C&P Exam Prep: DBQ Forms and Rating Criteria for 596 VA Conditions

What Veterans Need to Know Before Your Appointment

This guide explains what the VA's Compensation & Pension (C&P) exam is and how to walk in prepared. You will learn what the exam covers, why it matters to your claim, and how examiners document your symptoms and functional limits so the VA can assign an accurate rating. It shows you how to review your claim, read the relevant DBQs and rating criteria, describe your symptoms in terms of functional impact, and avoid the missteps that weaken your exam record. Whether this is your first exam or you're appealing a decision, this guide helps you communicate your condition clearly and protect the evidence that matters most.

Structure of the exam

A typical C&P exam has four parts:

• Medical history review: When symptoms started and how they progressed.
• Symptom evaluation: Current symptoms, frequency, severity, and triggers.
• Physical examination: Varies by claim. Range of motion (with a goniometer) for orthopedic claims, a clinical interview for mental-health claims, pulmonary function testing for respiratory claims, and so on.
• Functional impact assessment: How the condition affects work and daily activities.

Questions the examiner will ask

• When the condition started.
• Description of current symptoms, frequency, severity.
• Treatments that have been tried.
• How the condition affects daily life.
• How the condition affects work.
• Mental-health exams: standardized screening questions about thoughts of self-harm or harm to others (PC-PTSD-5, PHQ-2, C-SSRS, etc., depending on the DBQ).

What VA regulations require examiners to record

The examiner is filling out a Disability Benefits Questionnaire (DBQ). The fields the examiner has to complete are governed by these regulations and case law:

• Severity over the rating period, not a single snapshot. 38 CFR § 4.2 requires examiners and raters to reconcile the medical evidence to reflect the level of disability over the rating period.
• Range of motion is recorded at the point pain begins. 38 CFR § 4.59 and Mitchell v. Shinseki, 25 Vet. App. 32 (2011), require examiners to document where painful motion begins.
• Functional loss after repetitive use. 38 CFR § 4.40 and § 4.45 require examiners to assess any additional limitation due to pain, weakness, fatigability, or incoordination after repetitive use.
• Average impairment of earning capacity. 38 CFR § 4.1 directs raters to evaluate the average impairment of earning capacity from the disability.
• Reasonable doubt. 38 CFR § 4.3 directs that, when there is an approximate balance of positive and negative evidence, reasonable doubt is resolved in the veteran’s favor.
• Pyramiding. 38 CFR § 4.14 bars rating the same disability under different diagnoses. Examiners are expected to identify each separately ratable manifestation.

What to bring

• A current medication list (dosages and prescribers).
• A written symptom history (dates, frequency, triggers).
• The DBQ for the condition. DBQs are public forms published at va.gov/find-forms. Reading the DBQ in advance shows exactly which fields the examiner is required to complete.

After the exam

• The examiner’s completed DBQ goes into the claims file (the “C-file”) and is reviewed by a VA Rating Veterans Service Representative (RVSR), who applies the 38 CFR Part 4 rating schedule.
• Veterans can request a copy of the completed DBQ through a FOIA / Privacy Act request or by viewing it in the C-file via the VA self-service URLs.
• If the rating decision relies on the C&P exam, the regulations cited above are the standards a decision letter or appeal can be evaluated against.

What the exam request document tells you

Before the exam takes place, the VA creates an internal document called the exam request (sometimes called the exam scheduling request). This document specifies the conditions to be examined, the Disability Benefits Questionnaire (DBQ) the examiner is required to complete, the type of medical opinion requested (direct service connection, secondary, increased rating, etc.), and the records that have been released to the examiner or the contracted exam company.

Contracted exam vendors (QTC, VES, LHI, and others) receive only the records the VA lists in the exam request. The examiner reviews those listed records and completes the assigned DBQ. They are not given access to the full claims file or any records not listed. Under the 38 CFR § 3.159 duty to assist, the VA is required to make reasonable efforts to obtain relevant service treatment records and other evidence before a rating decision is issued. If records are missing from the exam request, that gap can be documented and raised in a higher-level review as a potential duty-to-assist error.

Veterans can request a copy of the exam request through a FOIA or Privacy Act request, or by asking at a regional VA office for the specific document. The exam request is also sometimes accessible through the VA self-service tools or via a FOIA request. Key things to look for when reviewing your exam request:

• Conditions listed: Are all conditions you claimed included, with the correct claim type (new, increase, secondary)?
• DBQ assigned: Does the DBQ match the condition? For example, a sleep disturbance could be assigned a mental health DBQ or a respiratory DBQ depending on how it was categorized.
• Records provided: Are service treatment records (government facility records) listed? Are relevant VA medical records (CAPRI records) included for the condition being examined? Are private treatment records you submitted listed?
• Medical opinions requested: If you claimed something as secondary to another condition, does the exam request include a secondary medical opinion? If not, the examiner cannot provide one.

The exam request does not appear in the rating decision narrative. Under VA procedures, most rating decisions use a short-form narrative that does not have to cite each piece of evidence reviewed. The exam request is the document that shows what evidence was actually before the examiner.

Understanding the examiner's role

The C&P examiner is a licensed clinician, either a VA employee or a contractor. Their job is to document findings on the assigned DBQ. They do not issue a rating. The rater (Rating Veterans Service Representative, or RVSR) is the VA employee who reads the completed DBQ and applies the 38 CFR Part 4 rating schedule to assign a disability percentage.

The examiner's scope is defined by the exam request. They complete the DBQ fields for the assigned condition, document current severity, and, when a medical opinion is requested, provide a rationale with a standard such as "at least as likely as not." They may also order additional testing (such as range-of-motion measurements or pulmonary function tests) if that testing is needed to complete the DBQ. They are not permitted to review records outside what was listed in the exam request or to expand the exam beyond what was requested.

Examiners are required to reconcile their findings with the prior medical history in the record (see 38 CFR § 4.2). Where a discrepancy exists, the examiner should note it and provide an explanation.

After the exam, the examiner has no further role in the rating decision. The completed DBQ becomes part of the claims file (the C-file). If a veteran believes the examiner did not review all available records, the exam request (not the rating decision) is the document that shows which records were provided. If the examiner did not receive relevant records, a higher-level review can cite that as a duty-to-assist issue under 38 CFR § 3.159. If the examiner received all the relevant records but reached a different medical conclusion, a supplemental claim with new and relevant evidence would be the appropriate next step.

Veterans may ask the examiner factual questions during the appointment, such as confirming which records were provided to them or whether the DBQ they are completing covers all conditions that were claimed. The examiner documents findings. All rating decisions are made separately by the RVSR. See the VA's C&P exam overview on VA.gov for more on the exam process.