DVBCQMO2.m

DVBCQMO2 ;;ALB-CIOFO/ECF,SBW - MEDICAL OPINION QUESTIONNAIRE ; 4/APR/2011

 ;;2.7;AMIE;**166**;Apr 10, 1995;Build 6

 ;

TXT ;

 ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for

 ;; disability benefits.  VA will consider the information you provide on this 

 ;; questionnaire as part of their evaluation in processing the Veteran's claim.

 ;;

 ;; 1. Definitions

 ;; Aggravation of preexisting nonservice-connected disabilities.

 ;; A preexisting injury or disease will be considered to have been aggravated

 ;; by active military, naval, or air service, where there is an increase in

 ;; disability during such service, unless there is a specific finding that the

 ;; increase in disability is due to the natural progress of the disease.

 ;;

 ;; Aggravation of nonservice-connected disabilities. 

 ;; Any increase in severity of a nonservice-connected disease or injury that

 ;; is proximately due to or the result of a service-connected disease or injury,

 ;; and not due to the natural progress of the nonservice-connected disease, will

 ;; be service connected.

 ;;

 ;; 2. Evidence review

 ;; Was the Veteran's VA claims file reviewed?

 ;; ___ Yes   ___ No

 ;; If yes, list any records that were reviewed but were not included in the

 ;; Veteran's VA claims file: ___________________________________________________

 ;; If no, check all records reviewed:

 ;;    ___ Military service treatment records

 ;;    ___ Military service personnel records

 ;;    ___ Military enlistment examination

 ;;    ___ Military separation examination

 ;;    ___ Military post-deployment questionnaire

 ;;    ___ Department of Defense Form 214 Separation Documents

 ;;    ___ Veterans Health Administration medical records (VA treatment records)

 ;;    ___ Civilian medical records

 ;;    ___ Interviews with collateral witnesses (family and others who have

 ;;        known the veteran before and after military service)

 ;;    ___ No records were reviewed

 ;;    ___ Other: ______________________________________

 ;;

 ;; Complete only the sections below that you are asked to complete in the

 ;; Medical Opinion DBQ request.

 ;;

 ;; 3. Medical opinion for direct service connection

 ;; Choose the statement that most closely approximates the etiology of the

 ;; claimed condition.  

 ;;

 ;; a. ___ The claimed condition was at least as likely as not (50 percent or 

 ;; greater probability) incurred in or caused by the claimed in-service injury,

 ;; event, or illness.  Provide rationale in section c.

 ;;

 ;; b. ___ The claimed condition was less likely than not (less than 50 percent

 ;; probability) incurred in or caused by the claimed in-service injury, event,

 ;; or illness.  Provide rationale in section c.

 ;;^TOF^

 ;; c. Rationale: _______________________________________________________________

 ;; _____________________________________________________________________________

 ;; _____________________________________________________________________________

 ;;

 ;; 4. Medical opinion for secondary service connection

 ;; a. ___ The claimed condition is at least as likely as not (50 percent or

 ;; greater probability) proximately due to or the result of the Veteran's

 ;; service connected condition.  Provide rationale in section c.

 ;;

 ;; b. ___ The claimed condition is less likely than not (less than 50 percent 

 ;; probability) proximately due to or the result of the Veteran's service

 ;; connected condition.  Provide rationale in section c.

 ;;

 ;; c. Rationale: _______________________________________________________________

 ;; _____________________________________________________________________________

 ;; _____________________________________________________________________________

 ;; _____________________________________________________________________________

 ;;

 ;; 5. Medical opinion for aggravation of a condition that existed prior to service

 ;; a. ___ The claimed condition, which clearly and unmistakably existed prior

 ;; to service, was aggravated beyond its natural progression by an in-service

 ;; injury, event, or illness.  Provide rationale in section c.

 ;;

 ;; b. ___ The claimed condition, which clearly and unmistakably existed prior

 ;; to service, was clearly and unmistakably not aggravated beyond its natural

 ;; progression by an in-service injury, event, or illness.  Provide rationale

 ;; in section c.

 ;;

 ;; c. Rationale: _______________________________________________________________

 ;; _____________________________________________________________________________

 ;; _____________________________________________________________________________

 ;; _____________________________________________________________________________

 ;;

 ;; 6. Medical opinion for aggravation of a nonservice connected condition by a

 ;; service connected condition

 ;; a. Can you determine a baseline level of severity of (claimed condition/

 ;; diagnosis) based upon medical evidence available prior to aggravation or the

 ;; earliest medical evidence following aggravation by (service connected 

 ;; condition)?

 ;; ___ Yes   ___ No

 ;; If "Yes" to question 6a., answer the following:

 ;;   i. Describe the baseline level of severity of (claimed condition/

 ;;      diagnosis) based upon medical evidence available prior to aggravation

 ;;      or the earliest medical evidence following aggravation by (service 

 ;;      connected condition): 

 ;;      ________________________________________________________________________

 ;;      ________________________________________________________________________

 ;;^TOF^

 ;;  ii. Provide the date and nature of the medical evidence used to provide 

 ;;      the baseline: __________________________________________________________

 ;;

 ;; iii. Is the current severity of the (claimed condition/diagnosis) greater

 ;;      than the baseline?

 ;;          ___ Yes   ___ No

 ;;          If yes, was the Veteran's (claimed condition/diagnosis) at least as

 ;;          likely as not aggravated beyond its natural progression by (insert

 ;;          "service connected condition")?

 ;;

 ;;          ___ Yes (provide rationale in section b.)

 ;;          ___ No  (provide rationale in section b.)

 ;;

 ;; If "No" to question 6a., answer the following:

 ;;   i. Provide rationale as to why a baseline cannot be established (e.g.

 ;;      medical evidence is not sufficient to support a determination of a

 ;;      baseline level of severity): ___________________________________________

 ;;  ii. Regardless of an established baseline, was the Veteran's (claimed

 ;;      condition/diagnosis) at least as likely as not aggravated beyond its

 ;;      natural progression by (insert "service connected condition")?

 ;;          ___ Yes (provide rationale in section b.)

 ;;          ___ No  (provide rationale in section b.)

 ;;

 ;; b. Provide rationale: _______________________________________________________

 ;; _____________________________________________________________________________

 ;; _____________________________________________________________________________

 ;; _____________________________________________________________________________

 ;;

 ;; 7. Opinion regarding conflicting medical evidence

 ;; I have reviewed the conflicting medical evidence and am providing the

 ;; following opinion:

 ;; _____________________________________________________________________________

 ;; _____________________________________________________________________________

 ;; _____________________________________________________________________________

 ;;

 ;; Physician signature: _____________________________________ Date: ____________

 ;;

 ;; Physician printed name: __________________________________ Phone: ___________

 ;;

 ;; Medical license #: _______________________________________ Fax: _____________

 ;;

 ;; Physician address: __________________________________________________________

 ;; 

 ;; NOTE: VA may request additional medical information, including additional

 ;; examinations if necessary to complete VA's review of the Veteran's

 ;; application.

 ;; ^END^

 Q

--- Routine Detail   --- with STRUCTURED ROUTINE LISTING ---DVBCQMO2   8240     printed  Mar 13, 2025@20:51:57                                                                                                                                                                                                    Page 2

DVBCQMO2  ;;ALB-CIOFO/ECF,SBW - MEDICAL OPINION QUESTIONNAIRE ; 4/APR/2011

 +1       ;;2.7;AMIE;**166**;Apr 10, 1995;Build 6

 +2       ;

TXT       ;

 +1       ;; Your patient is applying to the U. S. Department of Veterans Affairs (VA) for

 +2       ;; disability benefits.  VA will consider the information you provide on this 

 +3       ;; questionnaire as part of their evaluation in processing the Veteran's claim.

 +4       ;;

 +5       ;; 1. Definitions

 +6       ;; Aggravation of preexisting nonservice-connected disabilities.

 +7       ;; A preexisting injury or disease will be considered to have been aggravated

 +8       ;; by active military, naval, or air service, where there is an increase in

 +9       ;; disability during such service, unless there is a specific finding that the

 +10      ;; increase in disability is due to the natural progress of the disease.

 +11      ;;

 +12      ;; Aggravation of nonservice-connected disabilities. 

 +13      ;; Any increase in severity of a nonservice-connected disease or injury that

 +14      ;; is proximately due to or the result of a service-connected disease or injury,

 +15      ;; and not due to the natural progress of the nonservice-connected disease, will

 +16      ;; be service connected.

 +17      ;;

 +18      ;; 2. Evidence review

 +19      ;; Was the Veteran's VA claims file reviewed?

 +20      ;; ___ Yes   ___ No

 +21      ;; If yes, list any records that were reviewed but were not included in the

 +22      ;; Veteran's VA claims file: ___________________________________________________

 +23      ;; If no, check all records reviewed:

 +24      ;;    ___ Military service treatment records

 +25      ;;    ___ Military service personnel records

 +26      ;;    ___ Military enlistment examination

 +27      ;;    ___ Military separation examination

 +28      ;;    ___ Military post-deployment questionnaire

 +29      ;;    ___ Department of Defense Form 214 Separation Documents

 +30      ;;    ___ Veterans Health Administration medical records (VA treatment records)

 +31      ;;    ___ Civilian medical records

 +32      ;;    ___ Interviews with collateral witnesses (family and others who have

 +33      ;;        known the veteran before and after military service)

 +34      ;;    ___ No records were reviewed

 +35      ;;    ___ Other: ______________________________________

 +36      ;;

 +37      ;; Complete only the sections below that you are asked to complete in the

 +38      ;; Medical Opinion DBQ request.

 +39      ;;

 +40      ;; 3. Medical opinion for direct service connection

 +41      ;; Choose the statement that most closely approximates the etiology of the

 +42      ;; claimed condition.  

 +43      ;;

 +44      ;; a. ___ The claimed condition was at least as likely as not (50 percent or 

 +45      ;; greater probability) incurred in or caused by the claimed in-service injury,

 +46      ;; event, or illness.  Provide rationale in section c.

 +47      ;;

 +48      ;; b. ___ The claimed condition was less likely than not (less than 50 percent

 +49      ;; probability) incurred in or caused by the claimed in-service injury, event,

 +50      ;; or illness.  Provide rationale in section c.

 +51      ;;^TOF^

 +52      ;; c. Rationale: _______________________________________________________________

 +53      ;; _____________________________________________________________________________

 +54      ;; _____________________________________________________________________________

 +55      ;;

 +56      ;; 4. Medical opinion for secondary service connection

 +57      ;; a. ___ The claimed condition is at least as likely as not (50 percent or

 +58      ;; greater probability) proximately due to or the result of the Veteran's

 +59      ;; service connected condition.  Provide rationale in section c.

 +60      ;;

 +61      ;; b. ___ The claimed condition is less likely than not (less than 50 percent 

 +62      ;; probability) proximately due to or the result of the Veteran's service

 +63      ;; connected condition.  Provide rationale in section c.

 +64      ;;

 +65      ;; c. Rationale: _______________________________________________________________

 +66      ;; _____________________________________________________________________________

 +67      ;; _____________________________________________________________________________

 +68      ;; _____________________________________________________________________________

 +69      ;;

 +70      ;; 5. Medical opinion for aggravation of a condition that existed prior to service

 +71      ;; a. ___ The claimed condition, which clearly and unmistakably existed prior

 +72      ;; to service, was aggravated beyond its natural progression by an in-service

 +73      ;; injury, event, or illness.  Provide rationale in section c.

 +74      ;;

 +75      ;; b. ___ The claimed condition, which clearly and unmistakably existed prior

 +76      ;; to service, was clearly and unmistakably not aggravated beyond its natural

 +77      ;; progression by an in-service injury, event, or illness.  Provide rationale

 +78      ;; in section c.

 +79      ;;

 +80      ;; c. Rationale: _______________________________________________________________

 +81      ;; _____________________________________________________________________________

 +82      ;; _____________________________________________________________________________

 +83      ;; _____________________________________________________________________________

 +84      ;;

 +85      ;; 6. Medical opinion for aggravation of a nonservice connected condition by a

 +86      ;; service connected condition

 +87      ;; a. Can you determine a baseline level of severity of (claimed condition/

 +88      ;; diagnosis) based upon medical evidence available prior to aggravation or the

 +89      ;; earliest medical evidence following aggravation by (service connected 

 +90      ;; condition)?

 +91      ;; ___ Yes   ___ No

 +92      ;; If "Yes" to question 6a., answer the following:

 +93      ;;   i. Describe the baseline level of severity of (claimed condition/

 +94      ;;      diagnosis) based upon medical evidence available prior to aggravation

 +95      ;;      or the earliest medical evidence following aggravation by (service 

 +96      ;;      connected condition): 

 +97      ;;      ________________________________________________________________________

 +98      ;;      ________________________________________________________________________

 +99      ;;^TOF^

 +100     ;;  ii. Provide the date and nature of the medical evidence used to provide 

 +101     ;;      the baseline: __________________________________________________________

 +102     ;;

 +103     ;; iii. Is the current severity of the (claimed condition/diagnosis) greater

 +104     ;;      than the baseline?

 +105     ;;          ___ Yes   ___ No

 +106     ;;          If yes, was the Veteran's (claimed condition/diagnosis) at least as

 +107     ;;          likely as not aggravated beyond its natural progression by (insert

 +108     ;;          "service connected condition")?

 +109     ;;

 +110     ;;          ___ Yes (provide rationale in section b.)

 +111     ;;          ___ No  (provide rationale in section b.)

 +112     ;;

 +113     ;; If "No" to question 6a., answer the following:

 +114     ;;   i. Provide rationale as to why a baseline cannot be established (e.g.

 +115     ;;      medical evidence is not sufficient to support a determination of a

 +116     ;;      baseline level of severity): ___________________________________________

 +117     ;;  ii. Regardless of an established baseline, was the Veteran's (claimed

 +118     ;;      condition/diagnosis) at least as likely as not aggravated beyond its

 +119     ;;      natural progression by (insert "service connected condition")?

 +120     ;;          ___ Yes (provide rationale in section b.)

 +121     ;;          ___ No  (provide rationale in section b.)

 +122     ;;

 +123     ;; b. Provide rationale: _______________________________________________________

 +124     ;; _____________________________________________________________________________

 +125     ;; _____________________________________________________________________________

 +126     ;; _____________________________________________________________________________

 +127     ;;

 +128     ;; 7. Opinion regarding conflicting medical evidence

 +129     ;; I have reviewed the conflicting medical evidence and am providing the

 +130     ;; following opinion:

 +131     ;; _____________________________________________________________________________

 +132     ;; _____________________________________________________________________________

 +133     ;; _____________________________________________________________________________

 +134     ;;

 +135     ;; Physician signature: _____________________________________ Date: ____________

 +136     ;;

 +137     ;; Physician printed name: __________________________________ Phone: ___________

 +138     ;;

 +139     ;; Medical license #: _______________________________________ Fax: _____________

 +140     ;;

 +141     ;; Physician address: __________________________________________________________

 +142     ;; 

 +143     ;; NOTE: VA may request additional medical information, including additional

 +144     ;; examinations if necessary to complete VA's review of the Veteran's

 +145     ;; application.

 +146     ;; ^END^

 +147      QUIT