Disability Benefits Questionnaire
* Internal VA or DoD Use Only *
Name of Veteran/Service Member: / SSN:
Date: / VA Claim Number:
Contractor: / VES / VES Number:
The Veteran 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.
NOTE: The General Medical Questionnaire is a screening examination for all body systems and is not meant to elicit the detailed information about specific conditions that is necessary for rating purposes. Therefore, all claimed conditions, and any found or suspected conditions that were not claimed, should be addressed by referring to and following all appropriate Questionnaires to assure that the examination for each condition provides information adequate for rating purposes.
This exam is to ensure that any conditions that might not be specifically addressed on the original exam request are identified for possible entitlement to benefits.
PLEASE EVALUATE ALL OF THE VETERAN’S CONDITIONS, EVEN THOSE THAT OCCURRED BEFORE OR AFTER MILITARY SERVICE.
PLEASE DO NOT ADD ANY DBQs TO EVALUATE HIGH CHOLESTEROL; THIS IS NOT A COMPENSABLE CONDITION FOR VA RATING PURPOSES.
NOTE: ALL BLOOD PRESSURES SHOULD BE TAKEN WITH THE VETERAN SITTING IN CHAIR, FEET AND BACK SUPPORTED, ARM AT HEIGHT OF HEART.
Vital Signs
Height: / Weight:Pulse: / Blood Pressure:
1. Medical record review
*If no records were reviewed for this examination, please select “Other” and describe as “none”.
Indicate medical records reviewed in preparation of this report:
o C-file (VA only)
o Other, describe:
2. Medical history
Perform a thorough review of all body systems. Based on this review, complete the sections below that pertain to the Veteran’s symptoms. Complete the appropriate Questionnaire(s) based on your selections below.
a. Is there a skin and/or scar condition?
o Yes o No
If yes, check all that apply and complete the corresponding Questionnaire(s):
o Skin Diseases
o Scars
NOTE: THE SCAR DBQ SHOULD ONLY BE COMPLETED IF THE VETERAN HAS ANY SCARS THAT ARE PAINFUL, UNSTABLE, AND/OR GREATER THAN 39 SQUARE CENTIMETERS OR 6 SQUARE INCHES.
b. Is there a hemic and/or lymphatic condition?
o Yes o No
If yes, check all that apply and complete the corresponding Questionnaire(s):
o Hematologic (including Anemia) and Lymphatic (Including Non-Hodgkin’s Lymphoma)
o Hairy Cell & Other B-Cell Leukemias
c. Is there an eye condition?
o Yes o No
NOTE: Vision evaluations must be conducted by a specialist.
Please state the eye condition:
d. Is there an ear condition?
o Yes o No
If, yes check all that apply:
o Hearing Loss and Tinnitus
o Ear Conditions
Note: If hearing loss and/or tinnitus is the only ear complaint, there is no need to complete the Ear Disease DBQ. Please simply request an audiology consult by emailing .
For all other ear conditions, please add and complete the Ear Conditions questionnaire.
e. Is there a nose, sinuses, mouth and/or throat condition?
o Yes o No
If yes, check all that apply and complete the corresponding Questionnaire(s):
o Sinusitis/Rhinitis and Other Conditions of the Nose, Throat, Larynx and Pharynx
o Loss of Sense of Smell and/or Taste
o Oral and Dental Conditions (including mouth, lips and tongue)
o Temporomandibular Joint
f. Is there a respiratory condition other than tuberculosis?
o Yes o No
If yes, check all that apply and complete the corresponding Questionnaire(s):
o Respiratory Conditions (other than tuberculosis and sleep apnea)
o Sleep Apnea
g. Is there a disorder of the breast?
o Yes o No
If yes, complete the Breast Conditions and Disorders Questionnaire.
h. Is there a cardiovascular condition?
o Yes o No
If yes, check all that apply and complete the corresponding Questionnaire(s):
o Ischemic Heart Disease
o Heart Conditions (including arrhythmias, valvular disease, and cardiac surgery)
o Artery & Vein Conditions (vascular diseases including varicose veins)
o Hypertension
i. Is there an abdomen and/or digestive condition?
o Yes o No
If yes, check all that apply and complete the corresponding Questionnaire(s):
o Esophageal Conditions (GERD and Hiatal Hernia)
o Gallbladder and Pancreas
o Infectious Intestinal Disorders (including bacterial and parasitic infections)
o Intestinal Surgery (bowel resection, colostomy, and ileostomy)
o Intestinal Conditions (other than Surgical and Infectious)
o Hepatitis, Cirrhosis, and Other Liver Conditions\
o Peritoneal Adhesions
o Stomach and Duodenal Conditions
o Abdominal, Inguinal, and Femoral Hernias
o Rectum and Anus (Including Hemorrhoids)
j. Is there a male genitourinary or reproductive system condition?
o Yes o No
If yes, check all that apply and complete the corresponding Questionnaire(s):
o Kidney Conditions
o Male Reproductive System
o Prostate Cancer
o Urinary Tract (including Bladder and Urethral) Conditions
k. Is there a female genitourinary or reproductive system condition?
o Yes o No
If yes, check all that apply and complete the corresponding Questionnaire(s):
o Gynecological Conditions
o Kidney Conditions
o Urinary Tract (including Bladder and Urethral) Conditions
l. Is there a musculoskeletal condition?
o Yes o No
If yes, check all that apply and complete the corresponding Questionnaire(s):
Spine
o Back (Thoracolumbar Spine) Conditions
o Neck (Cervical Spine) Conditions
Joints and extremities
o Ankle
o Elbow and Forearm
o Hands and Fingers
o Hip and Thigh
o Knee and Lower Leg
o Shoulder and Arm
o Wrist
Feet
o Foot Conditions, Including Flatfoot
Miscellaneous
o Amputations
o Fibromyalgia
o Osteomyelitis
o Muscle Injuries
o Non-degenerative Arthritis (including inflammatory, autoimmune, crystalline and infectious arthritis) and Dysbaric Osteonecrosis
m. Is there an endocrine and/or metabolic condition?
o Yes o No
If yes, check all that apply and complete the corresponding Questionnaire(s):
o Diabetes Mellitus
o Thyroid and Parathyroid
o Endocrine Diseases (other than Thyroid, Parathyroid, or Diabetes Mellitus)
n. Is there a neurological condition?
o Yes o No
If yes, check all that apply and complete the corresponding Questionnaire(s):
o Parkinson’s Disease
o Amyotrophic Lateral Sclerosis (ALS)
o Cranial Nerves Diseases
o Diabetic Sensory-Motor Peripheral Neuropathy
o Disease of the Central Nervous System
o Fibromyalgia
o Narcolepsy
o Headaches (including Migraine Headaches)
o Multiple Sclerosis (MS)
o Peripheral Nerves
o Seizure Disorders (Epilepsy)
o Traumatic Brain Injury (Initial or Review)
o. Is there a psychiatric condition?
o Yes o No
If yes, check all that apply.
o Eating Disorders
o Mental Disorders (Other Than PTSD)
o PTSD (Initial or Review)
NOTE: Mental disorder evaluations must be conducted by a specialist.
p. Is there an infectious disease, an immune disorder and/or nutritional deficiency?
o Yes o No
If yes, check all that apply and complete the corresponding Questionnaire(s):
o Chronic Fatigue Syndrome
o Persian Gulf and Afghanistan Infectious Diseases
o HIV and Related Illness
o Infectious Diseases
o Systemic Lupus Erythematosus or other Autoimmune Disorders
o Nutritional Deficiencies
o Tuberculosis
q. Does the veteran have any Cold Injury residuals?
o Yes o No
If yes, complete the corresponding Questionnaire.
3. Diagnoses that are not addressed on other questionnaires
Provide a list of the Veteran’s diagnoses that have not been addressed on other questionnaires:
Diagnosis #1:ICD code:
Date of diagnosis:
Diagnosis #2:
ICD code:
Date of diagnosis:
Diagnosis #3:
ICD code:
Date of diagnosis:
If there are additional diagnoses, list using above format:
4. Physical Exam
o Normal PE
o Normal PE, except as noted on additional Questionnaires included as part of this report
o Other, describe:
5. Functional impact of each additional diagnosis not addressed on other questionnaires.
Does the Veteran have any conditions that impact his or her ability to work that are not addressed on other Questionnaires?
o Yes o No
If yes, describe the impact of each condition, providing one or more examples:
6. Remarks, if any:
NOTE: VA may request additional medical information, including additional examinations, if necessary to complete VA’s review of the Veteran’s application.
DBQ General Medical – Compensation / Name:Page 4 of 5 / VA Claim Number:
Contractor: VES