HomeVA Commonly Used FormsDisability Benefits Questionnaires (DBQ)Disability Benefits Questionnaire (DBQ) Forms

3.1. Disability Benefits Questionnaire (DBQ) Forms

Disability Benefits Questionnaires (DBQs) are medical examination forms used to obtain important information for evaluating disability compensation and/or pension claims.

 

The following DBQ can be obtained by visiting: http://www.benefits.va.gov/COMPENSATION/dbq_ListByDBQFormName.asp

 

Cardiovascular

Form #

Form Name

21-0960A-2

Artery and Vein Conditions (Vascular Diseases including Varicose Veins)

21-0960A-3

Hypertension

21-0960A-4

Heart Conditions (including IHD, Non-IHD, Arrhythmias, Valvular Disease and Cardiac Surgery)

 

Dental and Oral

Form #

Form Name

21-0960M-15

Temporomandibular Joint (TMJ) Conditions

21-0960D-1

Oral and Dental Conditions, including Mouth, Lips, and Tongue (other than Temporomandibular Joint Conditions)

 

Dermatological

Form #

Form Name

21-0960F-1

Scars/Disfigurement

21-0960F-2

Skin Diseases

 

Ear, Nose and Throat

Form #

Form Name

21-0960N-1

Ear Conditions (including Vestibular and Infectious Conditions)

21-0960N-3

Loss of Sense of Smell and/or Taste

21-0960N-4

Sinusitis, Rhinitis, and Other Conditions of the Nose, Throat, Larynx, and Pharynx

 

Endocrinological

Form #

Form Name

21-0960E-1

Diabetes Mellitus

21-0960E-2

Endocrine Diseases (other than Thyroid and Parathyroid, or Diabetes Mellitus)

21-0960E-3

Thyroid and Parathyroid Conditions

 

Gastrointestinal

Form #

Form Name

21-0960G-1

Esophageal Conditions (Including GERD, Hiatal Hernia and Other Esophageal Disorders)

21-0960G-2

Gallbladder and Pancreas Conditions

21-0960G-3

Intestinal Conditions (other than Surgical or Infectious) Including Irritable Bowel Syndrome, Crohn's Disease, Ulcerative Colitis and Diverticulitis

21-0960G-4

Intestinal Surgery (Bowel Resection, Colostomy, Illiostomy)

21-0960G-5

Hepatitis, Cirrhosis, and other Liver Conditions

21-0960G-6

Peritoneal Adhesions

21-0960G-7

Stomach and Duodenal Conditions (not including GERD or Esophageal Disorders)

21-0960G-8

Infectious Intestinal Disorders (including Bacterial and Parasitic Infections)

 

Genitourinary

Form #

Form Name

21-0960J-1

Kidney Conditions (Nephrology)

21-0960J-2

Male Reproductive Organ Conditions

21-0960J-3

Prostate Cancer

21-0960J-4

Urinary Tract (including Bladder and Urethra) Conditions (excluding Male Reproductive System)

 

Gynecological

Form #

Form Name

21-0960K-1

Breast Conditions and Disorders

21-0960K-2

Gynecological Conditions

 

Hematologic and Lymphatic

Form #

Form Name

21-0960B-1

Hairy Cell and Other B-Cell Leukemias

21-0960B-2

Hematologic and Lymphatic Conditions, including Leukemia

 

Infectious Diseases

Form #

Form Name

21-0960I-1

Persian Gulf and Afghanistan Infectious Diseases

21-0960I-2

HIV-Related Illnesses

21-0960I-3

Infectious Diseases (other than HIV-Related Illness, Chronic Fatigue Syndrome, or Tuberculosis)

21-0960I-4

Systemic Lupus Erythematosus (SLE) and Other Autoimmune Diseases

21-0960I-5

Nutritional Deficiencies

21-0960I-6

Tuberculosis

 

Musculoskeletal

Form #

Form Name

21-0960M-1

Amputations

21-0960M-2

Ankle Conditions

21-0960M-3

Non-Degenerative Arthritis (including Inflammatory, Autoimmune, Crystalline and Infectious Arthritis) and Dysbaric Osteonecrosis

21-0960M-4

Elbow and Forearm Conditions

21-0960M-6

Foot Conditions, Including Flatfoot (Pes Planus)

21-0960M-7

Hand and Finger Conditions

21-0960M-8

Hip and Thigh Conditions

21-0960M-9

Knee and Lower Leg Conditions

21-0960M-10

Muscle Injuries

21-0960M-11

Osteomyelitis

21-0960M-12

Shoulder and Arm Conditions

21-0960M-13

Neck (Cervical Spine) Conditions

21-0960M-14

Back (Thoracolumbar Spine) Conditions

21-0960M-16

Wrist Conditions

 

Neurological

Form #

Form Name

21-0960C-1

Parkinson's Disease

21-0960C-2

Amyotrophic Lateral Sclerosis (Lou Gehrig's Disease)

21-0960C-3

Cranial Nerve Conditions

21-0960C-4

Diabetic Sensory-Motor Peripheral Neuropathy

21-0960C-5

Central Nervous System and Neuromuscular Diseases (except TBI, ALS, PD, MS, Headaches, TMJ, Epilepsy, Narcolepsy, Peripheral Nerves, Sleep Apnea, Cranial Nerves, Fibromyalgia, and CFS)

21-0960C-6

Narcolepsy

21-0960C-7

Fibromyalgia

21-0960C-8

Headaches (Including Migraine Headaches)

21-0960C-9

Multiple Sclerosis (MS)

21-0960C-10

Peripheral Nerve Conditions (Not Including Diabetic Sensory-Motor Peripheral Neuropathy)

21-0960C-11

Seizure Disorders

 

Ophthalmological

Form #

Form Name

21-0960N-2

Eye Conditions

 

Psychological

Form #

Form Name

21-0960P-1

Eating Disorders

21-0960P-2

Mental Disorders (other than PTSD)

21-0960P-3

Review Post Traumatic Stress Disorder (PTSD)

 

Respiratory

Form #

Form Name

21-0960L-1

Respiratory Conditions (other than Tuberculosis and Sleep Apnea)

21-0960L-2

Sleep Apnea

 

Rheumatological

Form #

Form Name

21-0960Q-1

Chronic Fatigue Syndrome

 

General Surgery

Form #

Form Name

21-0960H-1

Hernias (including Abdominal, Inguinal, and Femoral Hernias)

21-0960H-2

Rectum and Anus Conditions (including Hemorrhoids)

 

 

This page was: Helpful | Not Helpful