Veterans claiming Meniere's syndrome, peripheral vestibular disorders, BPPV, chronic otitis externa or media, mastoiditis, cholesteatoma or ear neoplasms use this 9-page VA questionnaire. The clinician records how often vertigo, staggering and attacks occur and how long they last, findings of ear infection or inflammation, prior ear surgery, and an exam including the tympanic membrane, Romberg, Dix-Hallpike and finger-nose-finger tests.
The Veteran's treating or examining clinician completes the form and signs the Section XII examiner's certification. Hearing loss and tinnitus are handled on a separate Hearing Loss and Tinnitus questionnaire, not on this one.
Download the current version from the source each time; forms change without notice.
Ear Conditions (Including Vestibular and Infectious Conditions) Disability Benefits Questionnaire
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Yes. Meniere's syndrome is the first diagnosis listed on the Ear Conditions DBQ. Because Meniere's involves hearing impairment, the form says the Hearing Loss and Tinnitus Questionnaire must also be completed, and VA does not publish that questionnaire for private providers.
Section VI covers the external ear and auricle deformity, the ear canal, the tympanic membrane including perforations, gait, the Romberg test, the Dix-Hallpike (Nylen-Barany) test for vertigo or nystagmus, and finger-nose-finger limb coordination. Each item can be marked not indicated if that test does not apply.