Veterans claiming scars anywhere on the body, or disfigurement of the head, face or neck, can have a clinician document them on this 11-page questionnaire. It records each scar's location, size, pain, instability, burn depth and underlying tissue damage, along with facial distortion and pigment or texture changes. VA uses these 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 every applicable section and signs Section 5. The Veteran supplies the history of each scar but completes no part of the form.
State who requested the DBQ, whether you are a VA provider, whether the Veteran is regularly seen in your clinic, and whether the Veteran was examined 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, or check that none were reviewed.
1A asks whether the Veteran has scars anywhere on the body or disfigurement of the head, face or neck, and lists each diagnosis with ICD code and date. 1B and 1C route the exam: trunk or extremity scars go to Section 2, and head, face or neck scars or disfigurement go to Section 3. The measuring instructions printed here apply to the whole form: centimeters, square centimeters, widest points, and TNTC.
Describe the cause, origin and course of the trunk and extremity scars. State how many are painful and describe the pain, and how many are unstable with frequent loss of skin covering, identifying which scars are which. For burn scars, give the depth of each original burn: full thickness or sub-dermal, deep partial thickness, or less than deep partial thickness.
Mark each region affected or not affected: right and left upper extremity, right and left lower extremity, anterior trunk and posterior trunk. Number the scars in each region, give length and width, and check which are tender to palpation, unstable on inspection, or have underlying soft tissue damage. The 2-2 summary asks for the approximate combined total area per region, separately for scars without and with underlying tissue damage.
Give the history, painful and unstable scars, and burn depths as in Section 2. Then list each scar or disfigurement with its type, location, and length and width at the widest part. Record elevated or depressed surface contour, adherence to underlying tissue, missing soft tissue, hypo- or hyperpigmentation, induration and inflexibility, abnormal texture (such as irregular, atrophic, shiny or scaly), tenderness and instability, identifying each affected scar.
Give the approximate combined area in square centimeters of the head, face and neck that is hypo- or hyperpigmented, has abnormal texture, is missing underlying soft tissue, or is indurated and inflexible. Then state whether there is gross distortion or asymmetry of facial features or visible or palpable tissue loss, checking the nose, chin, forehead, cheeks, lips, eyes or ears affected, with the side, and describe it.
Complete this section for all scars regardless of location. Record any limitation of function, including limitation of motion, naming the scars responsible; limitation of motion also needs the appropriate musculoskeletal DBQ. Note other findings such as muscle or nerve damage, whether color photographs were taken, how the scars affect the Veteran's ability to work with examples, and remarks that identify the section they pertain to.
The examiner certifies that the information is accurate, complete and current, beneath a penalty statement for willful false statements. Complete 5A to 5H: signature, printed name and title, area of practice or specialty, date signed, phone and fax, National Provider Identifier, medical license number and state, and address.
Download the current version from the source each time; forms change without notice.
Scars/Disfigurement Disability Benefits Questionnaire
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Sources for this guide
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Number the scars in each region and give each one's length and width in centimeters, at the widest points for non-linear scars. The summary sections then ask for the approximate combined total area in square centimeters for each region. Where scars are too numerous to count, such as scattered shrapnel wound scars or acne scarring, write TNTC and estimate the combined area.
An unstable scar has frequent loss of covering of skin over the scar, for any reason. For each region the examiner records how many scars are unstable, describes the skin loss, and identifies which numbered scars are unstable on inspection, separately from scars that are painful or tender to palpation.
No. Section 4 states that color photographs are not required for scars or other disfigurements. If photographs of any scar or disfiguring condition were taken, though, the examiner checks Yes and the photographs must be provided with the examination report sent to VA.
Not always. Other DBQs, such as the Sleep Apnea and Peripheral Nerves questionnaires, record related scars themselves, with location and measurements. They send a scar to this form only when it is painful or unstable, the total area is 39 square centimeters (6 square inches) or more, or it is on the head, face or neck.