Form VA Form 21-0960B-2 VA Form 21-0960B-2 Hematologic and Lymphatic Conditions, Including Leukemia

OMB Approved No. 2900-0779
Respondent Burden: 15 Minutes
Expiration Date: XX/XX/XXXX

HEMATOLOGIC AND LYMPHATIC CONDITIONS, INCLUDING LEUKEMIA
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 HEMATOLOGIC OR LYMPHATIC CONDITION?
YES

NO

IF YES, SELECT THE VETERAN'S CONDITION(S) (check all that apply):
Acute lymphocytic leukemia (ALL)

ICD CODE:

Acute myelogenous leukemia (AML)

ICD CODE:

DATE OF DIAGNOSIS:
DATE OF DIAGNOSIS:

Chronic myelogenous leukemia (CML)

ICD CODE:

DATE OF DIAGNOSIS:

Chronic lymphocytic leukemia (CLL)

ICD CODE:

DATE OF DIAGNOSIS:

Hodgkin's disease

ICD CODE:

DATE OF DIAGNOSIS:

Non-Hodgkin's lymphoma

ICD CODE:

DATE OF DIAGNOSIS:

Multiple myeloma

ICD CODE:

DATE OF DIAGNOSIS:

Myelodysplastic syndrome

ICD CODE:

DATE OF DIAGNOSIS:

Plasmacytoma

ICD CODE:

DATE OF DIAGNOSIS:

Anemia (such as anemia of chronic disease, aplastic anemia, hemolytic

anemia, iron or vitamin-deficient anemias, thalassemias,
myelophthisic anemia, etc.)

ICD CODE:

DATE OF DIAGNOSIS:

Thrombocytopenia

ICD CODE:

DATE OF DIAGNOSIS:

Polycythemia vera

ICD CODE:

DATE OF DIAGNOSIS:

Sickle cell anemia

ICD CODE:

DATE OF DIAGNOSIS:

Splenectomy

ICD CODE:

DATE OF DIAGNOSIS:

Hairy cell or other B-cell leukemia: if checked, complete VA Form 21-0960B-1, Hairy Cell and other B-Cell Leukemias Disability Benefits Questionnaire
Other, specify
Other diagnosis #1:

ICD CODE:

DATE OF DIAGNOSIS:

Other diagnosis #2:

ICD CODE:

DATE OF DIAGNOSIS:

Other diagnosis #3:

ICD CODE:

DATE OF DIAGNOSIS:

1B. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO HEMATOLOGIC OR LYMPHATIC CONDITION(S), LIST USING ABOVE FORMAT:

SECTION II - MEDICAL HISTORY
2A. DESCRIBE THE HISTORY (including onset and course) OF THE VETERAN'S HEMATOLOGIC OR LYMPHATIC CONDITION (Brief summary):

2B. IS CONTINUOUS MEDICATION REQUIRED FOR CONTROL OF A HEMATOLOGIC OR LYMPHATIC CONDITION, INCLUDING ANEMIA OR THROMBOCYTOPENIA
CAUSED BY TREATMENT FOR A HEMATOLOGIC OR LYMPHATIC CONDITION?
YES

NO

IF YES, LIST ONLY THOSE MEDICATIONS REQUIRED FOR CONTROL OF THE VETERAN'S HEMATOLOGIC OR LYMPHATIC CONDITION, INCLUDING ANEMIA OR
THROMBOCYTOPENIA CAUSED BY TREATMENT FOR A HEMATOLOGIC OR LYMPHATIC CONDITION. PROVIDE THE NAME OF THE MEDICATION AND THE
CONDITION THE MEDICATION IS USED TO TREAT:

2C. INDICATE THE STATUS OF THE PRIMARY HEMATOLOGIC OR LYMPHATIC CONDITION:
ACTIVE
VA FORM
XXX XXXX

REMISSION

21-0960B-2

NOT APPLICABLE
SUPERSEDES VA FORM 21-0960B-2, FEB 2015,
WHICH WILL NOT BE USED.

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SECTION III - TREATMENT
3. HAS THE VETERAN COMPLETED ANY TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING ANY TREATMENT FOR ANY HEMATOLOGIC OR
LYMPHATIC CONDITION, INCLUDING LEUKEMIA?
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
Bone marrow transplant, if checked provide:
Date of hospital admission and location:
Date of hospital discharge after transplant:
Surgery, if checked describe:
Date(s) of surgery:
Radiation therapy, if checked provide:
Date of most recent treatment:
Date of completion of treatment or anticipated date of completion:
Antineoplastic chemotherapy, if checked provide:
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:

SECTION IV - ANEMIA AND THROMBOCYTOPENIA (Primary, secondary, idiopathic and immune)
4A. DOES THE VETERAN HAVE ANEMIA OR THROMBOCYTOPENIA, INCLUDING THAT CAUSED BY TREATMENT FOR A HEMATOLOGIC OR LYMPHATIC
CONDITION?
YES

NO

IF YES, COMPLETE THE FOLLOWING:
4B. DOES THE VETERAN HAVE ANEMIA?
YES

NO

IF YES, IS THE ANEMIA CAUSED BY TREATMENT FOR ANOTHER HEMATOLOGIC OR LYMPHATIC CONDITION?
YES

NO

IF YES, PROVIDE THE NAME OF THE OTHER HEMATOLOGIC OR LYMPHATIC CONDITION CAUSING THE SECONDARY ANEMIA:

4C. DOES THE VETERAN HAVE THROMBOCYTOPENIA?
YES

NO

IF YES, IS THE THROMBOCYTOPENIA CAUSED BY TREATMENT FOR ANOTHER HEMATOLOGIC OR LYMPHATIC CONDITION?
YES

NO

IF YES, PROVIDE THE NAME OF THE OTHER HEMATOLOGIC OR LYMPHATIC CONDITION CAUSING THE SECONDARY THROMBOCYTOPENIA:

IF YES, CHECK ALL THAT APPLY:
Stable platelet count of 100,000 or more
Stable platelet count between 70,000 and 100,000
Platelet count between 20,000 and 70,000
Platelet count of less than 20,000
With active bleeding
Other, describe:
4D. DOES THE VETERAN HAVE ANY COMPLICATIONS OR RESIDUALS OF TREATMENT REQUIRING TRANSFUSION OF PLATELETS OR RED BLOOD CELLS?
YES

NO

IF YES, INDICATE FREQUENCY OF TRANSFUSIONS IN THE PAST 12 MONTHS:
None
At least once per year but less than once every 3 months
At least once every 3 months
At least once every 6 weeks
VA FORM 21-0960B-2, XXX XXXX

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SECTION V - FINDINGS, SIGNS AND SYMPTOMS

5. DOES THE VETERAN CURRENTLY HAVE ANY FINDINGS, SIGNS AND SYMPTOMS DUE TO A HEMATOLOGIC OR LYMPHATIC DISORDER
OR TO TREATMENT FOR A HEMATOLOGIC OR LYMPHATIC DISORDER?
YES

NO

IF YES, CHECK ALL THAT APPLY:
Weakness

If checked, describe:

Easy fatigability

If checked, describe:

Light-headedness

If checked, describe:

Shortness of breath

If checked, describe:

Headaches

If checked, describe:

Dyspnea on mild exertion

If checked, describe:

Dyspnea at rest

If checked, describe:

Tachycardia

If checked, describe:

Syncope

If checked, describe:

Cardiomegaly
High output congestive heart failure
Other, describe:

SECTION VI - RECURRING INFECTIONS
6. DOES THE VETERAN CURRENTLY HAVE RECURRING INFECTIONS ATTRIBUTABLE TO ANY CONDITIONS, COMPLICATIONS OR RESIDUALS OF TREATMENT
FOR A HEMATOLOGIC OR LYMPHATIC DISORDER?
YES

NO

IF YES, INDICATE FREQUENCY OF INFECTIONS OVER PAST 12 MONTHS:
None
At least once per year but less than once every 3 months
At least once every 3 months
At least once every 6 weeks

SECTION VII - POLYCYTHEMIA VERA
7. DOES THE VETERAN HAVE POLYCYTHEMIA VERA?
YES

NO

IF YES, CHECK ALL THAT APPLY:
Stable with or without continuous medication
Requiring phlebotomy
Requiring myelosuppressant treatment
Other, describe:

NOTE: If there are complications due to polycythemia vera such as hypertension, gout, stroke or thrombotic disease, ALSO complete appropriate Questionnaire for
each condition.
SECTION VIII - SICKLE CELL ANEMIA
8. DOES THE VETERAN HAVE SICKLE CELL ANEMIA?
YES

NO

IF YES, CHECK ALL THAT APPLY:
Asymptomatic
In remission
With identifiable organ impairment
Following repeated hemolytic sickling crises with continuing impairment of health
Painful crises several times a year
Repeated painful crises, occurring in skin, joints, bones or any major organs
With anemia, thrombosis and infarction
Symptoms preclude other than light manual labor
Symptoms preclude even light manual labor
Other, describe:

SECTION IX - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS

9A. DOES THE VETERAN HAVE ANY SCARS (surgical or otherwise) RELATED TO ANY CONDITIONS OR TO THE TREATMENT OF ANY CONDITIONS LISTED IN
SECTION 1, 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)

VA FORM 21-0960B-2, XXX XXXX

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PATIENT/VETERAN'S SOCIAL SECURITY NO.

SECTION IX - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS (Continued)

9B. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS?
YES

NO

IF YES, DESCRIBE (Brief summary):

SECTION X - DIAGNOSTIC TESTING
NOTE: If testing has been performed and reflects veteran's current condition, no further testing is required. When appropriate, provide most recent complete blood count.
10A. HAS LABORATORY TESTING BEEN PERFORMED?
YES

NO

IF YES, PROVIDE RESULTS:
Hemoglobin (gm/100ml):

Date:

Hematocrit:

Date:

Red blood cell (RBC) count:

Date:

White blood cell (WBC) count:

Date:

White blood cell differential count:

Date:

Platelet count:

Date:

10B. 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 XI - FUNCTIONAL IMPACT
11. DOES THE VETERAN'S HEMATOLOGIC AND/OR LYMPHATIC CONDITION(S) IMPACT HIS OR HER ABILITY TO WORK?
YES

NO

IF YES, DESCRIBE IMPACT OF EACH OF THE VETERAN'S HEMATOLOGIC AND/OR LYMPHATIC CONDITIONS, PROVIDING ONE OR MORE EXAMPLES:

SECTION XII - REMARKS
12. REMARKS (If any)

SECTION XIII - PHYSICIAN'S CERTIFICATION AND SIGNATURE

CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
13A. PHYSICIAN'S SIGNATURE
13D. PHYSICIAN'S PHONE AND FAX NUMBER

13B. PHYSICIAN'S PRINTED NAME
13E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER

13C. DATE SIGNED
13F. 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 30 minutes to review the instructions, find the information, and complete the form. VA cannot conduct or sponsor a collection of information unless a valid
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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 21-0960B-2, XXX XXXX

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