Veterans claiming flatfoot, plantar fasciitis, Morton's neuroma, metatarsalgia, hammer toes, hallux valgus or rigidus, claw foot, tarsal or metatarsal malunion and other foot injuries use this public questionnaire to submit a private clinician's findings. Across 16 pages the clinician records each diagnosis by side, completes the matching condition sections, and documents pain and functional loss in both feet, assistive devices, imaging and work impact.
The Veteran's physician, podiatrist or other treating clinician completes the form and signs the Section XXI certification with NPI, license number and state, and specialty. The Veteran describes pain, flare-ups and functional loss in their own words for the clinician to record but completes no part of it.
After noting who requested the DBQ, whether the exam was in person and which records were reviewed, list the claimed conditions in 1A. In 1B, check each diagnosis with side, ICD code and date: flatfoot, plantar fasciitis, Morton's neuroma, metatarsalgia, hammer toes, hallux valgus or rigidus, acquired pes cavus, tarsal or metatarsal malunion or nonunion, foot injuries, arthritic and inflammatory conditions, or tendinopathy. A missing or changed diagnosis needs an explanation in the comments.
Item 2A summarizes onset and course. Item 2B records foot pain in the Veteran's own words, 2C the frequency, duration, triggers, relieving factors and severity of flare-ups, and 2D any functional loss, including after repeated use over time. These statements support the functional loss findings in Section XIV, where the examiner must cite and discuss case-specific evidence.
Mark every sign that applies, by side, even if it repeats elsewhere: pain on use or manipulation and whether accentuated, swelling on use, characteristic calluses, and whether arch supports or built-up shoes relieve symptoms. Then record extreme plantar tenderness, decreased longitudinal arch height on weight-bearing, marked deformity or pronation, a weight-bearing line over or medial to the great toe, other deformities altering that line, inward Achilles bowing, and marked inward displacement and spasm, noting whether orthopedic shoes or appliances help.
Record, by side, whether the Veteran has had non-surgical treatment and whether it relieved symptoms, then the same for surgical treatment. If there was no surgery, item 4E asks whether surgery was recommended but the Veteran was not a surgical candidate. Item 4F asks whether plantar fasciitis causes functional loss of either foot, with a description of that loss.
Mark the side affected by Morton's neuroma or metatarsalgia, and list which toes on each foot have hammer toes. For hallux valgus and hallux rigidus, choose mild or moderate symptoms, or severe symptoms with function equivalent to amputation of the great toe, by side. Hallux valgus surgery is recorded by type and date: resection of the metatarsal head, tarsal or metatarsal head osteotomy, or other surgery.
For claw foot, record effects on the toes, tenderness under the metatarsal heads or painful callosities, plantar fascia shortening or contraction with dropped forefoot, and limited dorsiflexion or varus deformity, naming any other cause. Grade tarsal or metatarsal malunion or nonunion as moderate, moderately severe or severe. Section XI covers injuries and conditions not described elsewhere, with severity, whether weight-bearing is chronically compromised, and whether arch supports, custom orthotics or shoe modifications are needed.
List any other foot surgery with procedure, side, date and residuals. Section XIII asks whether there is pain on exam in each foot and whether it contributes to functional loss, with a rationale if reported pain isn't found or doesn't limit function. Section XIV checks contributing factors such as weakened movement, deformity, disturbance of locomotion or interference with standing, then flare-up and repeated-use loss, and pain on passive, active, weight-bearing and nonweight-bearing testing of both feet.
Record other findings and any scars, which need the dermatological questionnaire. List assistive devices with frequency of use and the condition each serves, and state whether lower extremity function is so diminished that an amputation with prosthesis would serve equally well. Report imaging and other test results, work impact of the diagnosed conditions alone, and remarks by section. The examiner signs Section XXI with title, specialty, date, NPI, license number and state, and address.
Download the current version from the source each time; forms change without notice.
Foot Conditions, Including Flatfoot (Pes Planus) Disability Benefits Questionnaire
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Sources for this guide
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No. The form states that plain or weight-bearing foot x-rays are not required to diagnose flatfoot. Imaging is needed only to confirm degenerative or post-traumatic arthritis, and once that has been documented, even in the past, VA does not require further imaging even if the arthritis has worsened. Section XVIII records any imaging done.
Section III asks, by side, about pain on use and on manipulation and whether it is accentuated, swelling on use, characteristic calluses, relief from arch supports or built-up shoes, extreme plantar tenderness, decreased arch height on weight-bearing, marked deformity or pronation, the weight-bearing line, and inward bowing or spasm of the Achilles tendon.
Yes. VA intends public DBQs to be completed by the Veteran's own health care provider, and for foot conditions that is often a physician or podiatrist. The certification block asks for title, specialty, NPI and license number and state. VA reserves the right to confirm the authenticity of every DBQ and may still order its own exam.