This 13-page public DBQ documents a Veteran's ankle conditions for a VA disability compensation claim. The provider records diagnoses such as ligament sprains, tendonitis, arthritis and ankle replacement, measures range of motion with repetitive-use testing, estimates loss during flare-ups, and covers atrophy, ankylosis, instability testing, surgery and assistive devices. VA uses it to decide service connection and assign a rating.
The Veteran's treating or examining clinician (MD, DO, NP, PA or other licensed clinician) completes Sections 1 to 14 for each ankle and signs Section 15 with name and title, specialty, NPI, medical license number and state.
Download the current version from the source each time; forms change without notice.
Ankle Conditions Disability Benefits Questionnaire
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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The form acknowledges an exam during a flare-up is often not feasible. The examiner estimates, as clearly as possible, the additional functional loss during flare-ups, ideally in degrees of motion, using the Veteran's history, the exam findings and the medical evidence. The same approach applies to repeated use over time.
Yes, unless medically contraindicated. The range-of-motion note asks examiners to test the contralateral joint and address pain on active and passive motion and in weight-bearing and nonweight-bearing. If testing cannot be done, for example because of severe pain or risk of injury, explain why.
The Veteran's treating or examining healthcare provider, with the examiner block fully completed: printed name and title, area of practice, NPI, medical license number and state, address and signature. VA reserves the right to confirm authenticity and may still schedule its own exam.