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Compensation

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)