DBQ Submission Review Tool

• In-person exam → select In-person examination
• Telehealth → select Examination via approved video telehealth
• ACE exam → neither in-person nor telehealth selected
• Records reviewed must always be checked — records review is always required for musculoskeletal DBQs

• Inform Veteran to submit records to VA
• Summarize reviewed records in the Evidence Comments textbox
• Note in Remarks/Extra Remarks that records were brought in and Veteran was instructed to submit
• Physical copies must be reviewed if cited — cannot rely on Veteran report alone
• Do not hold the DBQ pending Veteran submission of records

• All contentions from the Contention Narrative must be listed here — if no diagnosis is warranted, explain in Remarks/Extra Remarks
• Sprain ≠ Strain — same rating but NOT interchangeable for diagnosis. If SC condition is knee strain but current exam yields a sprain, that is a diagnosis change and must be addressed in Remarks
• If a knee joint replacement is diagnosed alongside arthritis of the same side: either remove the arthritis diagnosis or explain in Remarks why both are appropriate
• Date of diagnosis can be the date of evaluation (initial) or approximate date from records or reported history

• Knee meniscal tear → Section 8 required
• Knee joint ankylosis → Section 5 required
• Stress fracture of tibia → Section 7 required
• Recurrent patellar dislocation → Section 7 required
• Recurrent subluxation / Knee instability / Patellar instability → Section 6 required
• Knee cartilage restoration surgery → Section 9 required
• Shin splints → Section 7; if also diagnosed with compartment syndrome → complete Muscles questionnaire instead of this DBQ

1. Onset date — when did the knee/lower leg condition begin?
2. Onset event/issue — what caused or triggered it?
3. Course — how has the condition progressed over time?
4. Current symptoms — what does the Veteran experience now?
5. Medications, surgeries, and/or procedures — state None if none

1. Frequency
2. Duration
3. Characteristics — nature of pain/symptoms during flare-up
4. Precipitating factors
5. Alleviating factors
6. Severity
7. Extent of functional impairment during flare-up

• If Yes: document the Veteran’s description of functional loss related to repeated use over time (RUOT) — paraphrased is acceptable
• ⚑ Discrepancy rule: If 2C=Yes and 3C procured evidence=No → reconciliation statement required in Remarks. Example: “Although Veteran subjectively reports functional loss with repeated use over time in 2C, there is no objective procurable evidence to suggest pain, fatigability, weakness, lack of endurance, or incoordination significantly limit functional ability during flare-ups and/or after repeated use over time.”

• If there is a diagnosis of knee instability or subluxation, 2D must be Yes
• If Section 6A (recurrent subluxation/instability) = Yes → 2D must also be Yes
• If Section 6E (patellar instability) = Yes → 2D must also be Yes
• Document the Veteran’s description — paraphrased is acceptable

• If “Unable to test” or “Not indicated” selected: provide explanation; do not enter ROM measurements
• If ROM is outside normal range but normal for this Veteran for reasons unrelated to the knee condition: describe in “outside normal range” field and leave “If abnormal” blank
• If ROM is abnormal: “If abnormal, does ROM contribute to functional loss?” is mandatory — explain if Yes
• If pain with active ROM: indicate which movements; also select “Active motion” under evidence of pain
• If pain with passive ROM: indicate which movements; also select “Passive motion” under evidence of pain
• Limitation attributable to pain/weakness/fatigability/incoordination: document degrees if different from initial active ROM (uncommon)

• If cannot be performed: explain why; leave remainder blank or N/A under factors
• If additional loss of ROM after 3 reps=Yes: ROM must be less than initial active ROM (3A) in at least one movement
• If additional loss of ROM=No: remainder of 3B must be blank or N/A under factors
• If only additional loss of function factors are selected but no ROM decrease from 3A: explanation required in Remarks/Extra Remarks
• Abnormal 3B findings are considered objective evidence to support a diagnosis unless explained otherwise in Remarks

• Both questions under 3C must always be answered: (1) Is exam being conducted immediately after RUOT? (2) Does procured evidence suggest significant functional limitation with RUOT?
• If 3C procured evidence=Yes: 2C should also be Yes; complete factors and estimated ROM; ROM must be less than 3A in at least one movement if exam is NOT immediately after RUOT
• If 3C=No: remainder of 3C must be blank or N/A under factors
• ⚑ Discrepancy rule: If 3C=No but 2C=Yes → reconciliation statement required in Remarks
• Abnormal 3C findings are considered objective evidence to support a diagnosis

• Both questions under 3D must always be answered: (1) Is exam being conducted during a flare-up? (2) Does procured evidence suggest significant functional limitation during flare-ups?
• If 3D procured evidence=Yes: 2B should be Yes; estimated ROM must match initial ROM in 3A (or 3B if exam is during flare-up)
• If 3D=No: remainder of 3D must be blank or N/A under factors
• ⚑ Discrepancy rule: If 3D=No but 2B=Yes → reconciliation statement required in Remarks
• Abnormal 3D findings are considered objective evidence to support a diagnosis

• If any factor other than “None” is selected: each individual factor must have its own description — grouped statements are a return reason
• If “None” is selected: no other checkbox can also be selected
• If “None” is selected: the description textbox must be blank

• 4A=Yes → 4B must be completed (is atrophy due to claimed condition?)
• 4B=Yes → 4C must be completed: location, circumference of more normal side (cm) and atrophied side (cm), measured at maximum muscle bulk
• 4B=No → 4C must be blank; provide rationale in textbox why atrophy is not due to claimed conditions in Sec I
• 4A=No → 4B and 4C must be blank

• Ankylosis = complete immobilization of the joint — no movement at all per VA guidelines
• 5A=Yes → select severity AND provide angle in degrees in 5B; ankylosis must be diagnosed in Sec I
• 5A=No → 5A severity blank; 5B must select “N/A, no ankylosis of knee joint”
• 5C (Muscle Group XIII — posterior thigh/hamstring): must be answered if 5A=Yes. If 5C=Yes → supplemental Muscle Injuries DBQ required
• 5A=No → 5C must be left blank

• 6A (recurrent subluxation/instability): if Yes → instability must be in Sec I; 2D must also be Yes
• 6B (ligament tear): must always be answered for the claimed side. If Yes → ligament tear dx must be in Sec I (unless resolved and explained in Remarks); indicate complete or incomplete/partial
• 6C (tear repaired?): only if 6B=Yes; indicate successful or failed. If 6B=No → 6C must be blank
• 6D (assistive device for instability/ligament tear): only if 6A or 6B=Yes. If both No → 6D must be blank
• 6E (patellar instability): must always be answered. If Yes → patellar instability must be in Sec I; 2D must also be Yes; complete 6F and 6G
• 6F (surgical repair for patellar instability): if described here, also address in Sec 9. If 6E=No → blank
• 6G (assistive device for patellar instability): only if 6E=Yes

• If 7A=Yes and a condition is selected: must be diagnosed in Sec I (if current) or explained in Remarks why current diagnosis is not warranted
• Stress fracture of lower leg: if it affects ankle ROM → also complete the Ankle questionnaire; if current diagnosis → imaging must be documented in Section 13
• Shin splints: indicate length of treatment and response to treatment. If shin splints + compartment syndrome → complete Muscles questionnaire instead of this DBQ

• If 8A=Yes: a meniscal condition must be diagnosed in Sec I — unless explained in Remarks/Extra Remarks
• For any symptoms selected in 8A: provide a description of each symptom selected

• If no surgery on claimed side: select “No surgery” checkbox; remainder of section must be blank
• If total knee joint replacement: indicate date; select one Residuals checkbox; replacement must be diagnosed in Sec I. Imaging is NOT required to confirm joint replacements
• If meniscectomy: meniscal condition must also be addressed in Section 8
• If residuals due to meniscectomy, arthroscopic repair, or other surgery: describe them. If no residuals: state this in Remarks/Extra Remarks
• If joint replacement in Sec 9 AND arthritis same side in Sec I: either remove arthritis or explain in Remarks why both are appropriate

• 10A: If Yes — enter summary of other findings/complications/conditions/signs/symptoms related to a Sec I diagnosis. If no Sec I diagnosis or no additional findings: must be No
• 10B (Scars): watch for surgeries — they may indicate potential scars. If scars present: select Yes and complete supplemental Scar/Disfigurement DBQ. If surgery occurred but no visible scarring on exam: answer 10B=No AND document this in Remarks/Extra Remarks

• These are assistive devices used as a normal mode of locomotion (other than those noted in Sec VI for instability/ligament tear)
• If Yes: select device(s); specify Frequency of use, Side affected (Left/Right/Both), and Condition for each — must correspond to a Sec I diagnosis
• If No: 11A and 11B must be blank

• This question is not for treatment purposes — it is solely to assess functional impact
• Usually answered No
• If 12A=Yes: complete 12B — identify the condition causing loss of function, describe loss of effective function, and provide specific examples
• If 12A=No: 12B must be blank

• 13D is for diagnostics from medical records only — not current exam imaging. Confirm date in DBQ matches the date in the records
• If Yes: add test/procedure, date, and results (up to 7 findings). After entry: confirm whether DT report was found in records (Yes) or not found (No — then explain in Extra Remarks)
• If Veteran brings hard copy diagnostics not in records: note in Remarks/Extra Remarks; diagnostics can remain cited in 13D
• If 13D=No: remainder of 13D must be blank
• Current stress fracture diagnosis: imaging must be documented here

• All potentially abnormal findings from diagnostics in 13D must be addressed in 13E — even if it seems redundant
• Describe the relationship of each abnormal finding to a diagnosed condition. Example: “Degenerative changes in the knee are consistent with the diagnosed degenerative arthritis”
• If a finding is irrelevant or insignificant: explain why
• If no diagnostics or no abnormal findings: 13E is N/A or blank

• Written from the examiner’s point of view — not the Veteran’s words or statements
• Provide one or more specific examples of how the condition impacts occupational tasks (standing, walking, lifting, sitting, etc.)
• Do not discuss employability or employment status
• Can still be answered No when a diagnosis is provided
• If no Sec I diagnosis: must be answered No

• 2B/3D discrepancy: if 2B=Yes and 3D=No → reconciliation statement required here
• 2C/3C discrepancy: if 2C=Yes and 3C=No → reconciliation statement required here
• ECQ: if review/increase claim (Veteran already SC) → established condition question must be addressed
• Diagnosis change: if diagnosis changed from prior SC condition → explanation required
• No diagnosis: if any contention has no diagnosis → explain why not warranted
• Medication discrepancy: if medications mentioned in DBQ but Supplemental Q1=No → reconciliation statement required
• Section identification: each remark should identify which section it pertains to
• No treatment recommendations

• These supplemental questions must always be answered — even if no diagnosis is established
• If No: Q2 and Q3 must be blank. If medications mentioned elsewhere in the DBQ but Q1=No → add reconciliation statement in Remarks/Extra Remarks
• If Yes: complete Q2

• Only answer Q2 if Q1=Yes
• Q2=No → Q3 must be blank
• Q2=Yes → complete Q3

• Only answer Q3 if Q2=Yes
• Q3=Yes → check all applicable functional losses; provide estimated additional functional loss for each; if possible, provide as additional loss of motion in Remarks/Extra Remarks
• Q3=No → explain in Remarks/Extra Remarks why evaluation without speculation is not possible. Explanation should not be based on examiner shortcomings or general aversion to offering an estimate

1. Date of onset — when did the back condition begin?
2. Onset event/issue — what happened or what caused it?
3. Course — how has the condition progressed over time?
4. Current symptoms — what is the Veteran experiencing now?
5. Medications, surgeries, procedures — all treatments received

For review/increase claims: describe pertinent history from the previous C&P exam to now.

1. Frequency
2. Duration
3. Characteristics
4. Precipitating factors
5. Alleviating factors
6. Severity (numeric scale or descriptor — most commonly missed)
7. Functional impairment during flare

⚠ If 2B = Yes but 3D (procured evidence) = No, a reconciliation statement is required in Remarks.

⚠ If 2C = Yes but 3C (procured evidence) = No, a reconciliation statement is required in Remarks. Example: "Although Veteran subjectively reports functional loss with repeated use over time in 2C, there is no objective procurable evidence to suggest pain, fatigability, weakness, lack of endurance, or incoordination significantly limit functional ability."

• Active ROM values documented for all planes (flexion, extension, lateral flexion L/R, rotation L/R)
• If pain on active motion: note which motion(s) exhibited pain
• "Does ROM contribute to functional loss?" answered
• Crepitus question answered (mandatory)
• Pain: if present, select at least one from weight-bearing/nonweight-bearing/active/passive/rest AND select Causes functional loss OR Does not cause functional loss
• If testing cannot be performed, explanation required
• Note: Unclaimed side question must be left blank for spine (no unclaimed side)

If any cannot be tested: explanation in Remarks. Cross-reference with lower extremity DBQs (same Case ID) for consistency. Abnormal findings can support radiculopathy/IVDS unless explained. If abnormal findings are unrelated to diagnosed conditions: explanation in Remarks. If muscle atrophy is present (4B=Yes): complete 4C (is it due to diagnosed condition?) and 4D (measurements in centimeters at maximum muscle bulk for both sides).

Cross-reference with other lower extremity DBQs (same Case ID). Reflex testing must be consistent across DBQs. Abnormal findings can support radiculopathy/IVDS unless explained. If any cannot be tested: explanation in Remarks.

• SLR must be performed for both right and left sides
• Positive = pain radiates BELOW the knee — pain only in the back or hamstring = Negative
• Test can be seated or supine; raise each leg until pain begins
• If Unable to perform: provide explanation
• A positive SLR supports a diagnosis of radiculopathy and/or IVDS unless otherwise explained
• This is a passive exam — the examiner raises the leg

• A selection must be made for each extremity under each symptom (even if None)
• Wholly sensory involvement = evaluate at mild or at most moderate degree
• If Veteran has BOTH constant and intermittent pain in same extremity: intermittent pain must be rated WORSE than constant. E.g., if constant = mild, then intermittent = moderate or severe

• IVDS diagnosis must appear in Sec I (if diagnosed here)
• If 11B = Yes (bedrest): bedrest must be physician-prescribed AND documented in records within the past 12 months
• If 11B = Yes: 11C must be completed including dates of treatment records, facility/provider, description of treatment
• If 11B = No: 11C must be blank
• IVDS can be standalone — radiculopathy is separate if also diagnosed

• 15A–C = ONLY imaging ordered/completed in conjunction with THIS exam (listed in MDE4Vets under DBQ/DT/IMO). Medical record imaging goes in 15E.
• If 15A = Yes: complete 15B (arthritis?) and 15C (type, date, results). Date in 15C must match the diagnostic results in MDE4Vets.
• If 15B = Yes (arthritis on imaging): degenerative/post-traumatic arthritis should be diagnosed in Sec I unless explained in Remarks
• Diagnosis of degenerative arthritis requires imaging confirmation. Once documented, no further imaging required even if worsened.
• If 15A = No: 15B and 15C must be blank

• Describe impact from examiner's perspective — not Veteran's words or statements
• Provide one or more specific occupational task examples (e.g., standing, walking, lifting, sitting)
• Do NOT mention employability or employment status
• Address only diagnosed back conditions — not other unrelated conditions or age
• If No diagnosis: question must be answered No
• Ensure consistency with physical exam findings

Example: "Veteran's lumbar arthritis causes back stiffness restricting ability to quickly bend. This limits ability to pick up objects, perform rapid or labor-intensive tasks, and requires frequent breaks."

Additional Remarks uses: discrepancy statements (2B vs 3D, 2C vs 3C), diagnosis change explanations, ECQ/progression statements, Gulf War disability patterns, explanation of why x-ray was not ordered, explanation of surgery with no scar, any unexplained abnormal findings. No treatment recommendations.

If No: Questions 2 and 3 must be blank. If the DBQ discusses medications but Q1 = No: add reconciliation statement to Remarks. Example: "Veteran reports/e-folder supports medication use related to the claimed condition; however, at the time of this examination, the Veteran confirms an unmedicated state."

If Yes: Continue to Ingram Q2.

• If Yes: Check applicable functional losses and provide estimated additional functional loss. If possible, provide as estimated additional loss of motion in Remarks.
• If No: Explain in Remarks WHY it is not possible to estimate — explanation cannot be based on examiner shortcomings or general aversion to offering estimates.

• 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

• 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

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)

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

• 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 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

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

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

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

• 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

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)

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?

• A diagnosis of sleep apnea must be confirmed by a sleep study — no sleep study = no confirmed diagnosis
• If there is no confirmed diagnosis, select the "No" option in the portal. Do not leave blank.
• If a different respiratory condition is diagnosed (e.g. COPD, asthma), use the Respiratory and/or Narcolopsy Questionnaire instead of this DBQ
• ICD-10 code and date of diagnosis must be entered

• Date of onset — when did the sleep disorder begin?
• Details of onset — what caused or triggered it?
• Course — how has the condition progressed over time?
• Current symptoms — what does the Veteran experience now?
• Treatments — medications, CPAP, procedures (state "None" if none)

• 2B is only for continuous/scheduled medications for the diagnosed sleep disorder condition from Section I
• If a medication is listed in 2A and used continuously for the sleep disorder → it must also appear in 2B
• PRN / as-needed medications → do not list in 2B
• If no diagnosis or no continuous medications → answer No

• Select Yes if the Veteran is prescribed a breathing assistance device (CPAP, BiPAP, etc.) — regardless of whether they are using it
• Non-compliance with the device can be documented in 2A or in the Remarks/Extra Remarks section — it does not change the Yes/No answer here
• CPAP mention is not required in 2A, but may appear there; 2C is the dedicated question

• If the Veteran has any current findings, signs, or symptoms attributable to the diagnosed sleep disorder → select Yes and check at least one finding
• If there is no diagnosis in Section I → answer No
• Section III can be answered No even if a diagnosis exists — if the Veteran has no current findings, signs, or symptoms at time of exam

• If Yes → enter a brief summary of any other pertinent physical findings, complications, or symptoms related to conditions listed in Section I
• If there is no diagnosis in Section I, or no other pertinent findings → answer No

• If Yes → evaluate whether the scar is painful or unstable, ≥39 sq cm (6 sq inches), or located on the head, face, or neck
• If the scar meets any of those criteria → also complete VA Form 21-0960F-1 (Scars/Disfigurement DBQ)
• If the scar does not meet those criteria → enter the location and measurements in centimeters. A Scars DBQ is not required.
• Multiple scars → enter additional locations and measurements in the Comments field (4C)
• An "unstable scar" = frequent loss of skin covering over the scar for any reason

• 4C is optional and can be left blank if there is nothing to add
• If multiple scars were identified in 4B, enter additional scar locations and measurements here

• Date, facility name, and results must all be entered regardless of whether the Veteran has documented Sleep Disorder Breathing
• If the facility name is not available → enter "Unknown"
• New claims: A sleep study must be conducted if there is no prior study confirming the diagnosis. DBQ must be held in queue until results are available — do not submit without them
• Service-connected or increase claims: If the prior sleep study is in records and results are available, a new study is not required. Details may be provided by the Veteran.
• If a home sleep study (WatchPAT) result is negative → confirm with the examiner whether an in-person PSG is needed and document reasoning in Extra Remarks
• If repeat or in-person PSG is needed → contact diagnostics@MDE4Vets.com and clinic manager; hold DBQ until results return

• 5B is a follow-up question and is only enabled if Yes was selected for 5A (sleep study was performed)
• Indicate whether the sleep study documents Sleep Disorder Breathing

• If Yes → each entry must include the type of test or procedure, date, and results (brief summary)
• Up to 7 diagnostic findings can be added; the Add button disables after 7 entries
• If No or not applicable, this question can be answered No

• Written from the examiner's clinical perspective — not the Veteran's own words or first-person statements
• Must include at least one specific example of how the condition impacts ability to work (e.g. daytime somnolence limiting sustained concentration, fatigue affecting physical endurance)
• Do not discuss employability or employment status — describe the functional impact of the symptoms
• Section VI can be answered No even with a diagnosis, if the sleep apnea does not impact the Veteran's ability to work
• If there is no diagnosis, Section VI must be answered No
• Never use "Pt" or "patient" — use Veteran, SM, or Claimant

• Do not include treatment recommendations
• May include: ECQ/progression statement (for review/increase claims), Gulf War disability pattern notes, explanations of diagnosis changes, section-specific clarifications

• All claimed conditions must have a diagnosis or Remarks explanation for why no diagnosis is warranted
• If no diagnosis → select "Veteran does not have a current diagnosis" and explain in Remarks/Extra Remarks
• PFTs are required for all respiratory exams to assess current status — except when: Veteran has active lung cancer; Veteran uses continuous oxygen; there is a clear medical contraindication (explain in remarks)
• Sleep Apnea and/or Narcolepsy → complete the Sleep Apnea and/or Narcolepsy Questionnaire(s) instead of this DBQ
• Interstitial lung diseases include asbestosis, diffuse interstitial fibrosis, hypersensitivity pneumonitis, pneumoconiosis, etc.
• Restrictive lung diseases include diaphragm paralysis, kyphoscoliosis, pneumothorax, post-surgical residuals, etc.
• Mycotic lung diseases include histoplasmosis, blastomycosis, cryptococcosis, aspergillosis, mucormycosis
• Additional "Other" diagnoses with ICD codes → list in the additional diagnoses field

• Date of onset
• Details of onset
• Course — progression over time
• Current symptoms
• Treatments — medications, surgery, procedures (state "None" if none)

• 2C (Inhaled medications): If Yes, checkboxes and frequency must be selected. Mandatory if 2+ diagnoses present and Yes is selected.
• 2D (Oral bronchodilators): If Yes, select the appropriate frequency option
• 2E (Antibiotics): If Yes, provide drug name, dose, frequency, and condition for which prescribed

• 2F (Outpatient oxygen): If Yes, also answer 2G. Mandatory if 2+ diagnoses present and Yes is selected.
• 2G (Continuous oxygen ≥17 hrs/day): If Veteran uses continuous oxygen, PFT is not required — this is an exemption to the PFT requirement
• Note any non-compliance or partial use in 2A and/or Remarks if relevant

• If No current diagnoses → leave all of Section III blank and proceed to Section IV
• Each diagnosis in Section I must have its corresponding Part checked in the question "Does the Veteran have any of the following pulmonary conditions?"
• Part L (Other) → for conditions not in Parts A–K (e.g., COPD, chronic bronchitis) and for scars due to pulmonary conditions
• If Asthma (Part A) with respiratory failure in past 12 months → also complete Part J (Respiratory Failure) unless explained in Remarks
• If Sarcoidosis (Part C) with ophthalmic/renal/cardiac/neurologic involvement → complete appropriate supplemental DBQs
• If Tumors/Neoplasms (Part K) → biopsy required for all new non-SC cancer diagnoses

• Asthma (A): If attacks with respiratory failure → indicate average per week; also complete Part J
• Asthma (A) 1B: Physician visits for exacerbations → frequency and severity required if Yes
• Bronchiectasis (B): Incapacitating episodes → total duration in past 12 months; "incapacitating" = prescribed bed rest + physician treatment
• Cardiopulmonary (I): If 2+ diagnoses → indicate which condition is predominantly responsible
• Respiratory Failure (J): Provide dates and description of episodes; if 2+ diagnoses → indicate predominant cause
• Neoplasm (K): Benign vs. malignant; if malignant → active/remission; primary/secondary; if secondary → primary site; treatment history; residuals/complications; additional neoplasms
• Other (L): If used for additional conditions → 12A must be Yes with condition description; 12B must be answered regarding scars

• If Part L selected and 12A answered → 12B must also be answered
• If scars are painful/unstable, have area ≥39 cm², or are on the head/face/neck → complete supplemental Scars/Disfigurement DBQ
• If scars do not meet threshold → provide location and measurements in centimeters
• Multiple scars → enter additional locations in Comments (12C)
• An "unstable scar" = frequent loss of skin covering over the scar
• If Part L not selected (no additional conditions, no scars) → 12B will be blank

• Imaging is not required for many respiratory conditions
• If in-record results reflect current condition → repeat testing not required
• Document results from both medical records and any new studies completed in conjunction with current exam (if clinically indicated)
• Biopsy required for all new non-SC cancer diagnoses — document results here; biopsy is the only way to confirm cancers for VA purposes
• Biopsy re-documentation not required for already service-connected cancers

• PFT must be performed for all respiratory examinations (major basis for rating evaluation)
• PFT conducted on day of exam OR from records if within past 12 months
• If conducted at exam → must be added in MDE4Vets with results uploaded
• PFT is NOT required only when: (1) Veteran requires outpatient oxygen; (2) Veteran had 1+ episodes of acute respiratory failure; (3) cor pulmonale/right ventricular hypertrophy/pulmonary hypertension diagnosed; (4) exercise capacity ≤20 ml/kg/min
• Active lung cancer, continuous oxygen use → also not required (document reason in "Other" checkbox with explanation)
• If PFT not done → a reason must be selected and the PFT reason field must be blank; if done → the reason field must be blank

• 4C: Confirm PFT results reflect Veteran's current pulmonary function
• 4D: Select the test result that most accurately reflects the Veteran's level of disability for the condition being evaluated
• 4E: If post-bronchodilator testing not completed → provide reason (otherwise leave blank)
• 4F (DLCO): Not required for any single claimed condition, but recognized as helpful adjunctive test. If not completed → provide reason
• 4G: If 2+ diagnoses → select Yes and indicate which condition predominantly causes pulmonary function limitation (if any)
• 4H (Exercise capacity): Results documented from records only; not typically ordered at current exam without approval

• Impact of only the diagnosed condition(s) — without consideration of other medical conditions or age
• Describe how the Veteran's functional status is impacted: standing, walking, lifting, sitting, etc.
• Must be described from the examiner's point of view — not Veteran's words or statements
• Provide one or more specific examples of occupational task limitations
• Question can still be answered No even with a diagnosis
• If no diagnosis in Section I → question must be answered No (no functional impact without diagnosis)
• Do not discuss employability or employment status

• Remarks and Extra Remarks are used to capture additional explanation and address requests from the Contention Narrative such as ECQ (Established Condition Question) and progression statements
• Address any diagnosis changes from prior exams
• If "no current diagnosis" was selected → explain why no diagnosis is warranted here
• No treatment recommendations in Remarks or Extra Remarks
• If physical records were brought by Veteran → note here (and in Evidence Comments) that records were reviewed and Veteran was instructed to submit to VA

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

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

• All claimed conditions must be addressed — either with a diagnosis or an explanation in Remarks/Extra Remarks for why no diagnosis is warranted
• If the Veteran has no diagnosis for a condition → select the "no current diagnosis" checkbox and explain in Remarks
• Peptic ulcer disease can be diagnosed by upper GI imaging or endoscopy — repeat testing not required if in-record and consistent with current condition
• Stenosis of the stomach → complete both the peptic ulcer disease section (III) and the complications of UGI surgery section (V)
• If Chronic gastritis checked → also select the applicable subtype checkboxes
• If Functional digestive disorder or GI dysmotility disorder checked → complete the Intestinal Conditions DBQ instead
• If diagnosis changed from a prior exam → explain in Remarks/Extra Remarks
• Date of diagnosis may be today's evaluation date if making the initial diagnosis

• Date of onset — when did the condition begin?
• Details of onset — what caused or triggered it?
• Course — how has the condition progressed over time?
• Current symptoms — what does the Veteran experience now?
• Treatments — medications, surgery, procedures (state "None" if none)

• 2B is only for continuous/scheduled medications for the diagnosed condition from Section I
• If a med appears in 2A and is taken continuously → list it in 2B as well
• PRN / as-needed meds → do NOT list in 2B
• If no diagnosis or no continuous meds → answer No

• If Yes — a corresponding peptic ulcer, gastritis, or other stomach diagnosis must exist in Section I
• If no corresponding diagnosis in Section I → question 3A must be answered No
• Peptic ulcer can be diagnosed by upper GI imaging or endoscopy — repeat not needed if testing is in-record and current
• If "Episodes of abdominal pain/nausea/vomiting lasting ≥3 consecutive days managed by daily prescribed medication" is checked → frequency must be indicated
• If additional hospitalizations or procedures → list with date and facility
• If vagotomy caused alkaline gastritis → Section III must be Yes

• If Yes → must indicate Post-operative or Pre-operative
• If Post-operative → Section V (5A) must be answered Yes
• If Pre-operative → select applicable symptom checkboxes
• Persistent partial bowel obstruction → must answer inoperable, refractory, and TPN questions

• If post-operative was selected in Section IV → 5A must be Yes
• If Yes → select all applicable post-op complications/residuals
• Vomiting checked → must indicate frequency of vomiting AND select the applicable treatment option
• Watery bowel movements checked → indicate frequency
• Nausea checked → indicate if managed by ongoing medical treatment

• If Yes → "Status post vagotomy with pyloroplasty and/or gastroenterostomy" must be diagnosed in Section I
• If not diagnosed in Section I → 6A must be No
• If vagotomy diagnosed → select Complete or Incomplete vagotomy
• If alkaline gastritis checkbox selected → Section III must be completed (3A = Yes)

• If Yes → a tumor/neoplasm must be diagnosed in Section I (unless otherwise explained)
• If No → leave 7B–7E blank
• If Malignant selected → both Active/In Remission AND Primary/Secondary are mandatory
• If Secondary (metastatic) → indicate primary site or enter "Unknown"
• New, non-SC malignancies must be confirmed by biopsy — biopsy is the only VA-accepted way to confirm cancer. Document biopsy results in Section IX
• SC cancers → biopsy not required (already established)
• 7E (additional neoplasms) → leave blank if no additional ones

• If any other pertinent findings exist → summarize in 8A; must be related to a diagnosed condition in Section I
• If no additional findings, or if there is no diagnosis in Section I → 8A must be answered No
• Scars (8B) — watch for surgeries. If surgery is noted in the DBQ, check if any visible scarring is present. If Yes → supplemental Scar/Disfigurement DBQ is required
• If surgery but no visible scarring → document in Remarks/Extra Remarks

• 9A (imaging/procedures), 9B (labs), 9C (other tests) — select applicable checkboxes
• For any diagnostics performed with this exam → the date must match what was uploaded in MDE4Vets
• Peptic ulcer diagnosis from prior imaging → repeat not needed if in-record and current
• New non-SC malignancy → biopsy results must appear here in 9A or 9C
• If no testing was done → answer No

• Written from the examiner's point of view — NOT the Veteran's words or statements
• Includes at least one specific example of how the condition limits the Veteran's ability to work
• Does NOT discuss employability or employment status
• Can be answered No even with a diagnosis

• ECQ statement — if this is a review/increase claim (Veteran is already SC for the GI condition), an ECQ must be present selecting one of 6 standard options. New claims → not required
• Any claimed condition with no diagnosis → explanation why no diagnosis was warranted
• Any diagnosis change from a prior exam → must be explained
• Each remark should identify the section it pertains to (e.g., "Re: Section 4B —")
• No treatment recommendations

If supplemental questions are requested, a stomach/duodenum condition must be diagnosed in Section I (or explained in Remarks). If Yes is selected to the opening question, all applicable follow-ups must be answered.

• Abdominal pain → indicate frequency (periodic or continuous)
• Anemia → provide hemoglobin/hematocrit in Section IX Diagnostic Testing
• Weight loss → provide baseline weight AND current weight; must be due to the diagnosed stomach/duodenum condition
• Nausea → indicate severity, number of episodes per year, and average duration of episodes
• Vomiting → indicate severity, number of episodes per year, and average duration of episodes
• Hematemesis → indicate severity, number of episodes per year, and average duration of episodes
• Melena → indicate severity, number of episodes per year, and average duration of episodes
• Recurring severe episodes → indicate number per year and average duration
• Recurring less-than-severe episodes → indicate number per year and average duration

• Hypertrophic gastritis → must be confirmed by gastroscope; gastroscope results must be in Section IX; must be diagnosed in Section I; indicate severity
• Atrophic gastritis → must be diagnosed in Section I; identify the underlying condition
• Postgastrectomy syndrome → must be diagnosed in Section I; indicate severity
• Peritoneal adhesions/stomach injury symptoms → select all signs/symptoms; indicate level of severity (Levels I–IV); stomach injury must be diagnosed in Section I
• History of peritonitis/ruptured appendix/perforated ulcer/operation with drainage → select all that apply
• Vagotomy → if Yes, Section VI 6A must also be Yes; diagnosis must be in Section I
• Dumping syndrome → indicate severity
• Recurrent ulcer with incomplete vagotomy → incomplete vagotomy must be selected in Section VI
• Recurrent ulcer following complete vagotomy → complete vagotomy must be selected in Section VI; follow-up questions required

• Select all applicable diagnoses; include ICD code and date for each
• If no diagnosis — explain in Remarks/Extra Remarks
• If diagnosis changed from a previous SC diagnosis — explain in comments
• Diagnosis-specific section triggers:
  • Hydronephrosis → Section III (3A, 3E)
  • Kidney transplant → Section VI (6B)
  • Nephrolithiasis (kidney stones) → Section IV (4A)
  • Neoplasm of the kidney → Section VII (7A–7C)
  • Renal tubular disorders → Section III (3A, 3B)
  • Kidney removal → Section VI (6A)

• Clarifying a diagnosis that changed from a prior SC condition
• Noting a complication diagnosis related to the primary claimed condition
• Any other additional diagnostic comments the examiner needs to document

• New claims: date of onset, details of onset, course, current symptoms, treatments (or "None")
• Review/increase claims: pertinent history from the previous C&P exam through the current exam
• Use Veteran, SM, or Claimant — never "Pt," "patient," or name/pronoun

• If Yes — list all medications taken continuously/scheduled for the diagnosed condition
• PRN (as-needed) meds not required here
• Must be No if there is no diagnosis in Section I

• Option A: 2 GFRs < 60, separated by at least 3 months
• Option B: 2 GFRs of 60–89, separated by at least 3 months, plus at least one qualifier: RBC casts, WBC casts, granular casts, structural kidney abnormality (cystic/obstructive/glomerular), or proteinuria
• If 3A = Yes → minimum 2 GFR readings must appear in Section IX (9C)
• If no renal dysfunction / no diagnosis → 3A = No, and 3B–3F must be blank

• 3B (Dialysis): If dialysis is documented anywhere in the DBQ, 3B must reflect that
• 3C (Structural abnormality): If Yes → describe the test/evidence used to confirm
• 3D (Renal tubular disorder): Must be diagnosed in Section I if 3D = Yes; indicate if symptomatic
• 3E (Hydronephrosis): Must be diagnosed in Section I; indicate severity. Note: signs/symptoms from urolithiasis go in Section IV (4E), not here
• 3F (Renal colic): Not from urolithiasis; indicate occasional vs. frequent. Colic from stones goes in Section IV (4F)
• All 3B–3F must be blank if 3A = No

• If 4A = Yes → nephrolithiasis or urolithiasis must be diagnosed in Section I (or explained in Remarks)
• 4B: Location of calculi — check all that apply
• 4C: Ureteral stricture — if Yes, describe test/evidence used to confirm
• 4D (Treatment): If Diet therapy → specify diet + dates. If Drug therapy → list medication + dates. If Invasive/non-invasive procedures → include average times/year, date and facility of most recent
• 4E: Signs/symptoms from urolithiasis (catheter drainage, pyonephrosis, hydronephrosis, impaired function, other)
• 4F: Colic attacks from urolithiasis — indicate frequency
• If 4A = No → 4B–4F must be blank

• If 5A = Yes → a corresponding diagnosis must be in Section I (or explained in Remarks)
• 5B (Etiology): List the etiology — if unknown, enter "Unknown"
• 5C (Treatment): Check all that apply. If "No treatment" selected → no other treatment option can be checked
• If 5A = No → 5B and 5C must be blank

• If 6A = Yes → a corresponding diagnosis must be in Section I (or explained in Remarks)
• Transplant eligibility for VA purposes = kidney function declined enough to warrant transplant — placement on a list is not required
• 6B (Kidney removed): If Yes → provide reason for removal; kidney removal diagnosis must be in Section I
• 6C: Date renal function declined enough to warrant transplant consideration
• 6D (Transplant): If Yes → provide date, eligibility date, facility name, admission date, discharge date
• 6E (Remaining kidney pathology): If Yes → an additional diagnosis for the remaining kidney must be in Section I
• 6F (Transplanted kidney pathology): If Yes → an additional diagnosis for the transplanted kidney must be in Section I
• If 6A = No → 6B–6F must be blank

• If 7A = Yes → tumor/neoplasm must be diagnosed in Section I; if 7A = No → 7B–7F must be blank
• If Malignant selected → both Active/In Remission AND Primary/Secondary are required
• If Secondary → indicate primary site (or "Unknown")
• New, non-SC malignancies must be confirmed by biopsy — document biopsy results in Section IX. SC cancers do not need biopsy redocumentation
• 7C (Voiding dysfunction): If Yes → a Urinary Tract Conditions DBQ must be triggered
• 7D (Treatment): If "Treatment completed" selected → also select individual treatments completed
• 7E (Residuals): If Yes → list residuals and trigger appropriate supplemental DBQs
• 7F (Additional neoplasms): Leave blank if none

• 8A (Other findings): If Yes → describe pertinent findings, complications, or symptoms. Must be No if no diagnosis or no other findings
• 8B (Scars): Watch for surgeries — scars are common after kidney procedures
• If 8B = Yes → complete a supplemental Scars/Disfigurement DBQ
• If 8B = No → state "no visible scars" in Extra Remarks

• 9A = medical records diagnostics ONLY — not current exam results
• 9B = diagnostics ordered and completed with the current exam ONLY
• Do not mix 9A and 9B. If labs exist in the record that reflect current renal function persisting ≥3 months, repeat testing is not required
• For new cancer claims → biopsy results must be documented here

• If Section III (3A) = Yes → minimum 2 GFR readings required in 9C
• At least 2 GFRs within the most recent 12-month period, each separated by ≥3 months
• GFR, eGFR, and creatinine-based approximations calculated by a medical professional are all acceptable
• Additional GFRs can be ordered in conjunction with the current exam if needed
• If 3A = No, GFR inclusion is at examiner discretion
• 9C should contain GFR-type results only

• 9D: If Yes → select applicable findings (ACR ≥30 mg/g, RBC casts, WBC casts, granular casts) for ≥3 consecutive months in past 12 months. Describe test/evidence with dates
• 9E: Other diagnostic findings — add using the Add button; include test/procedure, date, and results. Maximum 7 entries

• Written from the examiner's point of view — not Veteran words or statements
• Must include at least one specific example of impact on occupational tasks (standing, walking, lifting, sitting, etc.)
• Do not discuss employability or employment status
• Impact reflects the diagnosed condition only — not other conditions or age
• Can be answered No even with a diagnosis; must be No if no diagnosis in Section I

• Identify which section each remark pertains to where appropriate
• Use Remarks/Extra Remarks for ECQ/progression statement (review/increase claims) and Gulf War disability patterns
• No treatment recommendations

• 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

• 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)

• 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)

• 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

• 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

• 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

• 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)

• NPI number
• State License Number
• State of Issue (state that issued the license)
• NO treatment recommendations — opinions only