Veterans claiming a mid or low back condition use this public questionnaire to give VA a private clinician's findings. Over 14 pages it covers diagnoses from lumbosacral strain to IVDS and vertebral fracture, active and passive range of motion with pain, repetitive-use and flare-up estimates, strength, reflexes, sensation, straight leg raising, radiculopathy, ankylosis, prescribed bed rest and imaging. VA weighs it as claim evidence and may still order its own exam.
The Veteran's treating or examining clinician, such as an MD, DO, NP or PA, completes every section and signs the Section XVIII certification with NPI, license number and state, and specialty. The Veteran describes flare-ups and functional loss in their own words for the clinician to record but fills in no part of the form.
After the opening questions on who requested the DBQ, whether the Veteran was examined in person and which records were reviewed, list the claimed conditions in 1A. In 1B, check each diagnosis with its ICD code and date: ankylosing spondylitis, degenerative arthritis, degenerative disc disease other than IVDS, lumbosacral strain, IVDS, sacroiliac injury or weakness, segmental instability, spinal fusion, spinal stenosis, spondylolisthesis, traumatic paralysis, vertebral dislocation or fracture, or other. If there is no diagnosis, or it differs from a prior one, explain why in Remarks.
Item 2A is a brief history of onset and course. Item 2B asks whether the Veteran reports flare-ups and, if so, their frequency, duration, characteristics, triggers, relieving factors, severity and the functional impairment they cause. Item 2C records any functional loss, including after repeated use over time, in the Veteran's own words. These answers feed the flare-up and repeated-use estimates later in Section III.
Record whether initial ROM is normal, abnormal, unable to test or not indicated, and whether abnormal motion itself causes functional loss. Measure active forward flexion, extension, both lateral flexions and both rotations in degrees, mark which motions are painful and note degrees lost to pain, weakness, fatigability or incoordination. Repeat for passive ROM or explain why it wasn't done. Then report pain on weight-bearing, nonweight-bearing and rest, crepitus, and localized tenderness.
Perform at least three repetitions and record any added loss of motion and its causes. For repeated use over time and for flare-ups, state whether the exam coincides with either, whether the Veteran's statements suggest significant limitation, and estimate endpoints in degrees with case-specific evidence. Item 3E grades localized tenderness, muscle spasm and guarding by whether they cause abnormal gait or spinal contour. Item 3F lists other factors, such as interference with sitting or standing, swelling or disturbance of locomotion.
Rate hip flexion, knee extension, ankle plantar and dorsiflexion, and great toe extension on the 0/5 to 5/5 scale, and measure any atrophy in centimeters on both sides. Grade knee and ankle reflexes from 0 to 4+ and light-touch sensation by dermatome. A straight leg raise is positive when pain radiates below the knee. For radiculopathy, rate constant and intermittent pain, paresthesias and numbness per leg, name the nerve roots involved and explain the likely cause.
Section IX defines unfavorable ankylosis as the entire thoracolumbar spine or entire spine fixed in flexion or extension with listed complications; fixation in neutral is always favorable. Section X records other neurologic findings, such as bowel or bladder problems, which also need their own questionnaires. Section XI asks whether the Veteran has IVDS and, if so, the total duration of physician-prescribed bed rest in the past 12 months, with treatment dates, facility and treatment described when documented.
Mark any wheelchair, brace, crutch, cane or walker used as a normal mode of locomotion, with occasional, regular or constant use, and link each device to a condition and side. Section XIII asks whether function of any extremity is so diminished that an amputation with prosthesis would serve equally well. Section XIV covers other findings and scars. Section XV records imaging, arthritis, vertebral fracture with height loss, other test results and how abnormal results relate to the diagnoses.
Describe how the diagnosed conditions alone, without age or other conditions, affect occupational tasks such as standing, walking, lifting and sitting, regardless of current employment, giving examples. Use Remarks to explain findings, naming the section each remark refers to. The examiner then certifies the information is accurate, complete and current and enters signature, printed name and title, specialty, date signed, phone and fax, NPI, medical license number and state, and address.
Download the current version from the source each time; forms change without notice.
Back (Thoracolumbar Spine) 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.
Sources for this guide
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Not for every condition. Degenerative or post-traumatic arthritis must be confirmed by imaging, but once documented VA needs no new imaging even if it has worsened. Imaging is not required to diagnose IVDS, and EMG is rarely required for radiculopathy. Item 15D asks whether imaging shows a thoracolumbar vertebral fracture and whether 50 percent or more of its height is lost.
Section XI counts episodes of acute IVDS signs and symptoms that required bed rest prescribed by a physician and treatment by a physician in the past 12 months. The examiner picks the total duration, from no episodes through bands of at least 1 week up to at least 6 weeks, and states whether it comes from the Veteran's history alone or from documented treatment records.
Item 3D asks for an estimate in degrees for each motion based on all procurable information: the Veteran's statements, treatment records and other lay evidence, and the examiner's expertise. The examiner cites and discusses that evidence. If an estimate isn't feasible, the examiner explains why, and the form says that explanation cannot rest on a general aversion to estimating.
VA intends the public DBQs to be completed by the Veteran's own health care provider. The signature block asks for title, with examples such as MD, DO, NP and PA-C, plus specialty, NPI and license number and state. VA reserves the right to confirm the authenticity of every questionnaire and may still schedule its own examination.