This 14-page questionnaire documents a Veteran's peripheral nerve conditions, such as nerve injuries, neuralgia, neuritis or radiculopathy, for a VA disability claim; diabetic sensory-motor peripheral neuropathy is excluded. The clinician records symptoms by extremity, strength, reflexes, sensation, trophic changes, gait and median nerve tests, then rates each affected nerve. VA uses those ratings to decide service connection and the disability rating.
The Veteran's treating or examining clinician, such as an MD, DO, NP or PA, completes the whole form and signs Section XVIII. The Veteran has no section of his or her own; history and symptoms come from the interview and the records.
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. Then check whether records were reviewed, identifying service, VA or private treatment records and the date range they cover, or check that no records were reviewed.
1A asks whether the Veteran has a peripheral nerve condition or peripheral neuropathy. 1B lists only diagnoses that pertain to it, each with ICD code and date of diagnosis, and 1C takes any others. The definitions printed below separate neuralgia, a dull and intermittent pain in a distribution that identifies the nerve, from neuritis, with loss of reflexes, muscle atrophy, sensory disturbances and constant pain, at times excruciating.
2A gives a brief history of onset and course, and 2B records the dominant hand. 3A rates symptoms attributable to the nerve condition in each extremity as none, mild, moderate or severe: constant pain, which may be excruciating at times; intermittent pain, usually dull; paresthesias and/or dysesthesias; and numbness. 3B describes any other symptoms with their location and severity.
Rate strength by muscle group and side from 0/5 (no muscle movement) to 5/5, and record any atrophy with its location and centimeter measurements of the normal and atrophied sides at maximum muscle bulk. Grade deep tendon reflexes from 0 (absent) to 4+. Record light-touch sensation by region, beginning with the shoulder area (C5), as normal, decreased or absent, and note other sensory findings.
Section VII asks about trophic changes attributable to peripheral neuropathy, such as loss of extremity hair or smooth, shiny skin. Section VIII records whether gait is normal and, if not, describes the abnormal gait and its etiology. Section IX records Phalen's and Tinel's signs on each side when special tests for the median nerve were indicated and performed.
For the radial, median, ulnar, musculocutaneous, circumflex and long thoracic nerves and the upper, middle and lower radicular groups, check normal, incomplete paralysis or complete paralysis for each side. The form prints what complete paralysis looks like for each nerve. Grade incomplete paralysis mild, moderate or severe; wholly sensory impairment should be mild or at most moderate.
Rate the sciatic, external popliteal (common peroneal), musculocutaneous (superficial peroneal), anterior tibial (deep peroneal), internal popliteal (tibial), posterior tibial, anterior crural (femoral), internal saphenous and obturator nerves, the external cutaneous nerve of the thigh and the ilio-inguinal nerve by side. The sciatic nerve adds moderately severe and severe, with marked muscular atrophy, to the incomplete paralysis grades.
Record assistive devices used as a normal mode of locomotion and how often, and whether any extremity retains no more function than an amputation with prosthesis would provide. Section XIV covers other findings and related scars, Section XV records EMG and other diagnostic results, and Section XVI describes how the nerve condition affects the Veteran's ability to work, with one or more examples.
Add any remarks, then certify that the information is accurate, complete and current, beneath the penalty statement for willful false statements. Complete 18A to 18H: signature, printed name and title, area of practice or 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.
Peripheral Nerves Conditions (Not Including Diabetic Sensory-Motor Peripheral Neuropathy) Disability Benefits Questionnaire
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No. The form's full title is Peripheral Nerves Conditions (Not Including Diabetic Sensory-Motor Peripheral Neuropathy). Use it for other peripheral nerve conditions, such as nerve injuries, neuralgia, neuritis or radiculopathy, and record each diagnosis with its ICD code and date of diagnosis in Section I.
Section X covers the radial, median, ulnar, musculocutaneous, circumflex and long thoracic nerves and the upper, middle and lower radicular groups. Section XI covers the sciatic, peroneal, tibial, posterior tibial, anterior crural, internal saphenous and obturator nerves, the external cutaneous nerve of the thigh and the ilio-inguinal nerve, each rated by side.
Usually not. Section XV says EMG studies are rarely required to diagnose specific peripheral nerve conditions in the appropriate clinical setting, and repeat studies are not indicated when EMG results already in the record reflect the current condition. If EMG was done, record the extremities tested, whether results were normal or abnormal, and the date.
For each affected nerve and side, check normal, incomplete paralysis or complete paralysis; the form describes complete paralysis for every nerve, such as foot drop for the common peroneal nerve. Incomplete paralysis is graded mild, moderate or severe, and the sciatic nerve adds moderately severe and severe with marked muscular atrophy. Wholly sensory impairment is mild or at most moderate.