United States Department of Veterans Affairs

List By DBQ Form Name

 

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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Cardiovascular

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)

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-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

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)