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VA Esophageal Conditions DBQ (GERD, Hiatal Hernia)

GERD, hiatal hernia, esophageal stricture, Barrett's esophagus, achalasia and other esophageal disorders are documented for VA disability claims on this 8-page questionnaire. The clinician records daily medication needs, dysphagia, how often dilatation is required and whether strictures are recurrent or refractory, undernutrition or weight loss, surgery and its complications, and EGD, barium swallow or biopsy results. VA rates the condition from these findings.

Who completes it

The Veteran's treating or examining clinician completes Sections 1 to 8 and signs the Section 9 examiner's certification with NPI and license details. The Veteran fills in no part of it.

Submitting and payment

How to submit it
The signed questionnaire is handed to the Veteran, who uploads it with the claim on VA.gov or mails it to the VA Evidence Intake Center; a representative may submit it instead.
Who pays
VA will not pay or reimburse the cost of completing this DBQ, so any fee is between the Veteran and the provider.

Good to know

  • The form notes GERD can be diagnosed clinically by symptom relief with proton pump inhibitors, H2 blockers or antacids; endoscopy is not required to establish it.
  • Esophageal stricture must be documented by barium swallow, CT or EGD, with the study date recorded in the diagnostic testing section.
  • Recurrent stricture means target diameter cannot be kept beyond 4 weeks; refractory means it cannot be reached despite at least 5 dilatations at 2-week intervals.
  • Item 3D covers chronic complications of esophageal or hiatal hernia surgery, including TPN or tube feeding for more than 30 consecutive days in the last six months.

Get the official form

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

Esophageal Conditions (Including Gastroesophageal Reflux Disease (GERD), Hiatal Hernia, and Other Esophageal Disorders) 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

Is there a separate VA DBQ for GERD?

No. GERD and hiatal hernia are documented on the Esophageal Conditions DBQ, whose full title names both. The examiner checks GERD in Section 1 and completes the signs and symptoms in Section 3, including whether daily medication is required and whether dysphagia or strictures are present.

How does this DBQ define substantial weight loss?

Involuntary loss of more than 20 percent of baseline weight, sustained for three months, with diminished self-care or work tasks. Baseline is the documented average weight for the two years before onset or the weight at the most recent discharge physical; otherwise ideal body weight, whichever method is most favorable to the Veteran.

What does the form ask about Barrett's esophagus?

Item 3B applies when Barrett's is documented by pathology. The examiner indicates high-grade, low-grade or no dysplasia with the biopsy date, whether Barrett's caused strictures, and whether it has been resolved by surgery, radiofrequency ablation or another treatment.