Shoulder and Arm Conditions DBQ explained

What this DBQ covers

The Shoulder and Arm DBQ documents diagnoses and how each affected shoulder functions. It includes movement measurements, pain, repeated use, flare-ups, and findings related to conditions such as rotator cuff problems and instability. The form also distinguishes the right and left sides and records the dominant hand. A diagnosis or scan alone does not fully describe what you can do with your arm during a normal day.

The important sections, explained

Movement and function above shoulder level

The movement section assesses several directions of shoulder motion and the effect of pain, repeated use and flare-ups. Explain which activities are limited, such as reaching to a shelf, washing your hair or carrying an item. The direction and duration matter. Let the examiner measure motion and determine clinical estimates; you do not need to stop at a preselected height or decide that one difficult task proves a particular degree of motion loss.

Read the official form: page 4

Rotator cuff, instability and operations

The form has separate areas for rotator cuff conditions, instability or dislocation, and other structures around the shoulder. These are different findings even when they all affect reaching. Bring the records for any diagnosed tear, reduction of a dislocation or operation. Describe events accurately, including whether a clinician documented an actual dislocation. A feeling of slipping or pain is relevant history but should not automatically be renamed as a confirmed recurrent dislocation.

Read the official form: page 9

How to prepare useful information

Prepare examples involving reaching overhead, carrying items, dressing, or working at a desk, where those activities are affected. Explain how often a flare occurs, how long it lasts, and what changes compared with your usual function. Bring surgery and rehabilitation records, including information about dislocations or replacements. Let the examiner measure movement and explain any testing that cannot safely be performed; do not force movement or estimate examination 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.

• Imaging and specialist notes identifying the diagnosis and affected side
• Records of dislocations, surgery, joint replacement, and rehabilitation
• Examples of lifting or reaching limits and the frequency and duration of flares

A detail that is easy to miss

Keep the side and usual dominant hand clear, particularly if both shoulders have different histories. Do not let an MRI finding replace the account of current use. If surgery improved stability but pain remains, explain both. Identify any neck or nerve symptoms separately so the clinician can consider whether they contribute to the arm difficulty being described.

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 1 - DIAGNOSISPage 1
2. SECTION 2 - MEDICAL HISTORYPage 3
3. SECTION 3 - RANGE OF MOTION (ROM) AND FUNCTIONAL LIMITATIONPage 4
4. SECTION 4 - MUSCLE ATROPHYPage 8
5. SECTION 5 - ANKYLOSISPage 9
6. SECTION 6 - ROTATOR CUFF CONDITIONSPage 9
7. SECTION 7 - SHOULDER INSTABILITY, DISLOCATION OR LABRAL PATHOLOGYPage 9
8. SECTION 8 - CLAVICLE, SCAPULA, ACROMIOCLAVICULAR (AC) JOINT AND STERNOCLAVICULAR JOINT CONDITIONSPage 10
9. SECTION 9 - CONDITIONS OR IMPAIRMENTS OF THE HUMERUSPage 11
10. SECTION 10 - SURGICAL PROCEDURESPage 11
11. SECTION 11 - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS, AND SCARSPage 11
12. SECTION 12 - ASSISTIVE DEVICESPage 12
13. SECTION 13 - REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIESPage 12
14. SECTION 14 - DIAGNOSTIC TESTINGPage 13
15. SECTION 15 - FUNCTIONAL IMPACTPage 14
16. SECTION 16 - REMARKSPage 14
17. SECTION 17 - EXAMINER'S CERTIFICATION AND SIGNATUREPage 14

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

Will a normal day at the examination show my flare-ups?

It may not. Tell the clinician how your shoulder behaves during flares and after repeated use, using accurate examples and any supporting records. The questionnaire asks the examiner to address those circumstances as well as the findings observed during the appointment.

Is a rotator cuff tear the same as shoulder instability?

No. The questionnaire evaluates them in separate sections. Your clinician determines the diagnosed conditions and relevant findings. Describe pain, weakness, slipping sensations and any documented dislocations distinctly rather than assuming they all describe one medical problem.

Should I explain what happens after repeated reaching?

Yes. Describe how symptoms change, when you need to stop and how long recovery takes. The form considers repeated use and flare-ups in addition to measurements during the appointment. Practical history helps the examiner assess those effects without asking you to choose a rating.