Professional Documents
Culture Documents
2900-0781
Respondent Burden: 30 Minutes
Expiration Date: 12/31/2022
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 (First, Middle Initial, Last)
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 RESPIRATORY CONDITION? (This is the condition the veteran is
claiming or for which an exam has been requested.)
YES NO (If "Yes," complete Item 1B)
NOTE: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed above. 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 appropriate date determined through record review or
reported history.
1B. SELECT THE VETERAN'S CONDITION (Check all that apply):
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.)
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.
SARCOIDOSIS ICD code: Date of diagnosis:
BENIGN OR MALIGNANT NEOPLASM OR METASTASES OF
RESPIRATORY SYSTEM (If checked, specify):
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.
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
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):
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
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)
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):
PART C - SARCOIDOSIS
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
Pulmonary involvement
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:
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)
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 G - PNEUMOTHORAX
1. INDICATE THE TYPE OF PNEUMOTHORAX, TREATMENT AND RESIDUAL CONDITIONS, IF ANY (Check all that apply):
2. IF THE VETERAN HAS MORE THAN ONE RESPIRATORY CONDITION, INDICATE WHICH CONDITION IS PREDOMINANTLY RESPONSIBLE FOR THE EPISODES
OF RESPIRATORY FAILURE:
2. IF THE VETERAN HAS MORE THAN ONE RESPIRATORY CONDITION, INDICATE WHICH CONDITION IS PREDOMINANTLY RESPONSIBLE FOR THE EPISODES
OF RESPIRATORY FAILURE:
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:
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:
Date of test:
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
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)):
8D. PHYSICIAN'S PHONE/FAX NUMBERS 8E. NATIONAL PROVIDER IDENTIFIER (NPI) 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.
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.