Va From 21 0960J 2 Form – Fill Out and Use This PDF

OMB Control No. 2900-0779

Respondent Burden: 15 Minutes

Expiration Date: 05/31/2021

MALE REPRODUCTIVE ORGAN CONDITIONS

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 EVER BEEN DIAGNOSED WITH ANY CONDITIONS OF THE MALE REPRODUCTIVE SYSTEM?

YES

NO

(If "Yes," complete Item 1B)

1B. INDICATE DIAGNOSES: (check all that apply)

Erectile dysfunction

ICD code:

Date of diagnosis:

Penis, deformity (e.g., Peyronie's)

ICD code:

Date of diagnosis:

Testis, atrophy, one or both

ICD code:

Date of diagnosis:

Testis, removal, one or both

ICD code:

Date of diagnosis:

Epididymitis, chronic

ICD code:

Date of diagnosis:

Epididymo-orchitis, chronic

ICD code:

Date of diagnosis:

Prostate injury

ICD code:

Date of diagnosis:

Prostate hypertrophy (BPH)

ICD code:

Date of diagnosis:

Prostatitis, chronic

ICD code:

Date of diagnosis:

Prostate surgical residuals (as addressed in items 3–6)

ICD code:

Date of diagnosis:

Neoplasms of the male reproductive system

ICD code:

Date of diagnosis:

Other male reproductive system condition (specify

diagnosis, providing only diagnoses that pertain to the

male reproductive system)

Other diagnosis #1:

ICD code:

Date of diagnosis:

Other diagnosis #2:

ICD code:

Date of diagnosis:

1C. IF THERE ARE ANY ADDITIONAL DIAGNOSES THAT PERTAIN TO THE MALE REPRODUCTIVE ORGAN CONDITIONS, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY

2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S MALE REPRODUCTIVE ORGAN CONDITION(S) (brief summary):

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

YES

NO

List medications taken for the male reproductive organ condition:

VA FORM	21-0960J-2	SUPERSEDES VA FORM 21-0960J-2, FEB 2015,
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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION III - VOIDING DYSFUNCTION

3A. DOES THE VETERAN HAVE A VOIDING DYSFUNCTION?

		YES			NO	(If yes, complete Items 3B thru 3E)
(If yes, provide etiology of voiding dysfunction):
3B. DOES THE VOIDING DYSFUNCTION CAUSE URINE LEAKAGE?
					NO
		YES

Indicate severity (check one):

Does not require the wearing of absorbent material

Requires absorbent material which must be changed less than 2 times per day

Requires absorbent material which must be changed 2 to 4 times per day

Requires absorbent material which must be changed more than 4 times per day

Other, describe:

3C. DOES THE VOIDING DYSFUNCTION REQUIRE THE USE OF AN APPLIANCE?

YES

NO

(If yes, describe the appliance):

3D. DOES THE VOIDING DYSFUNCTION CAUSE INCREASED URINARY FREQUENCY?

YES

NO

(If yes, check all that apply):

Daytime voiding interval between 2 and 3 hours

Nighttime awakening to void 2 times

Daytime voiding interval between 1 and 2 hours

Nighttime awakening to void 3 to 4 times

Daytime voiding interval less than 1 hour

Nighttime awakening to void 5 or more times

3E. DOES THE VOIDING DYSFUNCTION CAUSE SIGNS OR SYMPTOMS OF OBSTRUCTED VOIDING?

YES

NO

(If yes, check all that apply):

Hesitancy

If checked, is hesitancy marked?

YES

NO

Slow or weak stream

If checked, is stream markedly slow or weak?

YES

NO

Decreased force of stream

If checked, is force of stream markedly decreased?

YES

NO

Stricture disease requiring dilatation 1 to 2 times per year

Stricture disease requiring periodic dilatation every 2 to 3 months

Recurrent urinary tract infections secondary to obstruction

Uroflowmetry peak flow rate less than 10 cc/sec

Post void residuals greater than 150 cc

Urinary retention requiring intermittent catheterization

Urinary retention requiring continuous catheterization

Other, describe:

SECTION IV - URINARY TRACT/KIDNEY INFECTION

4A. DOES THE VETERAN HAVE A HISTORY OF RECURRENT SYMPTOMATIC URINARY TRACT OR KIDNEY INFECTIONS?

YES

NO (If yes, complete Item 4B)

(If yes, provide etiology of recurrent urinary tract or kidney infections):

4B. 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:

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION IV - URINARY TRACT/KIDNEY INFECTION (CONTINUED)

4B. INDICATE ALL TREATMENT MODALITIES USED FOR RECURRENT URINARY TRACT OR KIDNEY INFECTIONS (check all that apply) (Continued):

Hospitalization

If checked, indicate frequency of hospitalization:

1 or 2 per year

>2 per year

Drainage

If checked, indicate dates when drainage performed over past 12 months:

Continuous intensive management

If checked, indicate types of treatment and medications used over past 12 months:

Intermittent intensive management

If checked, indicate types of treatment and medications used over past 12 months:

Other, describe:

SECTION V - ERECTILE DYSFUNCTION

5A. DOES THE VETERAN HAVE ERECTILE DYSFUNCTION?

YES

NO (If yes, complete Items 5B and 5C)

(If yes, provide etiology of erectile dysfunction):

5B. IF THE VETERAN HAS ERECTILE DYSFUNCTION, IS IT AS LIKELY AS NOT (at least a 50% probability) ATTRIBUTABLE TO ONE OF THE DIAGNOSES IN SECTION I, INCLUDING RESIDUALS OF TREATMENT FOR THIS DIAGNOSIS?

(If yes, specify the diagnosis to which the erectile dysfunction is as likely as not attributable):

5C. IF THE VETERAN HAS ERECTILE DYSFUNCTION, IS HE ABLE TO ACHIEVE AN ERECTION SUFFICIENT FOR PENETRATION AND EJACULATION

(without medication)?

YES

NO

IF NO, IS THE VETERAN ABLE TO ACHIEVE AN ERECTION SUFFICIENT FOR PENETRATION AND EJACULATION (with medication)?

YES

NO

				SECTION VI - RETROGRADE EJACULATION
6A. DOES THE VETERAN HAVE RETROGRADE EJACULATION?
		YES		NO (If yes, complete Item 6B and provide etiology of retrograde ejaculation)

(If yes, provide etiology of retrograde ejaculation):

6B. IF THE VETERAN HAS RETROGRADE EJACULATION, IS IT AS LIKELY AS NOT (at least a 50% probability) ATTRIBUTABLE TO ONE OF THE DIAGNOSES IN SECTION I, INCLUDING RESIDUALS OF TREATMENT FOR THIS DIAGNOSIS?

(If yes, specify the diagnosis to which the erectile dysfunction is as likely as not attributable):

SECTION VII - MALE REPRODUCTIVE ORGAN INFECTIONS

7. DOES THE VETERAN HAVE A HISTORY OF CHRONIC EPIDIDYMITIS, EPIDIDYMO-ORCHITIS OR PROSTATITIS?

(If yes, indicate all treatment modalities used for chronic epididymitis, epididymo-orchitis or prostatitis (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

>2 per year

Continuous intensive management

If checked, indicate types of treatment and medications used over past 12 months:

Intermittent intensive management

If checked, indicate types of treatment and medications used over past 12 months:

Other, describe:

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION VIII - PHYSICAL EXAM

8A. PENIS

Normal

Not examined per veteran's request

Not examined per veteran's request; Veteran reports normal anatomy with no penile deformity or abnormality

Not examined; penis exam not relevant to condition

Abnormal

If abnormal, indicate severity:

Loss/removal of half or more of penis

Loss/removal of glans penis

Penis deformity (such as Peyronie's disease)

If checked, describe:

8B. TESTES

Normal

Not examined per veteran's request

Not examined per veteran's request; Veteran reports normal anatomy with no testicular deformity or abnormality

Not examined; testicular exam not relevant to condition

Abnormal

If abnormal, check all that apply:

Right testicle

Size 1/3 or less of normal

Size 1/2 to 1/3 of normal

Considerably harder than normal

Considerably softer than normal

Absent

Other abnormality

Describe:

Left testicle

Size 1/3 or less of normal

Size 1/2 to 1/3 of normal

Considerably harder than normal

Considerably softer than normal

Absent

Other abnormality

Describe:

8C. EPIDIDYMIS

Normal

Not examined per veteran's request

Not examined per veteran's request; veteran reports normal anatomy of epididymis with no deformity or abnormality

Not examined; epididymis exam not relevant to condition

Abnormal

If abnormal, check all that apply:

Right epididymis

Tender to palpation

Other, describe:

Left epididymis

Tender to palpation

Other, describe:

8D. PROSTATE

Normal

Not examined per veteran's request

Not examined; prostate exam not relevant to condition

Abnormal

If abnormal, describe:

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION IX - TUMORS AND NEOPLASMS

9A. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DIAGNOSIS?

9B. IS THE NEOPLASM:

9C. 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 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 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:

9D. 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?

9E. 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 X - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS

10A. 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?

(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)?)

(If yes, also complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire.)

10B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS?

SECTION XI - DIAGNOSTIC TESTING

NOTE: If imaging studies, diagnostic procedures or laboratory testing has been performed and reflects the veteran's current condition, provide most recent results; no further studies or testing are required for this examination. When appropriate, provide most recent results. No specific studies are required for this examination.

11A. HAS A TESTICULAR BIOPSY BEEN PERFORMED?

YES NO

Date of biopsy:

Results:

Spermatozoa present

Other, describe:

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

				SECTION XI - DIAGNOSTIC TESTING (CONTINUED)
11B. HAVE ANY OTHER IMAGING STUDIES, DIAGNOSTIC PROCEDURES OR LABORATORY TESTING BEEN PERFORMED AND ARE THE RESULTS AVAILABLE?
		YES		NO (If yes, provide type of test or procedure, date and results (brief summary)):

				SECTION XII - FUNCTIONAL IMPACT
12. DOES THE VETERAN'S MALE REPRODUCTIVE SYSTEM CONDITION(S), INCLUDING NEOPLASMS, IF ANY, IMPACT HIS ABILITY TO WORK?
		YES		NO (If yes, describe impact of each of the veteran's male reproductive system conditions, providing one or more examples):

SECTION XIII- REMARKS

13. REMARKS (if any)

SECTION XIV - PHYSICIAN'S CERTIFICATION AND SIGNATURE

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

14D. PHYSICIAN'S PHONE AND FAX NUMBER	14E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER	14F. 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-2, MAY 2018

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