Peptic ulcer disease, chronic and drug-induced gastritis, H. pylori infection, stomach stenosis or injury, Zollinger-Ellison syndrome and the effects of stomach surgery are documented for VA disability claims on this 8-page questionnaire. The clinician records how often multi-day episodes of pain, nausea or vomiting occur on daily medication, bleeding and anemia, post-gastrectomy and vagotomy residuals, and endoscopy, imaging, CBC and H. pylori results.
The Veteran's treating or examining clinician completes the form and signs the Section XII examiner's certification. The Veteran completes no part of the form.
Download the current version from the source each time; forms change without notice.
Stomach and Duodenal Conditions (Not Including GERD or Esophageal Disorders) Disability Benefits Questionnaire
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
No. The form's full title is Stomach and Duodenal Conditions (Not Including GERD or Esophageal Disorders). GERD and hiatal hernia are documented on the Esophageal Conditions DBQ. This form covers peptic ulcer, gastritis, H. pylori, stomach injury and post-surgical stomach conditions.
Section V records complications of upper GI surgery, such as TPN or tube feeding for more than 30 consecutive days in the last six months, medications for dumping syndrome or delayed gastric emptying, and pain within an hour of eating. Section VI covers complete or incomplete vagotomy with pyloroplasty or gastroenterostomy.