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VA Amputations DBQ (Disability Benefits Questionnaire)

Veterans with service-related amputations can have their provider document them on this six-page public DBQ for a VA compensation claim. The provider records each amputation's level and side for arms, forearms, thumbs, fingers, thighs, lower legs and toes, whether the site allows a suitable prosthesis, scars and other findings, assistive devices, and the impact on work. VA uses it to decide service connection and the rating.

Who completes it

The Veteran's treating or examining clinician (MD, DO, NP, PA or other licensed clinician) completes the sections that apply to each amputation site and signs Section XIII with name and title, specialty, NPI, medical license number and state.

Submitting and payment

How to submit it
The Veteran uploads the completed DBQ with the claim on VA.gov or mails it to VA's Evidence Intake Center; a representative can also submit it.
Who pays
VA does not pay or reimburse any cost of completing a DBQ; any provider fee is between the Veteran and the provider.

Good to know

  • Arm levels use the deltoid insertion, forequarter amputation (with scapula, clavicle or ribs) or disarticulation; forearm levels use the pronator teres insertion.
  • Sections IV and VI ask, for each side, whether the upper or lower extremity amputation site allows use of a suitable prosthetic appliance.
  • Imaging studies are not required to document amputations, though Section X still records any significant diagnostic test findings.
  • Section XI asks how only the amputations affect the ability to work, regardless of employment status and without considering age or other conditions.

Get the official form

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

Amputations Disability Benefits Questionnaire

Official pagePDF

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 and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Does the VA amputations DBQ need X-rays?

No. The form notes that imaging studies are not required to document amputations. Section X still asks whether there are any significant diagnostic test findings or results, so include relevant results that already exist in the record.

What amputation details does the VA DBQ ask for?

For each site, the level and side: arms relative to the deltoid insertion, forequarter or disarticulation; forearms relative to the pronator teres; thumb and finger levels; above-knee thigh amputations; below- or through-knee lower leg amputations including forefoot; and toes. It also asks whether each site allows a suitable prosthesis.

Who can complete the VA amputations DBQ?

The Veteran's own treating or examining provider, such as an MD, DO, NP or PA. VA requires every clinician information block to be completed and the form signed and dated. VA may verify the questionnaire's authenticity and can still order its own examination.