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 ---[H[J[2J[HDVBCQMO2 8240 printed Apr 09, 2024@20:44:46 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
