Breast Conditions DBQ explained

What this DBQ covers

The breast questionnaire documents diagnosis, history, treatment or surgery and remaining findings. It includes information about benign or malignant tumors and effects of treatment. The type of procedure and the current residuals are distinct facts. Operative and pathology records can provide details that are difficult to reconstruct from a brief description of surgery alone.

The important sections, explained

Treatment type, date and side

The treatment and surgery section records different procedures and therapies for breast conditions. Include the side and the exact procedure name from the report when available. A biopsy, removal of a lump and more extensive surgery are not the same operation. If treatment occurred in stages, keep those dates separate. The examiner uses the medical record to understand the disease and treatment course rather than estimating the procedure from the appearance of a scar.

Read the official form: page 2

Remaining effects after treatment

The objective-findings and residuals section addresses lasting effects, including findings related to surgery or radiation. The history also asks about residual conditions such as arm swelling or nerve damage. Describe current movement, discomfort or activity limitations and bring any relevant rehabilitation or follow-up records. The clinician determines the medical relationship. An improvement in the original breast condition does not automatically explain whether a separate treatment-related effect has resolved.

Read the official form: page 4

How to prepare useful information

Bring treatment dates and follow-up notes, and describe continuing effects such as discomfort, swelling or activity limitations if they occur. Explain what improved as well as what remains. The clinician should determine how each finding relates to the condition or treatment and whether another questionnaire is needed for a separate effect. Do not estimate tissue loss or other clinical measurements yourself.

Records to gather

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

• Pathology, imaging and specialist records supporting the diagnosis.
• Operative, radiation or other treatment records and follow-up documenting residuals.
• Descriptions and available records of pain, swelling, scars or movement limitations after treatment.

A detail that is easy to miss

Check that each record identifies the treated side and date. If both sides were treated at different times, preserve that distinction. A follow-up note saying treatment is complete does not necessarily describe every remaining symptom. Mention ongoing effects accurately, and do not describe an earlier active malignancy as currently active unless supported by the present clinical assessment.

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 - TREATMENT/SURGERYPage 2
4. SECTION IV - OBJECTIVE FINDINGS AND RESIDUALSPage 4
5. SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS, AND SCARSPage 4
6. SECTION VI - DIAGNOSTIC TESTINGPage 4
7. SECTION VII - FUNCTIONAL IMPACTPage 5
8. SECTION VIII - REMARKSPage 5
9. SECTION IX - EXAMINER'S CERTIFICATION AND SIGNATUREPage 5

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

Is the surgery name enough for the clinician to complete the form?

It may not provide every detail the questionnaire requests. The operative report and follow-up can explain the procedure, tissue involved and any lasting effects. Provide those records when available, and let the clinician make the required medical findings rather than estimating them from the procedure name.

Does this questionnaire only cover cancer?

No. It asks about breast disorders and includes both benign and malignant neoplasms as well as treatment and surgery. The applicable sections depend on the diagnosed condition. Your provider should use the actual pathology and clinical findings rather than assume all breast treatment involved cancer.

Should I include rehabilitation records after surgery?

Relevant therapy or follow-up records can help explain documented effects such as arm movement problems or swelling. Bring them with the treatment history. The clinician decides whether the effects relate to the breast condition or its treatment and how they should be recorded.