Va Form 21 0960L 1 – Fill Out and Use This PDF

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.

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?

Inhalational anti-inflammatory medication

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

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?

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

(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

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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):

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):

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

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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

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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?

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?

2. IS THE NEOPLASM:

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

(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?

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

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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?

(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?

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)

	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?

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

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

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