Va from 21 0960j 2 Form 2012

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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. 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.,...

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