This 14-page questionnaire lets a Veteran's own clinician document shoulder and arm conditions for a VA disability claim. It records diagnoses by side, range of motion for both shoulders, losses after repeated use and during flare-ups, special tests for the rotator cuff, instability and the AC joint, humerus and clavicle conditions, surgery, imaging and work impact. VA uses it to decide service connection and the rating.
The Veteran's treating or examining clinician, such as an MD, DO, NP or PA, completes every section and signs Section 17. The Veteran contributes history, including flare-ups and functional loss described in his or her own words, but has no section to complete.
Indicate who requested the DBQ, whether you are a VA health care provider, whether the Veteran is regularly seen in your clinic and whether the exam was done in person, describing the method if not. Mark whether records were reviewed, naming them with the date range. Record the dominant hand, since most later items are answered separately for the right and left shoulder.
1A lists the claimed conditions. 1B checks each diagnosis found, with side, ICD code and date of diagnosis, such as shoulder strain, impingement syndrome, bicipital tendonitis or tear, rotator cuff tendonitis or tear, labral tear including SLAP, glenohumeral joint instability or osteoarthritis, acromioclavicular joint separation, ankylosis or joint replacement. If no current diagnosis is found, or it differs from an earlier one, explain the findings in the remarks section.
2A summarizes the onset and course of the shoulder or arm condition. 2B documents flare-ups as the Veteran describes them: frequency, duration, characteristics, precipitating and alleviating factors, severity and the extent of functional impairment. 2C records functional loss or impairment, including after repeated use over time, in the Veteran's own words.
For each shoulder, report initial ROM as all normal, abnormal, unable to test or not indicated. Give active flexion and abduction (normal 180 degrees) and internal and external rotation (normal 90 degrees), mark painful motions, and record passive ROM or why it was not performed. Address pain on active and passive motion and on weight-bearing and nonweight-bearing, and test the contralateral joint unless medically contraindicated.
3B records whether at least three repetitions were possible and any added loss. 3C and 3D require estimated ROM in degrees after repeated use over time and during flare-ups, drawing on the Veteran's statements, records and your expertise, or an explanation of why no estimate is feasible. Name the factors causing loss: pain, fatigability, weakness, lack of endurance or incoordination. 3E lists any additional factors contributing to disability.
For each shoulder, state whether atrophy is present and whether it is due to the claimed condition, giving a rationale if not. Measure atrophy in centimeters on the normal and atrophied sides at maximum muscle bulk, specifying where the measurement was taken. Section 5 asks whether the scapula and humerus move as one piece, the angle of ankylosis in degrees of abduction, and whether Muscle Groups I and II are involved.
Record results for the rotator cuff tests, the crank apprehension and relocation test and the cross-body adduction test, or whether a condition is suspected when testing is not possible. Note mechanical symptoms such as clicking or catching, residuals of recurrent dislocation, clavicle or scapula malunion, nonunion or dislocation, and humerus conditions such as flail shoulder, false flail shoulder, fibrous union or malunion with moderate or marked deformity, and whether each affects shoulder motion.
List shoulder surgeries with dates, such as total shoulder joint replacement. Record other findings and related scars, any brace or other assistive device and how often it is used, and whether remaining function is no better than an amputation with prosthesis would give. Section 14 records imaging and arthritis by side; Section 15 describes the impact on occupational tasks from the diagnosed conditions only, regardless of employment status.
Use Remarks for the explanations the form asks for, identifying the section each remark pertains to. Section 17 certifies that the information is accurate, complete and current, under a penalty statement for willful false statements. 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.
Shoulder and Arm Conditions Disability Benefits Questionnaire
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Sources for this guide
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Usually yes. The form's note says examiners should test the contralateral joint unless medically contraindicated, and the ROM block asks whether the unclaimed joint is damaged or undamaged; if undamaged, range of motion testing must be done. Pain on active and passive motion, weight-bearing and nonweight-bearing should be addressed for each side.
Section 6 lists the Hawkins' impingement, empty can, external rotation/infraspinatus strength and lift-off subscapularis tests for rotator cuff conditions. Section 7 uses the crank apprehension and relocation test for instability, and Section 8 the cross-body adduction test for AC joint pathology. If a test cannot be done, the form asks whether the condition is still suspected.
Not for every condition. The diagnostic testing section says degenerative or post-traumatic arthritis must be confirmed by imaging, but once it is documented, even in the past, VA needs no further imaging. Record whether imaging was done with this exam, which side shows arthritis, and any other significant results and how they relate to the diagnoses.
VA does not. The form and VA's public DBQ page say VA will not pay or reimburse any expense of completing or submitting it, so any fee is agreed between the Veteran and the provider. VA may still order its own examination, and the Veteran must attend if one is scheduled.