Veterans claiming hypertension or isolated systolic hypertension use this four-page public questionnaire to give VA their clinician's documentation. Its focus is blood pressure: how the initial diagnosis was confirmed, whether diastolic pressure has run predominantly 100 or more, continuous medication, and three current readings. The clinician also notes complications, scars and work impact before signing, and VA may still request its own exam.
The Veteran's treating or examining clinician (MD, DO, NP, PA or other licensed clinician) completes the whole form and signs the Section VI examiner's certification with NPI, license and specialty. Readings can come from existing medical records or from visits scheduled to measure blood pressure.
Before the clinical sections, mark who requested the questionnaire (the Veteran, a third party or other), whether you are a VA provider, whether the Veteran is regularly seen in your clinic, and whether the exam was in person or, if not, how it was conducted. Then indicate whether records were reviewed and identify them, such as service, VA or private treatment records, with the date range.
Item 1A asks whether the Veteran currently has hypertension or isolated systolic hypertension under VA's criteria: diastolic predominantly 90 mm or greater, or systolic predominantly 160 mm or greater with diastolic under 90 mm. Give the ICD code and date of diagnosis, plus up to two other related diagnoses. Item 1B lists any additional related diagnoses. Note 3 directs the examiner to complete separate questionnaires for complications, such as the Kidney DBQ.
Item 2A is a brief history of the condition's onset and course. Item 2B asks whether the treatment plan includes taking continuous medication for hypertension or isolated systolic hypertension and, if so, lists only the medications used for those diagnosed conditions, not the Veteran's full medication list.
Item 2C asks whether the initial diagnosis was confirmed by readings taken two or more times on at least three different days, with those readings and dates if known; answering unknown leads to 2D and 2E. Item 2D asks about a history of diastolic pressure predominantly 100 or more, with frequency and severity. Item 2E records three current readings with dates, taken seated with back and feet supported, which suffice for a previously established diagnosis.
Item 3A records any other findings, complications or symptoms related to the diagnoses, as a brief summary. Item 3B asks whether there are scars, surgical or otherwise, related to the conditions or their treatment; if yes, the appropriate dermatological questionnaire must also be completed. Item 3C holds any comments.
Item 4A asks whether hypertension or isolated systolic hypertension affects the Veteran's ability to work and, if so, asks for a description with one or more examples. Item 5A is free text for remarks, useful for explaining readings taken outside the visit or why the diagnosis differs from earlier records.
The examiner certifies that the information is accurate, complete and current, under a penalty statement covering willful false statements. Items 6A to 6H record the signature, printed name and title, area of practice or specialty, date signed, phone and fax numbers, NPI, medical license number and state, and address. VA may verify the authenticity of the completed questionnaire.
Download the current version from the source each time; forms change without notice.
Hypertension Disability Benefits Questionnaire
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Sources for this guide
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Item 2E asks for three current readings, each with its date, which are sufficient if the Veteran already has an established diagnosis. To confirm an initial diagnosis, VA requires readings taken two or more times on at least three different days, and item 2C has room for those readings and their dates if known.
Item 2C can be answered unknown, and the examiner then completes 2D and 2E. Item 2D asks about a history of diastolic pressure predominantly 100 or more. If there is none, the form asks for readings taken two or more times on at least three different days to confirm the diagnosis, unless the Veteran is on treatment for hypertension.
VA intends public DBQs to be completed by the Veteran's own health care provider, such as an MD, DO, NP or PA. The certification block asks for title, specialty, NPI, medical license number and state, and address. VA reserves the right to confirm the authenticity of every DBQ and may obtain more information, including its own examination.
The current public version, updated July 11, 2024, prints no VA form number. Public DBQs were formerly issued in the VA Form 21-0960 series. The form is identified by its title, Hypertension Disability Benefits Questionnaire, and the version date in its footer.