📋 DBQ Form Library — Find the Right Form for Your Condition

Examiner evaluates range of motion (flexion, extension, lateral), pain on movement, muscle spasm, guarding, radiculopathy, incapacitating episodes (IVDS), and functional loss during flare-ups.

Examiner measures cervical range of motion, pain, muscle spasm, radiculopathy into upper extremities, IVDS episodes, and impact on daily activities.

Examiner tests flexion, extension, stability (anterior, posterior, medial, lateral), meniscal conditions, locking, effusion, crepitus, and functional impact.

Examiner measures flexion, extension, abduction, adduction, rotation, pain on weight-bearing, and functional loss. Includes flail joint and ankylosis evaluation.

Examiner tests flexion, abduction, internal/external rotation, pain, instability, dislocation history, and functional impact. Dominant vs. non-dominant arm matters.

Examiner evaluates dorsiflexion, plantar flexion, pain, instability, ankylosis, and impact on walking and standing.

Examiner measures dorsiflexion, palmar flexion, ulnar/radial deviation, pain, ankylosis, and grip strength impact.

Examiner evaluates individual finger range of motion, grip and pinch strength, ankylosis, amputation residuals, and functional impact on daily tasks.

Examiner evaluates weight-bearing, pain on manipulation, swelling, calluses, arch deformity, pronation, hallux valgus/rigidus, hammer toes, and use of orthotics.

Examiner tests flexion, extension, supination, pronation, pain, joint stability, and whether dominant or non-dominant arm.

Examiner documents widespread pain, tender points, fatigue, sleep disturbance, stiffness, paresthesias, headaches, and whether symptoms are constant or episodic.

Examiner measures inter-incisal range of motion, lateral excursion, pain, clicking, locking, and impact on eating and speaking.

Examiner assesses stressor verification, symptom criteria (intrusion, avoidance, cognition/mood changes, arousal), occupational and social impairment level, and suicide risk.

Used for re-evaluations. Examiner documents current symptom severity, treatment history, medication effects, and changes in occupational/social functioning since last exam.

Covers depression, anxiety, bipolar, schizophrenia, and other conditions. Examiner evaluates diagnosis, symptom severity, and level of occupational/social impairment.

Examiner documents diagnosis, BMI, binge/purge frequency, nutritional deficiency, hospitalization history, and impact on daily functioning.

Examiner identifies affected nerves, tests sensation, motor strength, reflexes, and classifies paralysis as complete or incomplete (mild, moderate, severe).

Examiner evaluates 10 facets: memory, attention, concentration, executive function, judgment, social interaction, orientation, motor activity, visual-spatial, and communication. Each rated 0–3.

Examiner documents frequency, duration, characteristic prostrating attacks, and whether headaches are economically debilitating (key for 50% rating).

Examiner documents seizure type (grand mal, petit mal), frequency, last occurrence, medication, and impact on employability.

Examiner tests specific cranial nerve function (trigeminal, facial, etc.), documents paralysis severity, and identifies affected side.

Covers conditions like multiple sclerosis, meningitis, and encephalitis. Examiner evaluates neurological deficits, residuals, and functional impact.

Examiner documents frequency of sleep attacks, cataplexy episodes, medication use, and impact on ability to work and drive.

Examiner evaluates tremor, rigidity, bradykinesia, postural instability, speech changes, and overall functional impairment.

Examiner records PFT results (FEV-1, FVC, DLCO), medication requirements, frequency of exacerbations, oxygen use, and exercise capacity.

Examiner documents sleep study results, CPAP/BiPAP use, daytime hypersomnolence, and whether respiratory failure with CO2 retention is present.

Examiner evaluates frequency of incapacitating episodes, antibiotic courses, obstruction percentage, polyps, and surgical history.

Examiner records METs level (exercise capacity), ejection fraction, ECG/echocardiogram results, episodes of congestive heart failure, and medication requirements.

Examiner records multiple blood pressure readings, medication history, and complications (heart, kidney, or eye involvement).

Examiner evaluates claudication distance, ankle/brachial index, edema, stasis dermatitis, ulceration, and vascular surgery history.

Examiner documents reflux severity, dysphagia, substernal pain, regurgitation, weight loss, and impact on nutrition.

Examiner evaluates pain, nausea, vomiting, hematemesis, weight loss, anemia, and incapacitating episodes.

Examiner documents bowel frequency, diarrhea/constipation alternation, abdominal distress episodes, nutritional status, and need for continuous medication.

Examiner evaluates liver function tests, portal hypertension, ascites, hepatomegaly, incapacitating episodes, and dietary restrictions.

Examiner documents colic episodes, surgical history (cholecystectomy), residual symptoms, and dietary impact.

Examiner performs audiometric testing (pure tone thresholds and speech discrimination). Tinnitus is separately rated. Results are plotted on the VA hearing loss tables.

Covers Meniere's disease, vertigo, chronic otitis, and other ear conditions. Examiner documents frequency of episodes, balance problems, and associated hearing loss.

Examiner tests visual acuity, visual field, eye muscle function, and documents conditions like glaucoma, cataracts, macular degeneration, and diabetic retinopathy.

Examiner documents affected body surface area percentage, exposed area percentage, treatment type (topical vs. systemic), and frequency of flare-ups.

Examiner measures scar area, stability, pain on palpation, disfigurement characteristics (head/face/neck), and whether scars limit function of affected body part.

Examiner documents insulin/oral medication use, dietary regulation, activity restriction, frequency of hypoglycemic episodes, hospitalizations, and complications (neuropathy, retinopathy, nephropathy).

Examiner evaluates hormone levels, medication requirements, symptoms (fatigue, weight changes, tremor), and cardiovascular/neurological complications.

Examiner evaluates BUN/creatinine levels, dialysis requirements, hypertension, edema, albumin/protein in urine, and transplant history.

Examiner documents voiding dysfunction, urinary frequency, erectile dysfunction, and whether condition requires absorbent materials or catheterization.

Examiner evaluates menstrual irregularities, pelvic pain, surgical history, urinary symptoms, and impact on daily functioning.

Examiner evaluates blood counts, transfusion requirements, splenomegaly, immunosuppressive therapy, and frequency of infections or crises.

Examiner documents active vs. inactive disease, treatment regimen, residual complications, and functional impact on daily life and employment.

Examiner evaluates loss of teeth, bone loss, speech impairment, masticatory function, and whether prosthetics can restore function.

Examiner identifies muscle groups affected, classifies injury severity (slight, moderate, moderately severe, severe), documents cardinal signs (loss of power, weakness, fatigue, pain, incoordination), and evaluates tissue loss.