MOAA DBQ Worksheet

MOAA DBQ Worksheet
MOAA DBQ Worksheet Users Guide
If you complete a Disability Benefits Questionnaire (DBQ) the processing time for your VA claim will decrease. Instead of waiting
for the VA to schedule you for an exam, your private physician fills out a form explaining your diagnosis and the severity of your
condition. DBQs start on the next page.
The VA will not pay for or reimburse you for any expenses associated with getting a DBQ form filled out by a private physician.
Generally p
TRICARE
physicians
will not fill a DBQ or make a medical statement in support
y
y
pp of a VA claim.
y
ask your physician if they are willing to fill out the DBQ form before you schedule your appoinment. You will also need to submit
an Authorization and Consent to Release form (VA 21-4142) to the VA for your DBQ. The form must be completed, printed and
signed or the VA will not accept it.
Information about how the VA evaluates disabilities and what the VA considers a disability for rating purposes can be found in
Title 38 of the United States Code and Title 38 of the Code of federal Regulations.
There is a DBQ available for most conditions ratable by the VA, but not all. You will need to have a VA exam for certain conditions.
Disabilities or Conditions for which there is no DBQ available for use by
United States Code
Code of Federal Regulations
Private Doctors.
Title 38 CFR § 4.129
Initial Diagnosis of PTSD
Title 38 USC § 1155
Hearing Loss or Tinnitus
Residuals of Traumatic Brain Injury (TBI)
Title 38 USC § 1155
Title 38 CFR § 4.87
Title 38 USC § 1155
Title 38 CFR § 3.159 & 3.26 & 3.28
Residuals of Cold Injury
Title 38 USC § 1155
Title 38 CFR § 3.159 & 3.26 & 3.28
Prisoner of War Exam Protocol
Title 38 USC § 1155
Title 38 CFR § 3.17
Gulf War Medical Exam
General Exam for Compensation
Title 38 USC § 1155
Title 38 CFR § 3.17
Title 38 USC § 1155
Title 38 CFR § 3.159 & 3.26 & 3.28
General Exam for Pension
Title 38 USC § 1155
Title 38 CFR § 3.159 & 3.26 & 3.28
Presumptive or Exposure Related Regulations
United States Code
Code of Federal Regulations
Herbicide Exposure
Title 38 USC § 1112
Title 38 USC § 1116
Title 38 CFR § 3.307 & 3.309
Gulf War (Undiagnosed Illness)
Title 38 USC § 1117
Title 38 CFR § 3.317
Ionizing Radiation
Title 38 USC § 501
Title 38 CFR § 3.311 & 3.715
Mustard Gas
Title 38 USC § 501
Title 38 CFR § 3.316
Title 38 USC § 1112
Title 38 CFR § 3.307 & 3.309
Presumption or Exposure
Tropical
Wartime Presumptions
Title 38 CFR § 3.816
Other Relevant Regulations
Rule or Regulation
United States Code
Code of Federal Regulations
Amputations
N/A
Title 38 CFR § 4.68
Paired Organs or Extremities (Bilateral Factor)
Title 38 USC § 1160
Title 38 CFR § 3.383 & 4.26
Spina Bifida
Title 38 USC § 1805 & 1811-1834
Title 38 CFR § 3.814 & 3.815
Multiple Non-Compensable Disablities
N/A
Title 38 CFR § 3.324
Presumption of soundness
Title 38 USC § 1111
Title 38 CFR § 3.303 - 3.305
Claims related to Tobacco Use
Title 38 USC § 1103
Title 38 CFR § 3.300
Duty to Assist
Title 38 USC § 5103A
Title 38 CFR § 3.159
Accrued Benefits
Title 38 USC § 5121
Title 38 CFR § 3.152 & 3.1000
Substitution
Title 38 USC § 5121A
N/A
Prohibition Against Duplication of Benefits (Concurrent Receipt)
Title 38 USC § 5304 & 5305
Title 38 CFR § 3.654 & 3.750 & 3.751
Annual Adjustment of Certain Benefit Rates (COLA)
Title 38 USC § 5312
N/A
Housebound (Survivors)
Title 38 USC § 1122 & 1502
Title 38 CFR § 3.351
Aid and Attendance (Survivors)
Title 38 USC § 1311 and 1315
Title 38 CFR § 3.351 & 3.352
Fugitive Felons
Title 38 USC § 5313B
Title 38 CFR § 3.665 & 3.666
Permanent and Total Ratings and Unemployability
Title 38 USC § 501 & 1155 & 1502
Special Monthly Compensation (Aid and Attendance for Veterans)
Title 38 USC § 1114
Title 38 CFR § 3.350 & 3.552
Analogous Ratings
N/A
Title 38 CFR § 4.20
Functional Loss
N/A
Title 38 CFR § 4.40
Painful Motion
N/A
Title 38 CFR § 4.59
Page 1 of 8
38 CFR § 3.340-3.342 & 4.16-4.18
MOAA DBQ Worksheet
Cardiovascular
Conditions/Symptoms
Form Name
Code of Federal Regulations
Diagnostic Codes
Ischemic Heart Disease
Ischemic Heart Disease
VA 21-0960A-1
The Cardiovascular System
38 CFR 4.100-4.104
7000-7123
Evaluation of varicose veins, arterial
diseases, producing swelling,
claudication of legs, or pain on walking,
skin/nail changes
Artery and Vein Conditions
(Vascular Diseases including
varicose veins)
VA 21-0960A-2
The Cardiovascular System
38 CFR 4.100-4.104
7000-7123
Evaluation of high blood pressure (BP):
how to determine significance of BP
readings or BP reading abnormalities.
Hypertension
VA 21-0960A-3
The Cardiovascular System
38 CFR 4.100-4.104
7000-7123
Conditions including: heart attack (MI),
irregular rhythm, heart murmurs and
heart surgery.
Heart conditions (Including IHD,
Non-IHD, Arrhythmias Valvular
Disease and Cardiac Surgery)
VA 21-0960A-4
The Cardiovascular System
38 CFR 4.100-4.104
7000-7123
Dental and Oral
Conditions/Symptoms
Form Name
Code of Federal Regulations
Diagnostic Codes
Evaluation of all dental and oral
conditions, except TMJ Conditions.
Dental and Oral Conditions
VA 21-0960D-1
Dental and Oral Conditions
38 CFR 4.150
9900-9916
Dental and Oral Conditions
38 CFR 4.150
9900-9916
Evaluation of conditions affecting the Temporomandibular Joint (TMJ)
Conditions
TMJ joint with pain in the jaw when biting
VA 21-0960M-15
and clicks and sounds in the jaw.
Dermatological
Conditions/Symptoms
Form Name
Code of Federal Regulations
Diagnostic Codes
Evaluation for infectious and noninfectious diseases of the skin: how to
evaluate rashes, spots, athlete's foot,
sweating, and acne skin lesions.
Skin Diseases
VA 21-0960F-2
The Skin
38 CFR 4.118
7800-7833
Evaluation of palpable or disfiguring
scars, producing distortion or asymmetry.
Scars and Disfigurement
VA 21-0960F-1
The Skin
38 CFR 4.118
7800-7833
Conditions/Symptoms
Form Name
Code of Federal Regulations
Diagnostic Codes
Evaluation of various conditions of the
ear including: infections, dizziness,
vertigo, acoustic tumors and other
conditions with ringing in the ears
(tinnitus).
Ear Condition (including:
Vestibular and Infectious
Conditions)
VA 21-0960N-1
Impairment of Auditory Acuity
38 CFR 4.85-4.87
6200-6260
Other Sense Organs
38 CFR 4.87a
6275-6276
Ear, Nose, Throat
Evaluation of Anosmia (inability to detect
any odor), Hyposmia (reduced ability to
Loss of Sense of Smell and/or
detect odors), Ageusia (complete lack of
Taste
taste), Hypogeusia (decrease in sense of
VA 21-0960N-3
taste) and other conditions affecting the
sense of smell and taste.
Evaluation of conditions affecting, the
sinuses, nose, throat, larynx, and
pharynx, including, but not limited to
deviated nasal septum and organic
aphonia, vocal chord problems.
Sinusitis, Rhinitis, and other
The Respiratory System
Conditions of the Nose, Throat,
Diseases of the Nose and Throat
Larynx, and Pharynx
38 CR 4.96-4.97
VA 21-0960N-4
Page 2 of 8
6502-6524
MOAA DBQ Worksheet
Endocrinological
Conditions/Symptoms
Form Name
Code of Federal Regulations
Diagnostic Codes
Evaluation of DM Type I or II, with
alteration of blood sugar regulation,
abnormal Glucose Tolerance Test (GTT),
requiring medication or hospitalization or
complications.
Diabetes Mellitus
VA 21-0960E-1
The Endocrine System
38 CFR 4.119
7900-7919
Evaluation of conditions affecting the
hormone glands, including, but not
limited to Cushing's syndrome,
Acromegaly, and Addison's Disease.
Endocrine Diseases (other than
Thyroid and Parathyroid, or
Diabetes Mellitus)
VA 21-0960E-2
The Endocrine System
38 CFR 4.119
7900-7919
Evaluation of conditions affecting the
functions regulated by the thyroid and
parathyroid glands, including, but not
limited to growth and metabolism.
Thyroid and Parathyroid
Conditions
VA 21-0960E-3
The Endocrine System
38 CFR 4.119
7900-7919
Conditions/Symptoms
Form Name
Code of Federal Regulations
Diagnostic Codes
The Digestive System
38 CFR 4.110-4.114
7200-7354
The Digestive System
38 CFR 4.110-4.114
7200-7354
Evaluation of Irritable Bowel Syndrome
Intestinal Conditions (other than
(IBS) (chronic recurrent diarrhea or
surgical or infectious) including
constipation). Ulcerative colitis (chronic
Irritable Bowel Syndrome,
inflammatory bowel condition leading to
Crohn's Disease, Ulcerative
erosions and bleeding) and other
Colitis, and Diverticulitis
conditions with Bloody stools, fistulas,
VA 21-0960G-3
and/or abscess.
The Digestive System
38 CFR 4.110-4.114
7200-7354
Evaluation of hepatitis (which refers to a
variety of inflammatory and infectious
conditions) and Cirrhosis (chronic liver
disease resulting from liver injury leading
to degeneration of the liver) and other
conditions characterized by jaundice,
ascitis, fluid retention.
Hepatitis, Cirrhosis and Other
Liver Conditions
VA 21-0960G-5
The Digestive System
38 CFR 4.110-4.114
7200-7354
Evaluation of peritoneal adhesions,
which are scars of the visceral lining of
the abdominal structures that produces
episodes of partial or complete bowel
obstruction.
Peritoneal Adhesions
VA 21-0960G-6
The Digestive System
38 CFR 4.110-4.114
7200-7354
Evaluation of stomach and duodenum
Stomach and Duodenum
conditions such as peptic ulcer disease,
Conditions (not including GERD
recurrent pain relieved by antacids,
or Esophageal Disorders)
bloody stools, nausea or vomiting,
VA 21-0960G-7
indigestion.
The Digestive System
38 CFR 4.110-4.114
7200-7354
Evaluation of Amebiasis, dysentery, and Infectious Intestinal Disorders,
various types of intestinal parasites with including Bacterial and Parasitic
recurrent diarrhea, alteration in stool
Infections
consistency or foul smell.
VA 21-0960G-8
The Digestive System
38 CFR 4.110-4.114
7200-7354
Evaluation of removal of portions of the
intestine and reconstruction and
diversion of the intestinal tract: bowel
diversion that requires use of external
bags to collect stool.
The Digestive System
38 CFR 4.110-4.114
7200-7354
Gastrointestinal
Evaluation of conditions affecting the
Esophageal Conditions
esophagus such as stricture, spasm, or (including GERD, Hiatal Hernia,
other conditions with lump in throat or
and Other Esophageal
chest, pain on swallowing, or
Disorders)
regurgitation.
VA 21-0960G-1
Evaluation of gallbladder disease, with
inflammation, gallstones, pain after
eating fatty food, or pancreatic conditions
including pancreatitis that manifests as
severe recurrent abdominal pain.
Gallbladder and Pancreas
Conditions
VA 21-0960G-2
Intestinal Surgery (Bowel
Resection, Colostomy, and
Ileostomy)
VA 21-0960G-4
Page 3 of 8
MOAA DBQ Worksheet
Genitourinary
Conditions/Symptoms
Form Name
Code of Federal Regulations
Diagnostic Codes
Evaluation of renal diseases including
Nephritis, renal insufficiency, and other
Kidney Conditions (Nephrology)
diseases of the kidney: kidney failure,
VA 21-0960J-1
abnormal kidney function tests, protein in
the urine, edema, kidney stones.
The Genitourinary System
38 CFR 4.115-4.115b
7101 &
7500-7542
Evaluation of diseases of the urethra,
penis, testes, and scrotum, producing
pain on urination, swelling, blood in urine
or incontinence.
Male Reproductive Organ
Conditions
VA 21-0960J-2
The Genitourinary System
38 CFR 4.115-4.115b
7101 &
7500-7542
Evaluation of malignant lesions of the
prostate gland with frequent diurnal or
nocturnal urination.
Prostate Cancer
VA 21-0960J-3
The Genitourinary System
38 CFR 4.115-4.115b
7101 &
7500-7542
Evaluation of conditions affecting the
bladder and urethra, including, but not
limited to voiding dysfunctions and
infections.
Urinary Tract (Bladder and
Urethra)
VA 21-0960J-4
The Genitourinary System
38 CFR 4.115-4.115b
7101 &
7500-7542
Gynecological
Conditions/Symptoms
Form Name
Code of Federal Regulations
Diagnostic Codes
Evaluation of inflammatory neoplastic
and cystic lesions of the breast: Breast
mass or lumps.
Breast Conditions and
Disorders
VA 21-0960K-1
Gynecological and Disorders of
the Breast
38 CFR 4.116
7610-7627
Evaluation of diseases of the female
genital tract including: uterus, vagina,
cervix, ovaries, endometriosis,
complications of pregnancy, and other
conditions.
Gynecological Conditions
VA 21-0960K-2
Gynecological and Disorders of
the Breast
38 CFR 4.116
7610-7627
Hematologic and Lymphatic
Conditions/Symptoms
Form Name
Code of Federal Regulations
Diagnostic Codes
Hairy Cell and Other B-Cell Leukenias
Hairy Cell and Other B-Cell
Leukenias
VA 21-0960B-1
The Hemic and Lymphatic
System
38 CFR 4.117
7700-7717
Evaluation of conditions of red and white
blood cells, producing anemias,
leukemias on tumors such as
lymphomas.
Hemotologic and Lymphatic
Conditions
VA 21-0960B-2
The Hemic and Lymphatic
System
38 CFR 4.117
7700-7717
Infectious Diseases
Conditions/Symptoms
Form Name
Code of Federal Regulations
Infectious Diseases, Immune
Disorders and Nutritional
Deficiencies
38 CFR 4.88
Infectious Diseases, Immune
Disorders and Nutritional
Deficiencies
38 CFR 4.88
Diagnostic Codes
Evaluation of conditions associated with
the Human Immunodeficiency Virus (HIV)
and its treatment.
HIV Related Illnesses
VA 21-0960I-2
Evaluation of infectious diseases not
specifically-associated with either HIV or
military service in a tropical area, the
Persian Gulf, or Afghanistan.
Infectious Diseases
VA 21-0960I-3
Evaluation of infectious diseases
associated with military service in tropical
areas with exposure to salmonella,
shigella, etc. producing symptoms such
as chronic diarrhea.
Persian Gulf and Afghanistan
Infectious Diseases
VA 21-0960I-1
Infectious Diseases, Immune
Disorders and Nutritional
Deficiencies
38 CFR 4.88 &
38 CFR 3.317
6300-6354
Evaluation of conditions in which the
Systemic Lupus Erthematosus
immune system begins attacking healthy
(SLE) and Other Autoimmune
body tissues, including, but not limited to,
Diseases
Goodpasture's syndrome and GuillainVA 21-0960I-4
Barre syndrome.
Infectious Diseases, Immune
Disorders and Nutritional
Deficiencies
38 CFR 4.88
6300-6354
Page 4 of 8
6300-6354
6300-6354
MOAA DBQ Worksheet
Infectious Diseases
Conditions/Symptoms
Form Name
Code of Federal Regulations
Diagnostic Codes
Evaluation of pulmonary and
extrapulmonary tuberculosis symptoms.
Tuberculosis (TB)
VA 21-0960I-6
Infectious Diseases, Immune
Disorders and Nutritional
Deficiencies
38 CFR 4.88
6300-6354
For use in evaluation of vitamin
deficiencies (Beriberi, Pellagra,
syndromes of dermatitis, diarrhea
dementia in POW, post-GI surgery,
bypass procedures, undernutrition and
malabsorption.)
Nutritional Deficiencies
VA 21-0960I-5
Infectious Diseases, Immune
Disorders and Nutritional
Deficiencies
38 CFR 4.88
6300-6354
Musculoskeletal
Conditions/Symptoms
Form Name
Code of Federal Regulations
Diagnostic Codes
Evaluation of extremity, limb or digit
(complete or partial amputation), and
complications. Evaluation of stumps.
Amputations
VA 21-0960M-1
The Musculoskeletal System
Prosthetics & Amputations
38 CFR 4.40-4.73
5051-5173
Evaluation of ankle pain, persistent
deformity (ankylosis), ankle injuries,
reduction of movement, and use of
assistive device.
Ankle Conditions
VA 21-0960M-2
The Musculoskeletal System
The Ankle
38 CFR 4.40-4.73
5270-5274
Evaluation for non-degenerative arthritic
conditions such as Gout and Rheumatoid
Arthritis: recurrent painful and swollen
joints.
Non-degenerative Arthritis
(including Inflammatory,
Autoimmune, Crystalline, and
Infectious Arthritis) and
Dysbaric Osteonecrosis
VA 21-0960M-3
The Musculoskeletal System
Acute, Subacute, or Chronic
Diseases
38 CFR 4.40-4.73
5000-5025
The Musculoskeletal System
38 CFR 4.40-4.73
5000-5329
Evaluation of injuries, deformities, loss of
Elbow and Forearm Conditions
elbow and forearm producing motion
VA 21-0960M-4
limitation.
Evaluation of flatfoot, and acquired
deformity of the foot.
Flatfoot (Pes Planus)
VA 21-0960M-5
The Musculoskeletal System
38 CFR 4.40-4.73
5000-5329
Evaluation of reduction or loss of toe
function and motion, and alteration in
mobility.
Foot Miscellaneous (other than
Flatfoot)
VA 21-0960M-6
The Musculoskeletal System
38 CFR 4.40-4.73
5000-5329
Evaluation of alteration in motion of the
wrists or digits due to tendon or muscle
injuries, and alteration in motion and
function of the hand including ankylosis,
trigger finger, loss of finger movement.
Hand and Finger Conditions
VA 21-0960M-7
The Musculoskeletal System
38 CFR 4.40-4.73
5000-5329
Evaluation of alteration in extension and
flexion, poor postural and body support,
and alteration of rotation of the hip.
Hip and Thigh Conditions
VA 21-0960M-8
The Musculoskeletal System
38 CFR 4.40-4.73
5000-5329
Evaluation of ankylosis of the knee,
subluxation of the knee, knee instability,
Knee and Lower Leg Conditions
meniscus lesions, and functional
VA 21-0960M-9
limitations knee cartilage problems,
locked knee.
The Musculoskeletal System
38 CFR 4.40-4.73
5000-5329
Evaluation of traumatic and other injuries
resulting in loss or alteration of function,
location, type, tears, and weakness: torn
scarred muscles.
The Musculoskeletal System
38 CFR 4.40-4.73
5000-5329
Muscle Injuries
VA 21-0960M-10
Page 5 of 8
MOAA DBQ Worksheet
Musculoskeletal
Conditions/Symptoms
Form Name
Code of Federal Regulations
Diagnostic Codes
Evaluation of bone infections producing
fever, local alteration of function,
residuals from a bone infection with
persistent drainage or bone alteration
Osteomyelitis
VA 21-0960M-11
The Musculoskeletal System
Acute, Subacute, or Chronic
Diseases
38 CFR 4.40-4.73
5000-5025
Evaluation of arm limitation of function,
dislocation, alteration in joint function,
incomplete movements, deformity,
dislocation, nonunion, and fracture
complications : frozen shoulder.
Shoulder and Arm Conditions
VA 21-0960M-12
The Musculoskeletal System
38 CFR 4.40-4.73
5000-5329
Evaluation of arthritis and neck
deformities.
Neck (Cervical Spine)
Conditions
VA 21-0960M-13
The Musculoskeletal System
38 CFR 4.40-4.73
5319-5323
Evaluation of unfavorable or incomplete
wrist motion due to ankylosis (limitation
in range), painful or other alteration in
function, resulting from traumatic or other
injury complications, joint replacement.
Wrist Conditions
VA 21-0960M-16
The Musculoskeletal System
38 CFR 4.40-4.73
5000-5329
Evaluation of chronic low back pain,
arthritis and back injuries, spinal
conditions or disc disease: low back pain
with sciatica.
Back (Thoracolumbar Spine)
Conditions
VA 21-0960M-14
The Musculoskeletal System
38 CFR 4.40-4.73
5235-5243
Neurological
Conditions/Symptoms
Form Name
Code of Federal Regulations
Diagnostic Codes
Evaluation of progressive degenerative
disease of the brain and spinal cord with
progressive muscle weakness and
wasting, speech, swallowing and
breathing problems.
Amyotrophic Lateral Sclerosis
(Lou Gehrig's Disease)
VA 21-0960C-2
Neurological Conditions and
Convulsive Disorders
Organic Diseases of the Central
Nervous System
38 CFR 4.120-4.124a
8000-8025
Evaluation of alteration of the function of
the nerves (motor and sensory), related
to Diabetes Mellitus: weakness,
numbness, tingling of legs and arms
related to diabetes.
Diabetic Sensory-Motor
Peripheral Neuropathy
*Analogous Rating
VA 21-0960C-4
Neurological Conditions and
Convulsive Disorders
38 CFR 4.120-4.124a
8000-8914
Neurological Conditions and
Convulsive Disorders
38 CFR 4.120-4.124a
8000-8914
Neurological Conditions and
Convulsive Disorders
Diseases of the Cranial Nerves
38 CFR 4.120-4.124a
8205-8412
Neurological Conditions and
Convulsive Disorders
Miscellaneous Diseases
38 CFR 4.120-4.124a
8100-8108
Central Nervous System and
Neuromuscular Diseases
Evaluation of numerous other neurologic (except TBI, ALS, Parkinson's
conditions such as: meningitis, HIV, brain Disease, MS, Headaches, TMJ,
abscess, Lyme Disease, encephalitis,
Epilepsy, Narcolepsy,
stroke, brain tumor, and spinal cord
Peripheral Nerves, Sleep
injury.
Apnea, Cranial nerves,
Fibromyalgia, and CFS)
VA 21-0960C-5
Evaluation of conditions affecting the
following nerves in the Cranium: V
(trigeminal, VII (facial), IX
(glossopharyngeal), X (vagus), XI (spinal
accessory), and XII (hypoglossal).
Cranial Nerve Conditions
VA 21-0960C-3
Evaluation of recurrent episodes of head
Headaches (including Migraine
pain producing work limitation or
Headaches)
incapacitation: with other symptoms such
VA 21-0960C-8
as nausea, vomiting, tearing etc.
Page 6 of 8
MOAA DBQ Worksheet
Neurological
Conditions/Symptoms
Form Name
Code of Federal Regulations
Diagnostic Codes
Evaluation of fibromyalgia components,
including, but not limited to sleep
problems, muscle and joint pain, and
altered affect.
Fibromyalgia
VA 21-0960C-7
The Musculoskeletal System
Acute, Subacute, or Chronic
Diseases
38 CFR 4.40-4.73
5000-5025
Evaluation of disorders of the myelin
sheath of the central nervous systems
producing recurrent alterations of
neurological function: such as weakness,
numbness, urine incontinence, visual
symptoms.
Multiple Sclerosis (MS)
VA 21-0960C-9
Neurological Conditions and
Convulsive Disorders
Organic Diseases of the Central
Nervous System
38 CFR 4.120-4.124a
8000-8025
Evaluation of symptoms that may include
tremors, or trembling in hands, arms,
legs, jaw, and face; rigidity, or stiffness of
the limbs and trunk; bradykinesia, or
slowness of movement; and postural
instability, or impaired balance and
coordination.
Parkinson's Disease
*Analogous Rating
VA 21-0960C-1
Neurological Conditions and
Convulsive Disorders
Organic Diseases of the Central
Nervous System
38 CFR 4.120-4.124a
8000-8025
Evaluation of narcolepsy components,
including, but not limited to, sleep
attacks, sleepiness, paralysis, and
cataplexy.
Narcolepsy
VA 21-0960C-6
Neurological Conditions and
Convulsive Disorders
38 CFR 4.120-4.124a
8000-8914
Evaluation of alteration of the function of
Peripheral Nerve Conditions
Nerves associated with metabolic
(not including Diabetes Sensorydisorders, exposure to toxins, infections,
Motor peripheral Neuropathy)
immunological disorders, or inflammation
VA 21-0960C-10
and other conditions.
Neurological Conditions and
Convulsive Disorders
38 CFR 4.120-4.124a
8000-8914
Evaluation of seizure conditions including
epilepsy.
Neurological Conditions and
Convulsive Disorders
The Epilepsies
38 CFR 4.120-4.124a
8910-8914
Seizure Disorders
VA 21-0960C-11
Ophthalmological
Conditions/Symptoms
Form Name
Code of Federal Regulations
Diagnostic Codes
Evaluation of various diseases of the
eye, such as inflammation, infection,
glaucoma, deformities, alteration of tear
ducts, cataracts, retina disease, and
other conditions.
Eye Conditions
VA 21-0960N-2
Organs of Special Sense
38 CFR 4.75-4.79
6000-6091
Psychological
Conditions/Symptoms
Form Name
Code of Federal Regulations
Diagnostic Codes
Evaluation for anorexia, bulimia, and
other eating disorders.
Eating Disorders
VA 21-0960P-1
Mental Disorders
38 CFR 4.125-4.130
9201-9521
Evaluation of symptoms, history, and
impact related to mental disorders:
depression, mood and affective
disorders, psychosis, etc.
Mental Disorders (other than
PTSD)
VA 21-0960P-2
Mental Disorders
38 CFR 4.125-4.130
9201-9521
Evaluation of beginning and extent of
symptoms (acute - length of symptoms is
usually less than 3 months, chronic symptoms usually last 3 months or more,
with delayed onset - usually at least 6
months have passed between the
traumatic experience and the beginning
of symptoms).
Review Evaluation of PTSD
VA 21-0960P-3
Mental Disorders
38 CFR 4.125-4.130
9201-9521
Page 7 of 8
MOAA DBQ Worksheet
Respiratory
Conditions/Symptoms
Form Name
Code of Federal Regulations
Diagnostic Codes
Evaluation of the respiratory system
except Sleep Apnea and Tuberculosis.
Respiratory Conditions (other
than TB and Sleep Apnea)
VA 21-0960L-1
The Respiratory System
38 CR 4.96-4.97
6502-6847
Evaluation of disorder characterized by
cessation of breathing during sleep and
provides information necessary to
determine functional impact (sleep
apnea, snoring) daytime complications.
Sleep Apnea
VA 21-0960L-2
The Respiratory System
38 CR 4.96-4.97
6502-6847
Rheumatological Diseases
Conditions/Symptoms
Form Name
Code of Federal Regulations
Diagnostic Codes
Evaluation of Chronic Fatigue Syndrome.
Components including but not limited to
tiredness, loss of memory or
concentration and enlarged lymph nodes.
Chronic Fatigue Syndrome
VA 21-0960Q-1
Infectious Diseases, Immune
Disorders and Nutritional
Deficiencies
38 CFR 4.88
6354
General Surgical
Conditions/Symptoms
Form Name
Evaluation of conditions involving internal Hernias (including Abdominal,
organs bulging through the muscle,
Inguinal, and Femoral Hernias)
except hiatal hernia.
VA 21-0960H-1
Evaluation of rectum and anus conditions
causing alteration of sphincter control,
stricture of prolapse, fistula, and other
symptoms.
Code of Federal Regulations
Diagnostic Codes
The Musculoskeletal System
38 CFR 4.73 &
The Digestive System
38 CFR 4.110-4.114
5324-5329 &
7338-7340
The Digestive System
38 CFR 4.110-4.114
7330-7340
Rectum and Anus Conditions
(including Hemorrhoids)
VA 21-0960H-2
Additional Notes
Authorization and consent to release information to the
Department of Veterans Affairs (VA)
VA 21-4142
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