VA BENEFITS CONSULTANTS
HEART DISABILITIES
( Case Specific Disability Questionnaire)
Please answer the following questions regarding the current severity of your Heart Disability:
HOW MY HEART DISABILITY AFFECTS MY DAILY LIFE
Describe how your heart condition affects your daily activities and ability to work:
THE HISTORY OF YOUR HEART DISABILITY
Describe how your heart disability condition began, and how it progressed:
SURGERY and/or SCARS
Type of surgery related to this disability (if no surgeries, please type N/A)
Date of surgery (if no surgeries, please type N/A):
Is the surgical scar painful?
Yes | No | N/A - No Surgries |
How long is the scar? (if no surgery, type N/A)
HEART RELATED SYMPTOMS and INDICATIONS
Please check all symptoms that you are currently experiencing as a result of your condition, or have experienced within the last year:
Chest pain
Fatigue
Fainting
Dizziness
Difficulty breathing (dyspnea)
Other:
Chest pain | Fatigue | ||
Fainting | Dizziness | ||
Difficulty breathing (dyspnea) | Other: |
HEART ATTACKS
DATE(S)
TREATING FACILITY(IES):
METABOLIC EQUIVALENT TESTING (METS)
Slow walking, eating, showering or bathing, getting dressed (1 – 3 METS, up to 100%)
Brisk walking, light gardening or mowing (3 – 5 METS, up to 60%)
Heavy yard work, golfing (no cart), walking up a flight of stairs (5 – 7 METS, up to 30%)
Biking, jogging, chopping wood, swimming, climbing stairs rapidly (7- 10 METS, up to 10%)
Slow walking, eating, showering or bathing, getting dressed (1 – 3 METS, up to 100%) | Brisk walking, light gardening or mowing (3 – 5 METS, up to 60%) | ||
Heavy yard work, golfing (no cart), walking up a flight of stairs (5 – 7 METS, up to 30%) | Biking, jogging, chopping wood, swimming, climbing stairs rapidly (7- 10 METS, up to 10%) |
MEDICATIONS
Describe the medications you’re now receiving, or have historically received for your heart condition:
Dated:
SIGNED:
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