DBQ Submission Review Tool

What to doAlways select Yes — this is required for all VA C&P examination requests. There are no scenarios where No is appropriate.

What to select

• Saw the Veteran in person → check In-person examination
• Video call → check Examination via approved video telehealth
• Records only, no contact → select ACE option (do NOT check in-person or telehealth)
• Records + phone call → select the second ACE option

Always check Records reviewed — no exceptions.

What to doAlways check VA e-folder. If the Veteran brought physical records (like imaging printouts) that aren't in the e-folder:

• Tell the Veteran to submit them to VA
• Summarize those records in the Evidence Comments box
• Note in Remarks that they were brought in and Veteran was instructed to submit

Do not hold the DBQ waiting for the Veteran to submit records.

What to doIn the portal, 1A is a text box where you list the conditions being evaluated. Every condition listed on the exam request must appear here. Cross-check your assignment — if anything is missing, add it before moving on.

What to doCheck the box that matches the diagnosis — Migraine including migraine variants, Tension, Cluster, or Other. Enter the ICD code and date of diagnosis for each one selected.

If there is no diagnosis: check "The Veteran does not have a current diagnosis" and explain why in the Remarks section.

If the diagnosis is different from a previous one, or a complication was found, explain in Remarks.

5 things that must be in 2A

1. Date of onset — when did headaches start?
2. Details of onset — what caused or triggered it?
3. Course — has it gotten better, worse, or stayed the same?
4. Current symptoms — what does the Veteran experience now?
5. Treatments — medications, surgeries, procedures (write "None" if none)

⚠ Important: Any symptoms you check in Section 3B (like light or sound sensitivity) must also be mentioned here in 2A. If they're in 3B but not in 2A, that's a return reason.

What to doOnly list medications that are (1) prescribed AND (2) taken daily or on a scheduled basis for the headache condition.

• OTC medications taken as-needed → do NOT list here
• No daily medications → select No
• No diagnosis in Section I → must select No

What to checkIf the Veteran has headache pain, select Yes and check all applicable symptoms (constant, pulsating, one-sided, both-sided, worsens with activity, other).

⚠ Laterality rule: If you select "Pain localized to one side" OR "Pain on both sides" here in 3A, the same selection must match what you choose in 3D (location). These must be consistent — a mismatch will cause a return.

Common return reason — read carefullyIf you check any symptom in 3B (nausea, vomiting, sensitivity to light, sensitivity to sound, vision changes, sensory changes, etc.), that symptom must also appear in 2A medical history.

The most common return here: an examiner checks Sensitivity to light and Sensitivity to sound in 3B, but never mentioned them in 2A. That inconsistency triggers a return every time.

Before checking anything in 3B, ask yourself: "Did I write this in 2A?" If not, go back and add it.

3C — Duration: Select how long a typical headache lasts (less than 1 day, 1–2 days, more than 2 days, or describe).

3D — Location: Select right side, left side, both sides, or other.

⚠ Must match 3A: Whatever side you selected in 3A (one-sided vs. both-sided) must match your 3D selection. Example: if 3A says "pain localized to one side," then 3D must say right side or left side — not "both sides."

What to doDoes the Veteran have characteristic prostrating attacks?

• Yes — select frequency (less frequent, once in 2 months, once a month, greater than once a month). Objective findings must support this. Also means Section VII functional impact MUST be Yes.
• No — select No. No frequency needed.

⚠ If 4B is Yes, then 4A must also be Yes.

4B is a higher level than 4A — completely prostrating means the Veteran must lie down in a dark room for extended periods.

• If the Veteran described needing to lie in a dark room in Section VII → 4B should be Yes
• If 4B is Yes → 4A must also be Yes
• If 4B is No despite significant functional impact → explain in Remarks why attacks are not considered completely prostrating
• Objective findings must confirm — cannot be based on Veteran report alone

What to doAre there any other findings related to the headache diagnosis — such as complications or associated conditions?

• Yes → briefly describe in the text box
• No diagnosis in Section I, or no additional findings → select No

What to doDo any conditions or treatments for the headache condition result in scars or skin disfigurement?

• Yes → also complete the supplemental Scar/Disfigurement DBQ
• No → select No

If surgery was documented in the DBQ but no visible scarring on exam → note in Remarks.

Good news — no required diagnostics for headachesYou do not need to order any tests for this DBQ. However, if there are relevant diagnostic results already in the Veteran's records (e.g., MRI, CT scan related to headaches), include them here with the test name, date, and a brief summary of results.

• No relevant tests in records → select No
• Relevant tests exist → select Yes, click Add, and enter details (max 7 entries)

Common return reason — read carefullyThe functional impact must be written from your perspective as the examiner — not the Veteran's words. The VA wants to know how the headache condition limits what the Veteran can physically do.

Rules:

• Do NOT write "Veteran states..." or "Patient reports..." — write as the examiner
• Do NOT mention employment or ability to work
• Give at least one specific example (e.g., "The Veteran is unable to perform tasks requiring sustained concentration during headache episodes")
• Only describe impact of the headache condition — not other medical issues or age
• If Section IV 4A is Yes (prostrating attacks) → this MUST be Yes

❌ Return example: "When walking she feels she is swaying over and cannot stand or walk for too long." — this is the Veteran's words, not the examiner's clinical perspective, and doesn't connect to the headache diagnosis.

Is this a review or increase claim? (i.e., the Veteran is already service-connected for this headache condition)

If yes — you must include an ECQ (Established Condition Question) statement in 8A. Choose one of these 6 options and add rationale where required:

1. SC diagnosis has remained the same without additional diagnosis
2. SC diagnosis has changed and is a correction from the previous diagnosis (reasoning required)
3. SC diagnosis remains the same, but symptoms have worsened, without an additional diagnosis
4. SC diagnosis has progressed to a new diagnosis or resulted in a new related diagnosis (rationale required)
5. SC diagnosis has remained the same and includes a new unrelated condition (rationale required — differentiate symptoms)
6. SC diagnosis has resolved (rationale required)

Also use 8A for any section-specific clarifications, discrepancies, or required explanations (e.g., why 4B was No despite dark room behavior). Note which section each remark applies to.

The Extra Remarks tab is pre-populated with credentials — use it if you need overflow space.

What to doThis is the last tab in the portal. Answer all 3 questions:

1. Is there a need for the Veteran to follow up with their primary care provider for any life-threatening findings? (Yes / No)
2. If Yes — was the Veteran notified to follow up?
3. If Yes — was a copy of the test result provided to the Veteran or their provider?

If there are no life-threatening findings, answer No to question I and leave II and III blank.

What to do in the portalSection 1A auto-populates from the contention narrative. Verify it's complete. If any requested opinions are missing, copy and paste them directly into 1A. All medical opinion requests for every contention on this MO must appear in 1A.

What to checkSelect the DBQ name that was actually completed. If a different DBQ was triggered and completed instead of the originally requested one, 1B must reflect the DBQ actually done. If standalone IMO, select "Other" and enter "Independent Medical Opinion only."

Portal Screening QuestionIf you already made a positive opinion for this contention elsewhere, answer Yes and the portal may disable Section 2.

Portal Screening QuestionA diagnosis must exist in Section I of the associated exam DBQ. For IMOs, the diagnosis must come from the most recent C&P exam in the records.

2A — Positive Direct SC "The claimed condition was at least as likely as not incurred in or caused by the claimed in-service injury, event, or illness." Your rationale must address all of the following:

• Current diagnosis — stated clearly from the DBQ
• In-service event/injury — specific incident from STRs
• Nexus — how the in-service event caused or is related to the current diagnosis (chronicity, continuity, or medical literature)
• Diagnostics — if imaging or labs are cited, address how they support the nexus
• Continuity of care — required if separation was more than 1 year ago: address symptoms between service and now

2B — Negative Direct SC "The claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness." Same rationale requirements as 2A — you still need to address the in-service event, current diagnosis, and nexus, but explain why the connection is not supported.

Portal Screening QuestionIf a positive is already rendered elsewhere for this contention, answer Yes.

Portal Screening QuestionA diagnosis must exist in the exam DBQ Section I before a secondary SC opinion is rendered.

3A — Positive Secondary SC "The claimed condition is at least as likely as not the result of the Veteran's service-connected condition." Your rationale must address:

• Medical plausibility — is it medically sound that the SC condition could cause or aggravate this condition?
• Supporting findings — do the exam findings, history, injuries, activities, or occupation since service confirm the secondary link?
• Clinical explanation — a thorough, medically sound explanation of the causal mechanism (not just a conclusion)

3B — Negative Secondary SC "The claimed condition is less likely than not the result of the Veteran's service-connected condition." Same rationale requirements as 3A — address plausibility, findings, and causal mechanism, but explain why the secondary connection is not supported.

What to enter in the portalSection 4 has separate contention and diagnosis fields at the top — unlike Sections 2 and 3, these are free-text, not dropdowns. Enter the contention name and the confirmed diagnosis from the exam DBQ Section I.

Baseline Determination — Choose One

4C — Positive Aggravation "The claimed condition is at least as likely as not aggravated by the service-connected condition." Your rationale must address:

• SC condition confirmed — identify the service-connected condition causing aggravation
• Progression documented — evidence of worsening from Veteran history and/or medical records
• Current severity — establish how severe the condition is now
• Literature — cite medical literature supporting aggravation if applicable (explain how it applies — don't just append a citation)

4D — Negative Aggravation "The claimed condition is less likely than not aggravated by the Veteran's service-connected condition." Same rationale requirements as 4C — SC condition, progression, current severity, and literature. Explain why aggravation is not supported.

Portal Screening QuestionIf a positive opinion has already been rendered for this contention elsewhere in this MO, answer Yes in the portal and Section 5 may be disabled by the system.

Portal Screening QuestionA confirmed diagnosis must exist in exam DBQ Section I. For IMOs, the diagnosis must come from the most recent C&P exam in the records.

5A — Positive Pre-Existing Aggravation "The claimed condition, which clearly and unmistakably existed prior to service, was aggravated beyond its natural progression by an in-service injury, event, or illness." Your rationale must trace the four-step progression: pre-service baseline → in-service worsening → post-service findings → conclusion that worsening exceeds natural progression.

5B — Negative Pre-Existing Aggravation "The claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably NOT aggravated beyond its natural progression by an in-service injury, event, or illness." Same four-step structure as 5A — trace the pre-service baseline, in-service period, and post-service findings, then explain why any worsening is consistent with the natural progression of the disease rather than service-related aggravation.

8A — Conflicting Evidence Reconciliation The portal pre-fills the statement: "I have reviewed the conflicting medical evidence and am providing the following opinion." Your rationale must:

• Cite every conflicting source — reference each prior exam or opinion named in the contention narrative by date and examiner where possible
• Address each conflict directly — a general statement is not sufficient; each specific conflict must be discussed
• Answer additional questions — if the contention narrative asks specific additional questions, all must be answered in this rationale

Type of MO Requested This is a free-text field in the portal. Enter exactly what type of opinion is being requested — e.g., "Combat Medical Opinion," "Obesity Secondary Opinion," "MOS Asbestos Exposure Opinion."

• Combat MO — can be supported by combat badges and lay statements even without specific documentation in STRs
• Obesity opinions — go here (or Section 3), not in a standard section
• MOS asbestos (Navy only) — specific to Navy MOS with documented asbestos exposure

Portal Screening QuestionAnswer Yes or No in the portal. If no diagnosis exists (e.g., undiagnosed condition being evaluated), answer No — this does not prevent the opinion from being rendered.

Additional MO Rationale Requirements vary by type — but core compliance rules always apply:

• Exact nexus language: "at least as likely as not" or "less likely than not"
• Records reviewed and cited (VA e-folder always required)
• No "Pt," "patient," or lowercase "veteran"
• Combat MO: combat badges and lay statements can substitute for STR documentation

Portal Screening QuestionIf a positive opinion has already been rendered for this contention elsewhere, answer Yes in the portal.

Portal Screening Question — affects TERA requirementsIf Yes: the 9 TERA points are required (unless TERA exception). If No: the 9 points are not required, but a rationale is still needed.

7A — Positive TERA Statement "The claimed condition was at least as likely as not caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran." The rationale must address all 9 TERA points (see list above) — or state which points are unknown, or state that the diagnosis is a TERA exception.

7B — Negative TERA Statement "The claimed condition was less likely than not caused by the indicated toxic exposure risk activity(ies), after considering the total potential exposure through all applicable military deployments of the Veteran and the synergistic, combined effect of all toxic exposure risk activities of the Veteran." Same 9-point TERA requirements as 7A. If any points are unknown, list them. If TERA exception or no diagnosis, state it.

Portal Screening QuestionIf a positive opinion has already been rendered for this contention elsewhere, answer Yes in the portal.

Portal Screening QuestionAnswer Yes if the Veteran has either: (a) a diagnosis related to the claimed condition from Southwest Asia service, OR (b) unexplainable symptomology resulting from Southwest Asia exposure. If No, Section 6 cannot be completed.

6B — Rationale Requirements by Pattern

6C — Gastrointestinal Disorder Question This question is always required regardless of which pattern was selected. If Yes, you must specify:

• Functional (patterns 1 or 2) — chronic symptoms with no structural/objective cause found on testing (e.g., IBS)
• Structural (patterns 3 or 4) — objective findings on testing explain the disorder (e.g., Crohn's disease confirmed on colonoscopy)

You must also explain how the functional/structural determination was made and reference any testing completed (or explain why no testing was done).