Muscle Injuries DBQ explained

What this DBQ covers

The muscle injuries questionnaire organizes the injury history, location and examination of the affected muscle groups. It also records related findings, devices and functional impact. A penetrating injury, surgical history or other muscle damage may require details about the original event and subsequent treatment. General soreness alone does not establish the specific muscle injury findings requested by the form.

The important sections, explained

Type and location of the injury

The history distinguishes penetrating injuries, such as fragment wounds, from non-penetrating injuries such as strains or tears. The location section identifies the affected muscle groups. Bring injury, operation and rehabilitation records where available so the clinician can trace the structures involved. A surface scar may help identify an old injury but does not by itself reveal every damaged muscle or the extent of tissue involvement beneath the skin.

Read the official form: page 2

Strength, fatigue and current muscle function

The muscle examination addresses findings beyond pain, including the clinical effects of the injury. Describe tasks that expose weakness, fatigue or difficulty sustaining movement, and identify the affected side. Explain what changes with repeated activity and what support is normally used. The examiner determines muscle groups and severity from the history and findings. You do not need to assign a muscle-group number or turn an activity limitation into a technical injury classification.

Read the official form: page 4

How to prepare useful information

Bring the injury and operative records when available, including treatment for wounds or other complications. Describe the affected tasks and how fatigue, weakness or other symptoms change with use. Keep the location and side clear, especially if several areas were injured. The clinician identifies muscle groups and evaluates the medical findings; you do not need to classify the injury's severity yourself.

Records to gather

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

• Original injury, wound-care and operative records identifying the affected area.
• Rehabilitation and examination records describing strength or other muscle findings.
• Examples of weakness, fatigue or task limitations, with the side and location clearly identified.

A detail that is easy to miss

A wound description without the operation or treatment history may leave uncertainty about which muscles were involved. Keep the side, site and sequence of procedures clear. Distinguish muscle fatigue from loss of feeling or joint stiffness where possible. If you do not know which tissue caused a symptom, report the symptom and let the clinician resolve the anatomy.

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 II - HISTORY OF MUSCLE INJURYPage 2
2. SECTION III - LOCATION OF MUSCLE INJURYPage 2
3. SECTION IV - MUSCLE INJURY EXAMPage 4
4. SECTION V - ASSISTIVE DEVICESPage 8
5. SECTION VI - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIESPage 9
6. SECTION VII - TUMORS AND NEOPLASMSPage 9
7. SECTION VIII - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND/OR SYMPTOMSPage 10
8. SECTION IX - DIAGNOSTIC TESTINGPage 11
9. SECTION X - FUNCTIONAL IMPACTPage 12
10. SECTION XI - REMARKSPage 12
11. SECTION XII - EXAMINER'S CERTIFICATION AND SIGNATUREPage 12

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 choose a muscle injury severity category before the exam?

No. Provide the actual injury history, treatment and functional examples. Severity classification requires medical findings and the relevant rules. The clinician should identify the affected muscle groups and document the examination rather than use a category selected from the form by the claimant.

Does this form only cover combat wounds?

No. The official questionnaire asks about both penetrating and non-penetrating muscle injuries. The relevant question is the diagnosed injury and its findings, not whether the event fits a particular story. Bring the records that describe what actually occurred.

Should I identify the muscle-group number myself?

The clinician identifies the affected muscle groups. You can help by pointing out the injury location, describing the activity limitations and bringing operative or rehabilitation records. Avoid selecting a group based only on a diagram or the position of a skin scar.