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 Apr 09, 2024@20:51:25 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
