Women Veterans claiming conditions of the vulva, vagina, cervix, uterus, fallopian tubes or ovaries use this 10-page VA questionnaire. The clinician records current pain and symptoms, whether treatment is needed and whether it controls symptoms for each organ, hysterectomy or oophorectomy, type of menopause and ovarian atrophy, urinary incontinence, fistulae, endometriosis, pelvic organ prolapse and female sexual arousal disorder. The form works organ by organ, so each affected organ gets its own answers.
The Veteran's treating or examining clinician completes Sections 1 to 20 and signs the Section 21 examiner's certification with NPI, license and specialty. The Veteran does not complete any part of the form.
Download the current version from the source each time; forms change without notice.
Gynecological 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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Yes. The form's note says a diagnosis of endometriosis must be substantiated by laparoscopy. Section 13 then records pelvic pain, heavy or irregular bleeding, and lesions involving the bowel or bladder confirmed by laparoscopy, and Section 17 asks for the laparoscopy date, facility and results.
Section 14 asks whether prolapse is due to injury, disease or surgical complications of pregnancy, which organs are involved (bladder, urethra, uterus, vaginal vault, small bowel or rectum) and whether the prolapse is complete or incomplete. Other obstetric or gynecologic complications are described in item 14B.
Yes. Section 11 asks whether urinary leakage is present, what causes it and whether it is due to a gynecologic condition, then grades it by absorbent material changes per day or the need for an appliance. Rectovaginal and urethrovaginal fistulae and their leakage frequency are covered in Section 12.