Lupus and Other Autoimmune Diseases DBQ explained

What this DBQ covers

This questionnaire documents systemic lupus erythematosus and other autoimmune diseases within its scope. It asks about the diagnosis, course, treatment, and clinical effects. An autoimmune disease can affect more than one part of the body, so the clinician may need supporting evaluations from several specialties. The form should distinguish medically attributed effects from symptoms whose cause remains uncertain and identify when another questionnaire is relevant.

The important sections, explained

Treatment and periods of worsening

The history section asks about medication, duration of use and exacerbations of the autoimmune disease. Describe which treatments were used during each period and what happened with them. A short course for an episode and ongoing treatment are different histories. Bring rheumatology and other relevant specialist notes. The clinician determines disease activity and treatment response rather than assuming that a medication name or an isolated difficult day establishes the overall level of impairment.

Read the official form: page 2

Skin findings and other affected systems

The cutaneous section concerns skin manifestations, while the findings section addresses other possible effects. Autoimmune disease can involve different systems, but the diagnosis does not make every symptom attributable to it. Identify the specific findings already assessed by your clinicians and describe remaining concerns accurately. Dated photographs may help explain variable skin changes when relevant, while laboratory, biopsy or other specialist reports provide different evidence. Keep their dates and medical interpretations attached.

Read the official form: page 4

How to prepare useful information

Bring rheumatology records, relevant laboratory findings, treatment history, and specialist notes for affected organs or systems. Describe the pattern of episodes, changes between them, and practical limitations. Include hospital or other significant treatment records where applicable. The clinician determines the disease activity and relationship of findings to the diagnosis; you can help by supplying a clear timeline without trying to assign every symptom to the same condition.

Records to gather

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

• Rheumatology records identifying the diagnosis and disease course
• Relevant laboratory results and assessments of affected organs or systems
• Treatment records and examples of episode-related or continuing limitations

A detail that is easy to miss

Do not treat a positive autoimmune laboratory result as the whole diagnosis or a measure of every current symptom. Include the specialist interpretation and treatment context. Keep systemic and localized diagnoses clear where the record distinguishes them. When counting exacerbations, describe separate periods and their effects instead of counting every treatment visit as a new flare.

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 - CUTANEOUS MANIFESTATIONSPage 4
4. SECTION IV - FINDINGS, SIGNS AND SYMPTOMSPage 5
5. SECTION V - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMSPage 7
6. SECTION VI - DIAGNOSTIC TESTINGPage 7
7. SECTION VII - FUNCTIONAL IMPACTPage 9
8. SECTION VIII - REMARKSPage 9
9. SECTION IX - EXAMINER'S CERTIFICATION AND SIGNATUREPage 9

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

Should I include records from specialists other than rheumatology?

Yes, when they describe effects relevant to the condition being evaluated. An autoimmune disease may involve different systems, and those records can help the clinician understand the full picture. The examiner should determine which findings are attributable to the disease and whether additional forms are appropriate.

Does a positive antibody test settle the DBQ?

No. Testing contributes to the clinical assessment, but the examiner also considers the diagnosis, symptoms, treatment and relevant body-system findings. Bring the complete dated report and specialist interpretation rather than making a severity conclusion from a flagged result alone.

Can I include photographs of a rash that has improved?

Relevant dated photographs can help explain the earlier appearance. Label the body area and period, and say that the current condition differs. The clinician considers them with treatment and examination findings; they should not be presented as proof that the rash is continuously present.