- DVBCQMO4 ;;ALB-CIOFO/ECF,SBW - MEDICAL OPINION QUESTIONNAIRE ; 14/JUNE/2011
- ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
- ;
- 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. Restatement of requested opinion
- ;;
- ;; a. Insert requested opinion from general remarks: __________________________
- ;;
- ;; ____________________________________________________________________________
- ;;
- ;; b. Indicate type of exam for which opinion has been requested (e.g. Skin
- ;; Diseases): _________________________________________________________________
- ;;
- ;; 3. 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.
- ;;^TOF^
- ;; 4. 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.
- ;;
- ;; c. Rationale: ______________________________________________________________
- ;;
- ;; ____________________________________________________________________________
- ;;
- ;; 5. 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: ______________________________________________________________
- ;;
- ;; ____________________________________________________________________________
- ;;
- ;; 6. 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: ______________________________________________________________
- ;;
- ;; ____________________________________________________________________________
- ;;^TOF^
- ;; 7. 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 7a., 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):
- ;; _______________________________________________________________________
- ;;
- ;; 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 7a., 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: ______________________________________________________
- ;;
- ;; ____________________________________________________________________________
- ;;
- ;;^TOF^
- ;; 8. 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[HDVBCQMO4 7927 printed Feb 18, 2025@23:13:42 Page 2
- DVBCQMO4 ;;ALB-CIOFO/ECF,SBW - MEDICAL OPINION QUESTIONNAIRE ; 14/JUNE/2011
- +1 ;;2.7;AMIE;**172**;Apr 10, 1995;Build 3
- +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 ;;
- +7 ;; Aggravation of preexisting nonservice-connected disabilities.
- +8 ;; A preexisting injury or disease will be considered to have been aggravated
- +9 ;; by active military, naval, or air service, where there is an increase in
- +10 ;; disability during such service, unless there is a specific finding that the
- +11 ;; increase in disability is due to the natural progress of the disease.
- +12 ;;
- +13 ;; Aggravation of nonservice-connected disabilities.
- +14 ;; Any increase in severity of a nonservice-connected disease or injury that
- +15 ;; is proximately due to or the result of a service-connected disease or injury,
- +16 ;; and not due to the natural progress of the nonservice-connected disease, will
- +17 ;; be service connected.
- +18 ;;
- +19 ;; 2. Restatement of requested opinion
- +20 ;;
- +21 ;; a. Insert requested opinion from general remarks: __________________________
- +22 ;;
- +23 ;; ____________________________________________________________________________
- +24 ;;
- +25 ;; b. Indicate type of exam for which opinion has been requested (e.g. Skin
- +26 ;; Diseases): _________________________________________________________________
- +27 ;;
- +28 ;; 3. Evidence review
- +29 ;;
- +30 ;; Was the Veteran's VA claims file reviewed?
- +31 ;; ___ Yes ___ No
- +32 ;; If yes, list any records that were reviewed but were not included in the
- +33 ;; Veteran's VA claims file: __________________________________________________
- +34 ;; If no, check all records reviewed:
- +35 ;; ___ Military service treatment records
- +36 ;; ___ Military service personnel records
- +37 ;; ___ Military enlistment examination
- +38 ;; ___ Military separation examination
- +39 ;; ___ Military post-deployment questionnaire
- +40 ;; ___ Department of Defense Form 214 Separation Documents
- +41 ;; ___ Veterans Health Administration medical records (VA treatment records)
- +42 ;; ___ Civilian medical records
- +43 ;; ___ Interviews with collateral witnesses (family and others who have
- +44 ;; known the veteran before and after military service)
- +45 ;; ___ No records were reviewed
- +46 ;; ___ Other: ______________________________________
- +47 ;;
- +48 ;; Complete only the sections below that you are asked to complete in the
- +49 ;; Medical Opinion DBQ request.
- +50 ;;^TOF^
- +51 ;; 4. Medical opinion for direct service connection
- +52 ;;
- +53 ;; Choose the statement that most closely approximates the etiology of the
- +54 ;; claimed condition.
- +55 ;;
- +56 ;; a. ___ The claimed condition was at least as likely as not (50 percent or
- +57 ;; greater probability) incurred in or caused by the claimed in-service injury,
- +58 ;; event, or illness. Provide rationale in section c.
- +59 ;;
- +60 ;; b. ___ The claimed condition was less likely than not (less than 50 percent
- +61 ;; probability) incurred in or caused by the claimed in-service injury, event,
- +62 ;; or illness. Provide rationale in section c.
- +63 ;;
- +64 ;; c. Rationale: ______________________________________________________________
- +65 ;;
- +66 ;; ____________________________________________________________________________
- +67 ;;
- +68 ;; 5. Medical opinion for secondary service connection
- +69 ;;
- +70 ;; a. ___ The claimed condition is at least as likely as not (50 percent or
- +71 ;; greater probability) proximately due to or the result of the Veteran's
- +72 ;; service connected condition. Provide rationale in section c.
- +73 ;;
- +74 ;; b. ___ The claimed condition is less likely than not (less than 50 percent
- +75 ;; probability) proximately due to or the result of the Veteran's service
- +76 ;; connected condition. Provide rationale in section c.
- +77 ;;
- +78 ;; c. Rationale: ______________________________________________________________
- +79 ;;
- +80 ;; ____________________________________________________________________________
- +81 ;;
- +82 ;; 6. Medical opinion for aggravation of a condition that existed prior to
- +83 ;; service
- +84 ;;
- +85 ;; a. ___ The claimed condition, which clearly and unmistakably existed prior
- +86 ;; to service, was aggravated beyond its natural progression by an in-service
- +87 ;; injury, event, or illness. Provide rationale in section c.
- +88 ;;
- +89 ;; b. ___ The claimed condition, which clearly and unmistakably existed prior
- +90 ;; to service, was clearly and unmistakably not aggravated beyond its natural
- +91 ;; progression by an in-service injury, event, or illness. Provide rationale
- +92 ;; in section c.
- +93 ;;
- +94 ;; c. Rationale: ______________________________________________________________
- +95 ;;
- +96 ;; ____________________________________________________________________________
- +97 ;;^TOF^
- +98 ;; 7. Medical opinion for aggravation of a nonservice connected condition by a
- +99 ;; service connected condition
- +100 ;;
- +101 ;; a. Can you determine a baseline level of severity of (claimed condition/
- +102 ;; diagnosis) based upon medical evidence available prior to aggravation or the
- +103 ;; earliest medical evidence following aggravation by (service connected
- +104 ;; condition)?
- +105 ;; ___ Yes ___ No
- +106 ;; If "Yes" to question 7a., answer the following:
- +107 ;; i. Describe the baseline level of severity of (claimed condition/
- +108 ;; diagnosis) based upon medical evidence available prior to aggravation
- +109 ;; or the earliest medical evidence following aggravation by (service
- +110 ;; connected condition):
- +111 ;; _______________________________________________________________________
- +112 ;;
- +113 ;; ii. Provide the date and nature of the medical evidence used to provide
- +114 ;; the baseline: _________________________________________________________
- +115 ;;
- +116 ;; iii. Is the current severity of the (claimed condition/diagnosis) greater
- +117 ;; than the baseline?
- +118 ;; ___ Yes ___ No
- +119 ;; If yes, was the Veteran's (claimed condition/diagnosis) at least as
- +120 ;; likely as not aggravated beyond its natural progression by (insert
- +121 ;; "service connected condition")?
- +122 ;;
- +123 ;; ___ Yes (provide rationale in section b.)
- +124 ;; ___ No (provide rationale in section b.)
- +125 ;;
- +126 ;; If "No" to question 7a., answer the following:
- +127 ;; i. Provide rationale as to why a baseline cannot be established (e.g.
- +128 ;; medical evidence is not sufficient to support a determination of a
- +129 ;; baseline level of severity): __________________________________________
- +130 ;; ii. Regardless of an established baseline, was the Veteran's (claimed
- +131 ;; condition/diagnosis) at least as likely as not aggravated beyond its
- +132 ;; natural progression by (insert "service connected condition")?
- +133 ;; ___ Yes (provide rationale in section b.)
- +134 ;; ___ No (provide rationale in section b.)
- +135 ;;
- +136 ;; b. Provide rationale: ______________________________________________________
- +137 ;;
- +138 ;; ____________________________________________________________________________
- +139 ;;
- +140 ;;^TOF^
- +141 ;; 8. Opinion regarding conflicting medical evidence
- +142 ;;
- +143 ;; I have reviewed the conflicting medical evidence and am providing the
- +144 ;; following opinion:
- +145 ;; ____________________________________________________________________________
- +146 ;;
- +147 ;; ____________________________________________________________________________
- +148 ;;
- +149 ;; Physician signature: ____________________________________ Date: ____________
- +150 ;;
- +151 ;; Physician printed name: _________________________________ Phone: ___________
- +152 ;;
- +153 ;; Medical license #: ______________________________________ Fax: _____________
- +154 ;;
- +155 ;; Physician address: _________________________________________________________
- +156 ;;
- +157 ;; NOTE: VA may request additional medical information, including additional
- +158 ;; examinations if necessary to complete VA's review of the Veteran's
- +159 ;; application.
- +160 ;;^END^
- +161 QUIT