Hepatitis A, B and C, autoimmune and drug-induced hepatitis, NASH, cirrhosis, primary biliary and sclerosing cholangitis, hemochromatosis and liver transplant are documented for VA disability claims on this 9-page questionnaire. The clinician records symptoms such as fatigue, anorexia and weight loss, cirrhosis complications with dates in the past 24 months, any MELD score, abscess or transplant details, and imaging, biopsy and lab results including hepatitis C genotype and viral titers.
The Veteran's treating or examining clinician completes the form and signs the Section XII examiner's certification. The Veteran does not complete any section.
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Hepatitis, Cirrhosis and Other Liver Conditions Disability Benefits Questionnaire
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Yes. Hepatitis C is a listed diagnosis. The examiner records symptoms, continuous medications, and whether parenteral antiviral and immunomodulatory therapy are both medically contraindicated, which routes the case to the cirrhosis section. Section VII captures RIBA, hepatitis C genotype and viral titers, AST, ALT, bilirubin, INR and biopsy results.
Section VI asks whether the Veteran is eligible for transplant surgery and the date a physician made that determination, whether the Veteran is awaiting a transplant, and, if transplanted, the surgery date, hospital admission and discharge dates, and current signs and symptoms.