Va Form 21-0960j-2 - Male Reproductive Organ Conditions Disability Benefits Questionnaire Page 4
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6SECTION VIII - PHYSICAL EXAM
8A. PENIS
Normal
Not examined per veteran's request
Not examined per veteran's request; Veteran reports normal anatomy with no penile deformity or abnormality
Not examined; penis exam not relevant to condition
Abnormal
If abnormal, indicate severity:
Loss/removal of half or more of penis
Loss/removal of glans penis
(such as Peyronie's disease)
Penis deformity
If checked, describe:
8B. TESTES
Normal
Not examined per veteran's request
Not examined per veteran's request; Veteran reports normal anatomy with no testicular deformity or abnormality
Not examined; testicular exam not relevant to condition
Abnormal
If abnormal, check all that apply:
Right testicle
Size 1/3 or less of normal
Size 1/2 to 1/3 of normal
Considerably harder than normal
Considerably softer than normal
Absent
Other abnormality
Describe:
Left testicle
Size 1/3 or less of normal
Size 1/2 to 1/3 of normal
Considerably harder than normal
Considerably softer than normal
Absent
Other abnormality
Describe:
8C. EPIDIDYMIS
Normal
Not examined per veteran's request
Not examined per veteran's request; veteran reports normal anatomy of epididymis with no deformity or abnormality
Not examined; epididymis exam not relevant to condition
Abnormal
If abnormal, check all that apply:
Right epididymis
Tender to palpation
Other, describe:
Left epididymis
Tender to palpation
Other, describe:
8D. PROSTATE
Normal
Not examined per veteran's request
Not examined; prostate exam not relevant to condition
Abnormal
If abnormal, describe:
Page 4
VA FORM 21-0960J-2, OCT 2012
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