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VA HIV-Related Illnesses DBQ

Veterans claiming an HIV-related illness for VA compensation use this 7-page questionnaire to document their clinician's findings. It records medications and their complications, constitutional symptoms, diarrhea and weight loss, secondary diseases by body system, opportunistic infections and cancers, current and nadir CD4 counts, and a severity summary that runs from asymptomatic to AIDS with secondary diseases in multiple body systems. VA rates the condition largely from that summary.

Who completes it

The Veteran's treating or examining clinician completes the form and signs the Section XI examiner's certification. The Veteran does not fill in any part.

Submitting and payment

How to submit it
The Veteran gets the signed DBQ and uploads it with the claim on VA.gov or mails it to the VA Evidence Intake Center; a representative may also submit it.
Who pays
VA will not pay or reimburse any cost of completing the HIV DBQ; any provider fee is between the Veteran and the clinician.

Good to know

  • The severity summary uses T4 cell bands (200 to 500, under 200), approved medication use, depression or memory loss with employment limits, and AIDS-related infections or neoplasms.
  • For VA purposes, approved medications include those prescribed under a research protocol at an accredited medical institution.
  • Secondary diseases are flagged by body system, and each one checked needs the matching questionnaire, such as musculoskeletal, respiratory or ENT.
  • Weight loss is measured against baseline weight, which VA defines as the average weight over the two years before the disease began.

Get the official form

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

HIV-Related Illnesses 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

Does the VA HIV DBQ ask for a CD4 count?

Yes. Item 8A asks for the CD4 (T4 cell) lymphocyte count with its date and the lowest (nadir) count if available. The current count also feeds the Section VI severity summary, which separates counts between 200 and 500 from counts under 200.

Which opportunistic conditions are listed on the HIV DBQ?

Item 5A lists HIV-related opportunistic infections and cancers, including candidiasis of the bronchi, trachea, esophagus or lungs, invasive cervical cancer, coccidioidomycosis, cryptococcosis, cryptosporidiosis, CMV retinitis and HIV-related encephalopathy, among others. Recurrent opportunistic infections are described separately in item 5C.