VA Form 21-0960K-2 GYNECOLOGICAL CONDITIONS DISABILITY BENEFITS QUESTIONNAI

OMB Approved No. 2900-0778
Respondent Burden: 30 Minutes
Expiration Date: XX/XX/XXXX

GYNECOLOGICAL 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 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. 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 SHE EVER HAD A GYNECOLOGICAL CONDITION?
YES

NO

(If "Yes," complete Item 1B)

NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed below. If there is no diagnosis, if the diagnosis is different
from a previous diagnosis for this condition, or if there is a diagnosis of a complication due to the claimed condition, explain your findings and reasons in the Remarks
section. Date of diagnosis can be the date of the evaluation if the clinician is making the initial diagnosis, or an approximate date is determined through record review or
reported history.
1B. PROVIDE ONLY DIAGNOSES THAT PERTAIN TO GYNECOLOGICAL CONDITION(S):
DIAGNOSIS # 1 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 2 -

ICD CODE -

DATE OF DIAGNOSIS -

DIAGNOSIS # 3 -

ICD CODE -

DATE OF DIAGNOSIS -

1C. IF THERE ARE ADDITIONAL GYNECOLOGICAL DIAGNOSES, LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY
2. DESCRIBE THE HISTORY (including cause, onset and course) OF EACH OF THE VETERAN'S GYNECOLOGICAL CONDITION(S):

SECTION III - SYMPTOMS
3. DOES THE VETERAN CURRENTLY HAVE SYMPTOMS RELATED TO A GYNECOLOGICAL CONDITION, INCLUDING ANY DISEASES, INJURIES OR ADHESIONS
OF THE FEMALE REPRODUCTIVE ORGANS?
YES

NO

(If yes, indicate current symptoms including frequency and severity of pain, if any - check all that apply):
Intermittent pain
Constant pain
Mild pain
Moderate pain
Severe pain
Pelvic pressure
Irregular menstruation
Frequent or continuous menstrual disturbances
Other signs and/or symptoms, describe and indicate condition(s) causing them:

SECTION IV - TREATMENT
4A. HAS THE VETERAN HAD TREATMENT FOR SYMPTOMS/FINDINGS FOR ANY DISEASES, INJURIES AND/OR ADHESIONS OF THE REPRODUCTIVE ORGANS?
YES

NO

(If yes, specify condition(s), organ(s) affected and treatment):
Date(s) of treatment:
4B. DOES THE VETERAN CURRENTLY REQUIRE TREATMENT OR MEDICATIONS FOR SYMPTOMS RELATED TO REPRODUCTIVE TRACT CONDITIONS?
YES

NO

(If yes, list current treatment/medications and the reproductive organ conditions being treated):

VA FORM
XXX XXXX

21-0960K-2

SUPERSEDES VA FORM 21-0960K-2, OCT 2012,
WHICH WILL NOT BE USED.

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SECTION IV - SYMPTOMS (Continued)
4C. IF YES, INDICATE EFFECTIVENESS OF TREATMENT IN CONTROLLING SYMPTOMS:
Symptoms do not require continuous treatment for the following organ/condition:
Symptoms require continuous treatment for the following organ/condition:
Symptoms are not controlled by continuous treatment for the following organ/condition:

SECTION V - CONDITIONS OF THE VULVA
5. HAS THE VETERAN BEEN DIAGNOSED WITH ANY DISEASES, INJURIES OR OTHER CONDITIONS OF THE VULVA (to include vulvovaginitis)?
YES

NO

(If yes, describe):

SECTION VI - CONDITIONS OF THE VAGINA
6. HAS THE VETERAN BEEN DIAGNOSED WITH ANY DISEASES, INJURIES OR OTHER CONDITIONS OF THE VAGINA?
YES

NO

(If yes, describe):

SECTION VII - CONDITIONS OF THE CERVIX
7. HAS THE VETERAN BEEN DIAGNOSED WITH ANY DISEASES, INJURIES, ADHESIONS OR OTHER CONDITIONS OF THE CERVIX?
YES

NO

(If yes, describe):

SECTION VIII - CONDITIONS OF THE UTERUS
8A. HAS THE VETERAN BEEN DIAGNOSED WITH ANY DISEASES, INJURIES, ADHESIONS OR OTHER CONDITIONS OF THE UTERUS?
YES

NO

8B. HAS THE VETERAN HAD A HYSTERECTOMY?
YES

NO

(If yes, provide date(s) of surgery, facility(ies) where performed and cause):

8C. DOES THE VETERAN HAVE UTERINE PROLAPSE?
YES

NO

(If yes, indicate severity):
Incomplete
Complete (through vagina and introitus)
(If yes, does the condition currently cause symptoms?)
YES

NO

(If yes, describe):

8D. DOES THE VETERAN HAVE UTERINE FIBROIDS, ENLARGEMENT OF THE UTERUS AND/OR DISPLACEMENT OF THE UTERUS?
YES

NO

(If yes, are there signs and symptoms?):
YES

NO

(If yes, check all that apply):
Adhesions
Marked displacement: If checked, indicate cause:
Marked enlargement: If checked, indicate cause:
Uterine fibroids
Irregular menstruation: If checked, indicate cause:
Frequent or continuous menstrual disturbances: If checked, indicate cause:
Other, describe and indicate cause:

VA FORM 21-0960K-2, XXX XXXX

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SECTION VIII - CONDITIONS OF THE UTERUS (Continued)
8E. HAS THE VETERAN BEEN DIAGNOSED WITH ANY OTHER DISEASES, INJURIES, ADHESIONS OR OTHER CONDITIONS OF THE UTERUS?
YES

NO

(If yes, describe):

SECTION IX - CONDITIONS OF THE FALLOPIAN TUBES
9. HAS THE VETERAN BEEN DIAGNOSED WITH ANY DISEASES, INJURIES, ADHESIONS OR OTHER CONDITIONS OF THE FALLOPIAN TUBES (to include pelvic

inflammatory disease)?
YES

NO

(If yes, describe):

SECTION X - CONDITIONS OF THE OVARIES
10A. HAS THE VETERAN UNDERGONE MENOPAUSE?
NO

YES

(If yes, indicate):

Natural menopause
Premature menopause
Surgical menopause
Chemical-induced menopause
Radiation-induced menopause
10B. HAS THE VETERAN UNDERGONE PARTIAL OR COMPLETE OOPHORECTOMY?
YES

NO

(If "No,", complete 10C.)
(If "Yes," check all that apply):
Partial removal of an ovary
Right

Both

Left

Complete removal of an ovary
Right

Left

Both

(If yes, provide date(s) of surgery, facility(ies) where performed and reason for surgery):

10C. DOES THE VETERAN HAVE EVIDENCE OF COMPLETE ATROPHY OF 1 OR BOTH OVARIES?
YES

NO

UNKNOWN

(If yes, etiology):

(If yes, indicate severity):
Partial atrophy of 1 or both ovaries
Complete atrophy of 1 ovary
Complete atrophy of both ovaries (excluding natural menopause)
10D. HAS THE VETERAN BEEN DIAGNOSED WITH ANY OTHER DISEASES, INJURIES, ADHESIONS AND/OR OTHER CONDITIONS OF THE OVARIES?
YES

NO

(If yes, describe):

SECTION XI - INCONTINENCE
11. DOES THE VETERAN HAVE URINARY INCONTINENCE/LEAKAGE?
YES

NO

(If yes, condition causing it):

(If yes, is the urinary incontinence/leakage due to a gynecologic condition?):
YES

NO

(If yes, check all that apply):
Does not require/does not use absorbent material
Stress incontinence
Requires absorbent material that is changed less than 2 times per day
Requires absorbent material that is changed 2 to 4 times per day
Requires absorbent material that is changed more than 4 times per day
Requiring the use of an appliance
If checked, describe appliance:

VA FORM 21-0960K-2, XXX XXXX

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SECTION XII - FISTULAE
12A. DOES THE VETERAN HAVE A RECTOVAGINAL FISTULA?
YES

NO

(If yes, cause):

(If yes, does the veteran have vaginal-fecal leakage?):
YES

NO

(If yes, indicate frequency (check all that apply)):
Less than once a week
1-3 times per week
4 or more times per week
Daily or more often
Requires wearing of pad or absorbent material
12B. DOES THE VETERAN HAVE AN URETHROVAGINAL FISTULA?
YES

NO

(If yes, cause):

(If yes, does the veteran have urine leakage?):
YES

NO

(If yes, check all that apply):
Does not require/does not use absorbent material
Requires absorbent material that is changed less than 2 times per day
Requires absorbent material that is changed 2 to 4 times per day
Requires absorbent material that is changed more than 4 times per day
Requires the use of an appliance
If checked, describe appliance:

SECTION XIII - ENDOMETRIOSIS

NOTE - A diagnosis of endometriosis must be substantiated by laparoscopy.
13. HAS THE VETERAN BEEN DIAGNOSED WITH ENDOMETRIOSIS?
YES

NO

(If yes, does the veteran currently have any findings, signs or symptoms due to endometriosis?)
YES

NO

(If yes, check all that apply):
Pelvic pain
Heavy or irregular bleeding requiring continuous treatment for control
Heavy or irregular bleeding not controlled by treatment
Lesions involving bowel or bladder confirmed by laparoscopy
Bowel or bladder symptoms from endometriosis
Anemia caused by endometriosis
Other, describe:

SECTION XIV - COMPLICATIONS AND RESIDUALS OF PREGNANCY OR OTHER GYNECOLOGIC PROCEDURES
14A. HAS THE VETERAN HAD ANY SURGICAL COMPLICATIONS OF PREGNANCY?
YES

NO

(If yes, check all that apply):
Relaxation of perineum
Rectocele
Cystocele
Other, describe:
14B. HAS THE VETERAN HAD ANY OTHER COMPLICATIONS RESULTING FROM OBSTETRICAL OR GYNECOLOGIC CONDITIONS OR PROCEDURES?
YES

NO

(If yes, describe):

NOTE - If obstetrical or gynecologic complications impact other body systems, also complete the additional appropriate Questionnaire(s)
VA FORM 21-0960K-2, XXX XXXX

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SECTION XV - TUMORS AND NEOPLASMS
15A. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DIAGNOSIS?
YES

(If "Yes," also complete Items 15B through 15E)

NO

15B. IS THE NEOPLASM
BENIGN

MALIGNANT

15C. 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 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
Date of most recent procedure:

If checked, describe procedure:
Other therapeutic treatment
If checked, describe treatment:
Date of completion of treatment or anticipated date of completion:

15D. 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 ITEM 15C?
YES

NO

(If "Yes," list residual conditions and complications - brief summary):

15E. IF THERE ARE ADDITIONAL BENIGN OR MALIGNANT NEOPLASMS OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN SECTION I, DESCRIBE
USING THE FORMAT IN ITEM 15C:

SECTION XVI - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
16A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
THE DIAGNOSIS SECTION?
YES

NO

(If "Yes," are any of the scars painful or unstable; have a total area equal to or greater than 39 square cm (6 square inches); or are located on the head, face or neck?)
YES

NO

(If "Yes," ALSO complete VA Form 21-0960F-1, Scars/Disfigurement Disability Benefits Questionnaire.)
(If "No,' provide location and measurements of scar in centimeters.)
Location:
Measurements: Length

cm X width

cm.

NOTE: An "unstable scar" is one where, for any reason, there is frequent loss of covering of the skin over the scar. If there are multiple scars, enter additional locations and measurements
in the Remarks section below. It is not necessary to also complete a Scars DBQ.
16B. DOES THE VETERAN HAVE ANY OTHER PERTINENT FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS RELATED TO ANY
CONDITIONS LISTED IN THE DIAGNOSIS SECTION?
YES

NO

(If yes, describe - brief summary):

VA FORM 21-0960K-2, XXX XXXX

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SECTION XVII - DIAGNOSTIC TESTING

NOTE - If laboratory test results are in the medical record and reflect the veteran's current condition, repeat testing is not required.
17A. HAS THE VETERAN HAD LAPAROSCOPY?
YES

(If yes, provide date(s), facility where performed, and results):

NO

17B. HAS THE VETERAN BEEN DIAGNOSED WITH ANEMIA? (If due to a gynecological condition noted in Section I.)
YES

(If yes, provide most recent test results):

NO

Hgb:

Hct:

Date of test:

17C. HAS THE VETERAN HAD ANY OTHER DIAGNOSTIC TESTING AND IF SO, ARE THERE SIGNIFICANT FINDINGS AND/OR RESULTS?
YES

NO

(If yes, provide type of test or procedure, date and results (brief summary)):

SECTION XVIII - FUNCTIONAL IMPACT
18. DOES THE VETERAN'S GYNECOLOGICAL CONDITION(S) IMPACT HER ABILITY TO WORK?
YES

NO

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

SECTION XIX - REMARKS
19. REMARKS (If any)

SECTION XX - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
20A. PHYSICIAN'S SIGNATURE

20D. PHYSICIAN'S PHONE AND FAX NUMBERS

20B. PHYSICIAN'S PRINTED NAME

20E. PHYSICIAN'S MEDICAL LICENSE NUMBER

20C. DATE SIGNED

20F. 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 21-0960K-2, XXX XXXX

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