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VAC PEN 6235: Thoracolumbar Spine Questionnaire

Veterans Affairs Canada uses this five-page questionnaire, part of its medical questionnaires that complement the Table of Disabilities, to document confirmed thoracolumbar spine diagnoses and assess the disability for disability benefits. The health professional records injuries, radicular and non-radicular pain, treatment, gait, leg length, active range of motion, nerve root tension signs and a lower extremity neurological examination.

Who completes it

General practitioners, including sport medicine physicians, specialists, nurse practitioners, chiropractors and physician assistants in listed provinces can complete it; physiotherapists may complete it for assessment or reassessment only, not diagnosis. The client is identified by name, date of birth, file and decision numbers.

Submitting and payment

How to submit it
VAC tells clients not to have a medical questionnaire completed until it gives specific instructions about which one is required, and the completed form is returned as VAC instructs.
Who pays
The form asks whether VAC is to be invoiced for its completion.

Good to know

  • Active range of motion norms are flexion 90 degrees, extension 30 degrees, and 35 degrees each for right and left lateral flexion and rotation; describe pain with movement and any ankylosis.
  • Record the straight leg raise in degrees, the femoral stretch test, and at least 2 of 3 further tests: the Hoover, cross over and bowstring tests.
  • The neurological examination covers both lower limbs: sensory impairment by dermatome, motor strength on a 0 to 5 scale, patellar and Achilles reflexes on a 0 to 4 scale, and Babinski.
  • For radicular pain or sciatica, describe radiation above or below the knee, the dermatomes affected and severity, and attach consultation, discharge and imaging reports.

Get the official form

Download the current version from the source each time; forms change without notice.

Medical Questionnaire: Thoracolumbar Spine Conditions

Questionnaire médical : Affections de la colonne dorsolombaire

Official pagePDFVersion française

Fill it with Vero

Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.

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Frequently asked questions

Who can complete VAC's thoracolumbar spine questionnaire?

The same professionals as VAC's knee questionnaire: general practitioners, including sport medicine physicians, specialists, nurse practitioners, physician assistants in listed provinces and chiropractors. Physiotherapists are accepted for assessment or reassessment of a disability only, not for diagnosis, and other regulated professionals may be considered case by case.

Which nerve root tension tests does PEN 6235 require?

The straight leg raising test measured in degrees, the femoral stretch test, and at least two of three further tests: the Hoover test, the cross over test and the bowstring test. The form describes how each test is performed and asks whether pain is reproduced on the symptomatic side in a dermatomal pattern.

Is PEN 6235 available in French?

Yes. VAC publishes it in English as PEN 6235e and in French as Questionnaire médical : Affections de la colonne dorsolombaire. The current PDF is dated 2024-05, runs five pages and is fillable, with a final page for additional information and the health professional's signature.