List By DBQ Form Name
Disability Benefits Questionnaires(DBQs) are medical examination forms used to capture essential information for evaluating disability compensation and/or pension claims.
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Form # | Form Name |
---|---|
21-0960A-1 | Ischemic Heart Disease (IHD) |
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) |
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) |
Form # | Form Name |
---|---|
21-0960F-1 | Scars/Disfigurement |
21-0960F-2 | Skin Diseases |
Form # | Form Name |
---|---|
21-0960N-1 | Ear Conditions (including Vestibular and Infectious Conditions) |
21-0960N-3 | |
21-0960N-4 | Sinusitis, Rhinitis, and Other Conditions of the Nose, Throat, Larynx, and Pharynx |
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 |
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) |
Form # | Form Name |
---|---|
21-0960K-1 | Breast Conditions and Disorders |
21-0960K-2 | Gynecological Conditions |
Form # | Form Name |
---|---|
21-0960B-1 | Hairy Cell and Other B-Cell Leukemias |
21-0960B-2 | Hematologic and Lymphatic Conditions, including Leukemia |
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 |
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-5 | Flatfoot (Pes Planus) |
21-0960M-6 | Foot Miscellaneous (other than 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 |
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 |
Form # | Form Name |
---|---|
21-0960N-2 | Eye Conditions |
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) |
Form # | Form Name |
---|---|
21-0960L-1 | Respiratory Conditions (other than Tuberculosis and Sleep Apnea) |
21-0960L-2 | Sleep Apnea |
Form # | Form Name |
---|---|
21-0960Q-1 | Chronic Fatigue Syndrome |
Form # | Form Name |
---|---|
21-0960H-1 | Hernias (including Abdominal, Inguinal, and Femoral Hernias) |
21-0960H-2 | Rectum and Anus Conditions (including Hemorrhoids) |