Veterans claiming a neck condition can ask their own clinician to complete this 14-page questionnaire and submit it with the claim. It captures diagnoses, cervical range of motion in degrees, losses after repeated use and during flare-ups, neurologic findings including radiculopathy, IVDS episodes, imaging and functional impact. VA uses the findings to decide service connection and assign a disability rating.
The Veteran's treating or examining clinician, such as an MD, DO, NP or PA, completes the whole form and signs Section XVII. The Veteran describes flare-ups and functional loss in his or her own words for the examiner to record, but has no section to fill in.
Record who requested the DBQ, whether you are a VA provider, whether the Veteran is regularly seen in your clinic, and whether the exam was in person, describing the method if not. Check whether records were reviewed and identify them, such as service, VA or private treatment records, with the date range. Then mark the dominant hand: right, left or ambidextrous.
1A lists the claimed conditions. 1B checks the diagnoses found on this evaluation, each with ICD code and date of diagnosis: ankylosing spondylitis, cervical strain, degenerative arthritis, degenerative disc disease other than IVDS, IVDS, segmental instability, spinal fusion, spinal stenosis, spondylolisthesis, vertebral dislocation or fracture, complete traumatic paralysis, or other. If there is no diagnosis, or it differs from a prior one, explain in Remarks. The date can be the exam date for a new diagnosis.
2A is a brief history of onset and course. 2B asks whether the Veteran reports flare-ups and, if so, their frequency, duration, characteristics, precipitating and alleviating factors, severity and the functional impairment they cause. 2C records any functional loss or impairment, including after repeated use over time, in the Veteran's own words. These answers support the estimates required later in Section III.
Report initial ROM as all normal, abnormal, unable to test or not indicated, with explanations. Give active ROM in degrees for forward flexion, extension and both lateral flexions (normal 45) and both lateral rotations (normal 80), and mark which motions were painful. Perform passive ROM or give the reason it was not done. Address pain on weight-bearing and nonweight-bearing, crepitus, and localized tenderness or pain on palpation.
3B asks whether the Veteran can do at least three repetitions and records any added loss in degrees, with causes such as pain, fatigability, weakness, lack of endurance or incoordination. 3C and 3D require estimated ROM after repeated use over time and during flare-ups, citing case-specific evidence, or an explanation of why no estimate is feasible. 3E covers tenderness, guarding and muscle spasm and whether they cause abnormal gait or spinal contour. 3F lists other contributing factors.
Rate strength from 0/5 to 5/5 and measure any atrophy in centimeters on the normal and atrophied sides at maximum muscle bulk. Grade deep tendon reflexes from 0 to 4+ and light-touch sensation by dermatome. Section VII records radicular symptoms by side and severity, other signs of radiculopathy, the nerve roots involved (C5/C6, C7, C8/T1) and, in 7D, the likely cause of any abnormal neurologic findings in Sections 4 to 7.
Section VIII asks about ankylosis using VA's definitions: unfavorable ankylosis fixes the spine in flexion or extension with listed complications, and fixation in neutral position is always favorable. Section IX covers other neurologic findings such as bowel or bladder problems or pathologic reflexes. Section X asks whether IVDS is present, the total duration of physician-prescribed bed rest over the past 12 months, and whether that rests on the Veteran's report or documented records.
Record any wheelchair, brace, crutches, cane or walker used as a normal mode of locomotion and how often, and whether an extremity keeps no more function than an amputation with prosthesis would give. List other findings and related scars. Section XIV records imaging done with this exam, documented arthritis, cervical vertebral fracture and other tests. Section XV describes the impact on occupational tasks, regardless of employment status, from the diagnosed conditions only.
Use Remarks to explain a missing or changed diagnosis and anything else the form refers there, naming the section each remark pertains to. In Section XVII certify that the information is accurate, complete and current, then complete 17A to 17H: signature, printed name and title, specialty, date signed, phone and fax, NPI, medical license number and state, and address.
Download the current version from the source each time; forms change without notice.
Neck (Cervical Spine) Conditions Disability Benefits Questionnaire
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Sources for this guide
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Yes, where feasible. The form asks for estimated degrees after repeated use over time and during flare-ups, based on the Veteran's statements, case records and your expertise. If an estimate is not feasible, explain why; the form says the explanation should not rest on the examiner's shortcomings or a general aversion to estimating what was not observed.
Not always. The form says testing is not indicated for every condition. Degenerative or post-traumatic arthritis must be confirmed by imaging, after which VA needs no repeat imaging even if it worsens. IVDS can be diagnosed without imaging, and EMG is rarely required to diagnose radiculopathy in the appropriate clinical setting.
Sections IV to VI record strength on a 0 to 5 scale, atrophy measurements, reflexes from 0 to 4+ and light-touch sensation by dermatome. Section VII rates constant pain, intermittent pain, paresthesias and numbness by side and severity, then the nerve roots involved, from C5/C6 to C8/T1. Wholly sensory involvement should be rated mild, or no more than moderate.
Yes. The form tells the examiner that VA may obtain more medical information, including an examination, if needed to complete its review, and that VA reserves the right to confirm the authenticity of all completed questionnaires. If VA schedules an exam, its public DBQ page says the Veteran must report for it.