

NO (If "Yes," complete the following):

Requires chronic low dose (maintenance) corticosteroids

Requires intermittent courses or bursts of systemic (oral or parenteral) corticosteroids

(If checked, indicate number of courses or bursts in past 12 months):

 

0

 

1

 

2

 

3

 

4 or more

Requires systemic (oral or parenteral) high dose (therapeutic) corticosteroids for control

Requires daily use of systemic (oral or parenteral) high dose corticosteroids or immuno-suppressive medications

Other, describe:

(If the veteran has more than one respiratory condition, indicate the condition which is predominantly responsible for the need for corticosteroids or immuno- suppressive medications):

3C. DOES THE VETERAN'S RESPIRATORY CONDITION REQUIRE THE USE OF INHALED MEDICATIONS?

 

YES

 

 

NO (If, "Yes," check all that apply):

 

 

 

 

 

Inhalational bronchodilator therapy

 

 

 

 

 

 

 

 

 

 

 

 

(If "Yes," indicate frequency):

 

Intermittent

 

 

 

 

 

 

 

Daily

Inhalational anti-inflammatory medication

(If "Yes," indicate frequency):

Intermittent

Daily

Other inhaled medications, describe:

(If the veteran has more than one respiratory condition, indicate the condition which is predominantly responsible for the need for inhaled medications):

3D. DOES THE VETERAN'S RESPIRATORY CONDITION REQUIRE THE USE OF ORAL BRONCHODILATORS?

YES NO

(If "Yes," indicate frequency):

Intermittent

Daily

3E. DOES THE VETERAN'S RESPIRATORY CONDITION REQUIRE THE USE OF ANTIBIOTICS?

YES NO

(If "Yes," list antibiotics, dose, frequency and condition for which antibiotics are prescribed):

3F. DOES THE VETERAN REQUIRE OUTPATIENT OXYGEN THERAPY FOR HIS OR HER RESPIRATORY CONDITION?

YES

NO

(If "Yes," does the veteran require continuous oxygen therapy (>17 hours/day)?):

YES

NO

(If the veteran has more than one respiratory condition, indicate the condition which is predominantly responsible for the requirement for oxygen therapy):

 

 

 

 

 

 

SECTION IV - PULMONARY CONDITIONS

 

 

 

 

 

4. DOES THE VETERAN HAVE ANY OF THE FOLLOWING PULMONARY CONDITIONS?

 

 

YES

 

 

NO (If "No," proceed to Section V) (If "Yes," check all that apply):

 

 

 

 

 

 

Asthma

 

(If checked, complete Part A below)

 

 

 

 

 

Bronchiectasis

(If checked, complete Part B below)

 

 

 

 

Sarcoidosis

 

(If checked, complete Part C below)

 

 

 

 

 

Pulmonary embolism and related diseases

(If checked, complete Part D below)

 

 

 

 

Bacterial lung infection

(If checked, complete Part E below)

 

 

 

 

Mycotic lung infection

(If checked, complete Part F below)

 

 

 

 

Pneumothorax

(If checked, complete Part G below)

 

 

 

 

Gunshot/fragment wound

(If checked, complete Part H below)

 

 

 

 

Cardiopulmonary complications

(If checked, complete Part I below)

 

 

 

 

Respiratory failure

(If checked, complete Part J below)

 

 

 

 

Tumors or neoplasms

(If checked, complete Part K below)

 

 

Other pulmonary conditions, pertinent physical findings or scars due to pulmonary conditions: (If checked, complete Part I below)

VA FORM 21-0960L-1, OCT 2012

Page 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION IV - PULMONARY CONDITIONS (CONTINUED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART A - ASTHMA

 

 

 

 

 

 

 

 

 

 

1. HAS THE VETERAN HAD ANY ASTHMA ATTACKS WITH EPISODES OF RESPIRATORY FAILURE IN THE PAST 12 MONTHS?

 

 

YES

 

 

 

NO (If "Yes," indicate average number of asthma attacks with episodes of respiratory failure per week in past 12 months):

 

 

 

 

 

 

 

0

 

 

1

 

2

 

3

 

4 or more

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. HAS THE VETERAN HAD ANY ASTHMA EXACERBATIONS IN THE PAST 12 MONTHS?

 

 

YES

 

 

 

NO (If "Yes," describe frequency and severity of exacerbations):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Indicate frequency of physician visits for required care of exacerbations over past 12 months):

Less frequently than monthly

At least monthly

PART B - BRONCHIECTASIS

1. INDICATE ANY FINDINGS, SIGNS AND SYMPTOMS THAT ARE ATTRIBUTABLE TO BRONCHIECTASIS:

Productive cough (If checked, indicate frequency and severity of productive cough (check all that apply)):

Intermittent

Daily with purulent sputum at times

Daily with blood-tinged sputum at times

Near constant with purulent sputum

Other, describe:

Acute infection

(If checked, indicate number of infections requiring a prolonged course of antibiotics (lasting 4 to 6 weeks) in the past 12 months):

0

1

2

3

4 or more

Requiring antibiotic usage almost continuously

Anorexia (If checked, describe):

Weight loss (If checked, provide baseline weight:and current weight:)

(NOTE - For VA purposes, baseline weight is the average weight for 2-year period preceding onset of disease) Frank hemoptysis (If checked, describe):

Other, describe:

2. HAS THE VETERAN HAD ANY INCAPACITATING EPISODES OF INFECTION DUE TO BRONCHIECTASIS?

(NOTE: For VA purposes, an incapacitating episode is a period of acute symptoms severe enough to require prescribed bed rest and treatment by a physician)

 

YES

 

NO (If "Yes," indicate total duration of incapacitating episodes of infection in past 12 months):

0 to no more than 2 weeks

2 to no more than 4 weeks

4 to no more than 6 weeks At least 6 weeks or more

PART C - SCARCOIDOSIS

1. DOES THE VETERAN HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO SARCOIDOSIS?

 

YES

 

 

NO

(If, "Yes," check all that apply):

 

 

 

 

 

 

 

 

No physiologic impairment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No symptoms

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Persistent symptoms (If checked, describe):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Chronic hilar adenopathy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Stable lung infiltrates

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pulmonary involvement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Progressive pulmonary disease (If checked, describe):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cardiac involvement with congestive heart failure

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fever (If checked, describe):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Night sweats (If checked, describe):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Weight loss (If checked, provide baseline weight:

 

 

and current weight:

 

)

 

 

 

 

 

(NOTE: For VA purposes, baseline weight is the average weight for a 2-year period preceding onset of disease)

Other, describe:

VA FORM 21-0960L-1, OCT 2012

Page 3

PART C - SCARCOIDOSIS (CONTINUED)

2. INDICATE STAGE DIAGNOSED BY X-RAY FINDINGS:

Stage 1: Bihilar lymphadenopathy

Stage 2: Bihilar lymphadenopathy and reticulonodular infiltrates

Stage 3: Bilateral pulmonary infiltrates

Stage 4: Fibrocystic sarcoidosis typically with upward hilar retraction, cystic and bullous changes

3. DOES THE VETERAN HAVE OPTHALMOLOGIC, RENAL, CARDIAC, NEUROLOGIC, OR OTHER ORGAN SYSTEM INVOLVEMENT DUE TO SARCOIDOSIS?

 

YES

 

NO (If "Yes," also complete appropriate additional Questionnaires)

PART D - PULMONARY EMBOLISM AND RELATED DISEASES

1.SELECT THE STATEMENT(S) THAT BEST DESCRIBE THE VETERAN'S PULMONARY VASCULAR DISEASE OR PULMONARY EMBOLISM CONDITION

(Check all that apply):

Asymptomatic, following resolution of pulmonary thromboembolism

Symptomatic, following resolution of acute pulmonary embolism

Chronic pulmonary thromboembolism requiring anticoagulant therapy

Following inferior vena cava surgery

Chronic pulmonary thromboembolism

Pulmonary hypertension secondary to other obstructive disease of pulmonary arteries or veins with evidence of right ventricular hypertrophy or cor pulmonale Other, describe:

PART E - BACTERIAL LUNG INFECTION

1. INDICATE CURRENT STATUS OF THE VETERAN'S BACTERIAL INFECTION OF THE LUNG (including actinomycosis, nocardiosis and chronic lung abscess):

ACTIVE INACTIVE

2. DOES THE VETERAN HAVE ANY FINDINGS, SIGNS AND SYMPTOMS ATTRIBUTABLE TO A BACTERIAL INFECTION OF THE LUNG OR CHRONIC LUNG ACCESS?

 

YES

 

 

NO (If "Yes," check all that apply):

 

 

 

 

 

 

 

 

Fever

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Night sweats

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Weight loss (If checked, provide baseline weight:

 

and current weight:

 

)

 

 

 

 

 

 

 

 

 

(NOTE: For VA purposes, baseline weight is the average weight for 2-year period preceding onset of disease)

 

Hemoptysis

Other, describe:

PART F - MYCOTIC LUNG DISEASES

1.INDICATE STATUS OF MYCOTIC LUNG DISEASE (including histoplasmosis of lung, coccidioidomycosis, blastomycosis, cryptococcosis, aspergillosis, or mucormycosis) (Check all that apply):

No symptoms

Chronic pulmonary mycosis

Healed and inactive mycotic lesions

Occasional productive cough

Occasional minor hemoptysis

Requires suppressive therapy

Fever

Night sweats

Weight loss (If checked, provide baseline weight:and current weight:)

(NOTE: For VA purposes, baseline weight is the average weight for a 2-year period preceding onset of disease)

Massive hemoptysis

Other, describe:

PART G - PNEUMOTHORAX

1. INDICATE THE TYPE OF PNEUMOTHORAX, TREATMENT AND RESIDUAL CONDITIONS, IF ANY (Check all that apply):

 

Spontaneous total pneumothorax

 

 

 

 

 

Spontaneous partial pneumothorax

 

 

 

 

 

 

 

 

 

 

Traumatic total pneumothorax

 

 

 

 

 

 

 

 

 

 

Traumatic partial pneumothorax

 

 

 

 

 

 

 

 

 

 

Resulting in hospitalization (If checked, provide date of hospital admission

 

and date of discharge

)

 

 

 

 

 

 

 

 

Resulting in residual conditions (If checked, describe):

 

 

 

 

 

 

 

 

 

 

 

Other, describe:

 

 

 

 

 

 

 

 

 

 

VA FORM 21-0960L-1, OCT 2012

Page 4

SECTION IV - PULMONARY CONDITIONS (CONTINUED)

PART H - GUNSHOT/FRAGMENT WOUND

1.SELECT THE STATEMENT(S) THAT BEST DESCRIBE THE VETERAN'S GUNSHOT OR FRAGMENT WOUND OR THE PLEURAL CAVITY AND RESIDUALS, IF ANY

(Check all that apply):

Bullet or missile retained in lung

Pain or discomfort on exertion

Scattered rales

Some limitation of excursion of diaphragm or of lower chest expansion

Other, describe:

(NOTE: If any muscles (other than those which control respiration) are affected by this injury, ALSO complete VA Form 21-0960M-10, Muscle Injury Disability Benefits Questionnaire)

PART I - CARDIOPULMONARY COMPLICATIONS

1.DOES THE VETERAN'S RESPIRATORY CONDITION RESULT IN CARDIOPULMONARY COMPLICATIONS SUCH AS COR PULMONALE, RIGHT VENTRICULAR HYPERTROPHY OR PULMONARY HYPERTENSION?

YES

NO (If "Yes,"check all that apply):

Cor pulmonale (right heart failure)

Right ventricular hypertrophy

Pulmonary hypertension (shown by echocardiogram or cardiac catheterization; report test results in Section 15, Diagnostic Testing)

Other, describe:

2.IF THE VETERAN HAS MORE THAN ONE RESPIRATORY CONDITION, INDICATE WHICH CONDITION IS PREDOMINANTLY RESPONSIBLE FOR THE EPISODES OF RESPIRATORY FAILURE:

PART J - RESPIRATORY FAILURE

1.PROVIDE DATES AND DESCRIBE THE VETERAN'S EPISODES OF ACUTE RESPIRATORY FAILURE:

2.IF THE VETERAN HAS MORE THAN ONE RESPIRATORY CONDITION, INDICATE WHICH CONDITION IS PREDOMINANTLY RESPONSIBLE FOR THE EPISODES OF RESPIRATORY FAILURE:

PART K - TUMORS AND NEOPLASMS

1. 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 the following section)

2. IS THE NEOPLASM:

BENIGN

MALIGNANT

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

YES

NO; WATCHFUL WAITING

(If, "Yes," indicate type of treatment (check all that apply)):

 

Treatment completed; currently in watchful waiting status

 

 

 

 

 

 

 

 

 

Surgery (If checked, describe:

 

 

 

 

 

Date(s) of surgery:

 

)

 

 

 

 

 

 

Radiation therapy (Date of most recent treatment:

 

Date of completion of treatment or anticipated date of completion:

 

)

 

 

Antineoplastic chemotherapy (Date of most recent treatment:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of completion of treatment or anticipated date of completion:

 

 

)

 

 

 

 

 

 

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):

 

 

 

 

 

 

 

 

 

4.DOES THE VETERAN CURRENTLY HAVE ANY RESIDUAL CONDITIONS OR COMPLICATIONS DUE TO THE NEOPLASM (including metastases) OR ITS TREATMENT, OTHER THAN THOSE ALREADY DOCUMENTED?

YES

NO (If "Yes," list residual conditions and complications (brief summary):

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

VA FORM 21-0960L-1, OCT 2012

Page 5

PART L - OTHER PERTINENT PHYSICAL FINDINGS, SCARS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS

1.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)

2.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):

SECTION V - DIAGNOSTIC TESTING

NOTE: If diagnostic test results are in the medical record and reflect the veteran's current respiratory condition, repeat testing is not required.

5A. HAVE IMAGING STUDIES OR PROCEDURES BEEN PERFORMED? (For VA purposes, imaging studies are not required for many respiratory conditions)

YES

NO (If "Yes," check all that apply):

 

Chest x-ray

Date:

 

Results:

 

Magnetic resonance imaging (MRI)

Date:

 

Results:

 

 

 

Computed tomography (CT)

Date:

 

Results:

 

 

 

High resolution computed tomography to evaluate

 

 

 

 

 

 

 

 

interstitial lung disease such as asbestosis (HRCT)

Date:

 

Results:

 

Bronchoscopy

Date:

 

Results:

 

 

 

Biopsy

Date:

 

Results:

 

 

 

Other, describe:

 

Date:

 

Results:

 

 

5B. HAS PULMONARY FUNCTION TESTING (PFT) BEEN PERFORMED?

YES

NO

(If "Yes," do PFT results reported below reflect the veteran's current pulmonary function?)

YES

NO

MOST RESPIRATORY CONDITIONS REQUIRE PULMONARY FUNCTION TESTING, SINCE PFT RESULTS REPRESENT A MAJOR BASIS FOR THEIR EVALUATION. HOWEVER, PULMONARY FUNCTION TESTING IS NOT REQUIRED IN ALL INSTANCES. FOR VA PURPOSES, IF THE VETERAN HAS ANY OF THE FOLLOWING CONDITIONS, PFTs ARE NOT REQUIRED. IF PFTs HAVE NOT BEEN COMPLETED, INDICATE REASON:

Veteran requires outpatient oxygen therapy

Veteran has had 1 or more episodes of acute respiratory failure

Veteran has been diagnosed with cor pulmonale, right ventricular hypertrophy or hypertension

Veteran has had exercise capacity testing and results are 20 ml/kg/min or less

Other, describe:

5C. PFT RESULTS:

 

 

 

 

 

 

 

 

 

 

Date of test:

 

 

 

 

 

 

 

 

 

 

 

Pre-bronchodilator:

 

 

 

Post-bronchodilator, if indicated:

 

 

 

 

FVC:

 

% predicted

 

 

FVC:

 

% predicted

 

 

 

 

 

 

 

 

 

 

 

 

FEV-1:

 

% predicted

 

 

FEV-1:

 

% predicted

 

 

 

 

 

 

 

 

 

 

FEV-1/FVC:

 

 

%

 

 

FEV-1/FVC:

 

 

%

 

 

 

 

 

DLCO:

 

% predicted

 

 

DLCO:

 

% predicted

 

 

 

5D. WHICH TEST RESULT MOST ACCURATELY REFLECTS THE VETERAN'S LEVEL OF DISABILITY (Based on the condition that is being evaluated for this report)?

THIS QUESTION IS IMPORTANT FOR VA PURPOSES.

FVC % predicted

FEV-1 % predicted

FEV-1/FVC

DLCO

5E. IF POST-BRONCHODILATOR TESTING HAS NOT BEEN COMPLETED, INDICATE REASON:

Pre-bronchodilator results are normal

Not indicated for veteran's condition

Not indicated in veteran's particular case (If checked, provide reason):

Other, describe:

VA FORM 21-0960L-1, OCT 2012

Page 6

SECTION V - DIAGNOSTIC TESTING (CONTINUED)

5F. IF DIFFUSION CAPACITY OF THE LUNG FOR CARBON MONOXIDE BY THE SINGLE BREATH METHOD (DLCO) TESTING HAS NOT BEEN COMPLETED, INDICATE REASON:

Not indicated for veteran's condition

Not indicated in veteran's particular case

Not valid for veteran's particular case

Other, describe:

5G. DOES THE VETERAN HAVE MULTIPLE RESPIRATORY CONDITIONS?

YES NO

(If "Yes," list conditions and indicate which condition is predominantly responsible for the limitation in pulmonary function, if any limitation is present):

5H. HAS EXERCISE CAPACITY TESTING BEEN PERFORMED?

 

 

YES

 

 

NO (If "Yes,"complete the following):

 

 

 

 

 

Maximum exercise capacity less than 15 ml/kg/min oxygen consumption (with cardiac or respiratory limitation)

 

 

 

 

 

 

 

 

 

 

Maximum oxygen consumption of 15-20 ml/kg/min (with cardiorespiratory limit)

 

 

 

 

 

 

5I. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?

 

 

YES

 

 

NO (If "Yes," describe (brief summary)):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION VI - FUNCTIONAL IMPACT

 

6. DOES THE VETERAN'S RESPIRATORY CONDITION IMPACT HIS OR HER ABILITY TO WORK?

 

 

YES

 

 

NO (If "Yes," describe impact of each of the veteran's respiratory conditions, providing one or more examples):

 

 

 

 

SECTION VII - REMARKS

7. REMARKS (If any)

SECTION VIII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.

8A. PHYSICIAN'S SIGNATURE

 

8B. PHYSICIAN'S PRINTED NAME

 

8C. DATE SIGNED

 

 

 

 

 

8D. PHYSICIAN'S PHONE AND FAX NUMBERS

8E. PHYSICIAN'S MEDICAL LICENSE NUMBER

8F. 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 21-0960L-1, OCT 2012

Page 7

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3. In this stage, review INDICATE MEDICAL RECORDS REVIEWED, CFILE VA ONLY, OTHER DESCRIBE, A DESCRIBE THE HISTORY including, SECTION III MEDICAL HISTORY, B DOES THE VETERANS RESPIRATORY, YES, If Yes complete the following, Requires chronic low dose, Requires intermittent courses or, If checked indicate number of, or more, Requires systemic oral or, Requires daily use of systemic, and Other describe. Each one of these should be taken care of with utmost accuracy.

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