Fillable HYPERTENSION DISABILITY BENEFITS QUESTIONNAIRE

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HYPERTENSION DISABILITY BENEFITS QUESTIONNAIRE

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NOTE: ALSO complete appropriate questionnaires for hypertension-related complications, if any (such as VA Form 21-0960J-1, Kidney Conditions (Nephrology)
Disability Benefits Questionnaire , if renal insufficiency is attributable to hypertension.)
HYPERTENSION DISABILITY BENEFITS QUESTIONNAIRE
2E. CURRENT BLOOD PRESSURE READINGS (SUFFICIENT IF VETERAN HAS A PREVIOUSLY ESTABLISHED DIAGNOSIS OF HYPERTENSION.)
2B. DOES THE VETERAN'S TREATMENT PLAN INCLUDE TAKING CONTINUOUS MEDICATION FOR HYPERTENSION OR ISOLATED SYSTOLIC HYPERTENSION?
2C. WAS THE VETERAN'S INITIAL DIAGNOSIS OF HYPERTENSION OR ISOLATED SYSTOLIC HYPERTENSION CONFIRMED BY BLOOD PRESSURE READINGS
TAKEN 2 OR MORE TIMES ON AT LEAST 3 DIFFERENT DAYS?
2D. DOES THE VETERAN HAVE A HISTORY OF A DIASTOLIC BP ELEVATION TO PREDOMINANTLY 100 OR MORE?
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 DBQ's completed by
private health care providers.
(If, "Yes," provide BP readings used to establish initial diagnosis, if known.)
(If "No," report BP readings taken 2 or more times on at least 3 different days in order to confirm diagnosis (unless veteran
is on treatment for hypertension.)
OMB Approved No. 2900-0776
Respondent Burden: 15 Minutes
Expiration Date: 03/31/2021
SECTION I - DIAGNOSIS
READING # 3:
2A. DESCRIBE THE HISTORY (INCLUDING ONSET AND COURSE) OF THE VETERAN'S HYPERTENSION CONDITION
(Brief summary):
NO
SECTION II - MEDICAL HISTORY
UNKNOWNYES
YES NO
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.
READING # 1:
NO
READING # 2:
YES
DATE OF READING:
DATE OF READING:
DATE OF READING:
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH HYPERTENSION OR ISOLATED SYSTOLIC HYPERTENSION BASED ON
THE FOLLOWING CRITERIA?
NOTE: For VA disability rating purposes, the term hypertension means that the diastolic blood pressure is predominantly 90mm or greater, and isolated systolic
hypertension means that the systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. For VA purposes, the
INITIAL diagnosis of hypertension or isolated systolic hypertension must be confirmed by readings taken 2 or more times on at least 3 different days. Blood pressure
results may be obtained from existing medical records or through scheduled visits for blood pressure measurements.
READING # 1: READING # 2:
READING # 1: READING # 2:
READING # 1: READING # 2:
DATE OF READING:
DATE OF READING:
DATE OF READING:
PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
NAME OF PATIENT/VETERAN
Page 1
21-0960A-3
VA FORM
MAR 2018
(If "Yes," provide only diagnoses that pertain to hypertension):
NOYES
1B. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO HYPERTENSION OR ISOLATED SYSTOLIC HYPERTENSION, LIST USING ABOVE FORMAT:
(If "Yes," list only those medications used for the diagnosed conditions):
(If "Yes," describe frequency and severity of diastolic BP elevation):
Hypertension
Isolated systolic hypertension
Other, specify:
ICD code: Date of diagnosis:
ICD code:
Date of diagnosis:ICD code:
Date of diagnosis:
Date of diagnosis:ICD code:
Other diagnosis #2:
Other diagnosis #1:
SUPERSEDES VA FORM 21-0960A-3, DEC 2014,
WHICH WILL NOT BE USED.
SECTION III - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMS
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.
3A. 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?
YES NO
(If "Yes," complete Item 3B)
6C. DATE SIGNED
6E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER 6F. PHYSICIAN'S ADDRESS
6B. PHYSICIAN'S PRINTED NAME
(VA Regional Office FAX No.)
6A. PHYSICIAN'S SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
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.
SECTION VI - PHYSICIAN'S CERTIFICATION AND SIGNATURE
IMPORTANT - Physician please fax the completed form to
6D. PHYSICIAN'S PHONE AND FAX NUMBER
NOTE - VA may request additional medical information, including additional examinations, if necessary to complete VA's review of the veteran's application.
5. REMARKS (If any)
VA FORM 21-0960A-3, MAR 2018
Page 2
3B. 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)
3C. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS RELATED TO THE
CONDITION(S) LISTED IN SECTION I, DIAGNOSIS?
YES NO
(If "Yes," describe-brief summary)
SECTION IV - FUNCTIONAL IMPACT
4. DOES THE VETERAN'S HYPERTENSION OR ISOLATED SYSTOLIC HYPERTENSION IMPACT HIS OR HER ABILITY TO WORK?
YES NO
(If "Yes," describe the impact of the veteran's hypertension or isolated systolic hypertension, providing one or more examples):
SECTION V - REMARKS
PATIENT/VETERAN'S SOCIAL SECURITY NO.
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HYPERTENSION DISABILITY BENEFITS QUESTIONNAIRE

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Completed 1 April 2021

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