Amputations DBQ explained

What this DBQ covers

The amputations questionnaire identifies the exact site and extent of anatomical loss. Separate sections address upper limbs, fingers, lower limbs and toes. The side, level and remaining function are more specific than a general statement that an amputation occurred. Operative records and examination findings help the clinician complete those details accurately.

The important sections, explained

The exact site and level

The amputation-site sections distinguish arms, forearms, fingers, legs and toes, with further questions about the anatomical level. That level is a clinical finding, not simply a description of the limb as missing. Bring the operative report if available, especially after revision surgery. The examiner needs to know the current anatomy, affected side and relevant history so the correct section is completed without relying on a general label such as leg amputation.

Read the official form: page 2

Prostheses, devices and everyday tasks

The assistive-device and functional-impact sections describe how you move or perform tasks with the condition. Explain the prosthesis or other devices you actually use and what remains difficult with usual support. If fitting problems or other symptoms limit use, describe the pattern and bring relevant rehabilitation or prosthetics records. The examiner can distinguish the anatomical loss from current function; one does not automatically provide a complete picture of the other.

Read the official form: page 4

How to prepare useful information

Bring the operative report and rehabilitation or prosthetic records when available. Explain what tasks remain difficult, what a device helps you do and any continuing problems documented during follow-up. The clinician records the anatomical and medical findings; you can provide examples of mobility, grasping or other daily functions. Do not estimate the surgical level from a photograph if the operative description is available.

Records to gather

Start with records you already have. Bring the relevant information to your clinician and explain any gaps or uncertain dates.

• Operative reports identifying the amputation site, level and side.
• Rehabilitation, prosthetic fitting and follow-up records.
• Descriptions of actual remaining function, device use and continuing complications.

A detail that is easy to miss

A prosthesis prescription does not show how it is used today. Include relevant fitting or rehabilitation updates and explain any variation in use. Keep revision procedures in date order. If there are symptoms involving the remaining limb, scar or another body area, identify them separately rather than treating every limitation as an anatomical feature of the amputation itself.

Find your way around the official form

These section headings come from the linked VA PDF. Each link opens the page where the section begins. Read the form's own instructions for the full questions and any required attachments.

1. SECTION I - DIAGNOSISPage 1
2. SECTION II - MEDICAL HISTORYPage 2
3. SECTION III - AMPUTATION(S) SITE(S)Page 2
4. SECTION IV - UPPER EXTREMITIES (NOT INCLUDING FINGERS)Page 2
5. SECTION V - FINGERSPage 3
6. SECTION VI - LOWER EXTREMITIES (NOT INCLUDING THE TOES)Page 3
7. SECTION VII - TOESPage 4
8. SECTION VIII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS, AND SCARSPage 4
9. SECTION IX- ASSISTIVE DEVICESPage 4
10. SECTION X - DIAGNOSTIC TESTINGPage 5
11. SECTION XI - FUNCTIONAL IMPACTPage 5
12. SECTION XII - REMARKSPage 6
13. SECTION XIII - EXAMINER'S CERTIFICATION AND SIGNATUREPage 6

Who completes the clinical sections?

The healthcare provider completes the clinical assessment, identifies the records reviewed, and signs the questionnaire. You can gather records and describe symptoms and daily limitations. Measurements, diagnoses, and clinical conclusions belong to the examiner.

Check the official form's instructions with your provider before the appointment, including any examination or testing requirements. VA does not pay or reimburse the costs of having a private DBQ completed or submitted.

A completed DBQ can help document the medical condition. Whether it also answers a particular service-connection question depends on its content and the other evidence. VA may verify the form or request another examination.

Common questions

Why does the exact amputation level matter on the form?

The questionnaire distinguishes different anatomical sites, including individual fingers and toes. A precise operative description helps the clinician document what was lost and what remains. The form also asks about devices and functional effects, so the procedure name alone may not capture the full medical picture.

Should I bring records from a revision operation?

Yes, a revision can change the anatomy described in an earlier report. Include the relevant operative and follow-up records so the examiner can identify the current level and condition. If those records are unavailable, explain the procedures you know occurred and any uncertain dates.

Should I describe function while using my prosthesis?

Describe your usual function with the devices you use, as well as documented difficulties or periods when you cannot use them. Be clear about each situation. The clinician records the anatomical findings and functional effects rather than assuming a device eliminates every limitation.