C&P Exam for Multi-joint arthritis, 2 or more joints, as an active process (DC 5002)

Diagnostic code: 5002Condition: Multi-joint arthritis (except post-traumatic and gout), 2 or more joints, as an active processRegulation: 38 CFR § 4.71aDBQ: DBQ RHEUM Arthritis

Which form the examiner uses

For multi-joint arthritis, 2 or more joints, as an active process (DC 5002), the C&P examiner completes the following Disability Benefits Questionnaire (DBQ):

DBQs are Department of Veterans Affairs Form 21-0960 series documents. Public DBQs are hosted on benefits.va.gov. A handful are examiner-only and are not posted publicly.

What the examiner records

The fields below are reproduced from the DBQ form the examiner completes for this diagnostic code. This is the structural map of the form, showing what the examiner is asked to measure, observe, and record. It is a factual reproduction of the public DBQ, not advice on how to answer.

This DBQ evaluates non-degenerative arthritis conditions (including inflammatory and autoimmune arthritides), documenting joint involvement, systemic involvement, and exacerbations.

How DC 5002 maps to this DBQ: for this diagnostic code specifically, the examiner typically completes sections I-VI and IX-XI of this form. Sections III-V are the condition-specific sections for this code. Sections VII-VIII cover unrelated conditions on this DBQ and are skipped.

DIAGNOSIS (Section I)
  • 1A. List the claimed condition(s) that pertain to this questionnaire:
  • 1B. Select diagnoses associated with the claimed condition(s) (check all that apply): The Veteran does not have a current diagnosis associated with any claimed conditions listed above.
  • Multi-joint arthritis (except post-traumatic and gout), 2 or more joints, as an active process - ICD Code:
  • Multi-joint arthritis (except post-traumatic and gout), 2 or more joints, as an active process - Date of Diagnosis:
  • Please specify diagnosis(es):
  • Arthritis, gonorrheal - ICD Code:
  • Arthritis, gonorrheal - Date of Diagnosis:
  • Arthritis, pneumococcic - ICD Code:
  • Arthritis, pneumococcic - Date of Diagnosis:
  • Arthritis, typhoid - ICD Code:
  • Arthritis, typhoid - Date of Diagnosis:
  • Arthritis, syphilitic - ICD Code:
  • Arthritis, syphilitic - Date of Diagnosis:
  • Arthritis, streptococcic - ICD Code:
  • Arthritis, streptococcic - Date of Diagnosis:
  • Decompression illness (previously dysbaric osteocrenosis/caisson disease) - ICD Code:
  • Decompression illness (previously dysbaric osteocrenosis/caisson disease) - Date of Diagnosis:
  • Other specified forms of arthropathy (excluding gout) - ICD Code:
  • Other specified forms of arthropathy (excluding gout) - Date of Diagnosis:
  • Please specify diagnosis:
  • Other diagnosis #1 - ICD Code:
  • Other diagnosis #1 - Date of Diagnosis:
  • Other diagnosis #2 - ICD Code:
  • Other diagnosis #2 - Date of Diagnosis:
  • Other diagnosis #3 - ICD Code:
  • Other diagnosis #3 - Date of Diagnosis:
  • If there are additional diagnoses that pertain to non-degenerative arthritis conditions, list using above format:
MEDICAL HISTORY (Section II)
  • 2A. Describe the history (including onset and course) of the Veteran's inflammatory, autoimmune, crystalline or infectious arthritis, or decompression illness (brief summary):
  • 2B. Does the Veteran require continuous use of medication for the arthritis condition?
  • If yes, list only those medications used for this arthritis condition:
  • 2C. Has the Veteran lost weight due to the arthritis condition?
  • If yes, provide baseline weight (average weight for 2-year period preceding onset of disease):
  • and current weight:
  • If yes, does the Veteran's weight loss (attributable to the arthritis condition) cause impairment of health?
  • If yes, describe the impairment:
  • 2D. Does the Veteran have anemia due to the arthritis condition?
  • If yes, does the Veteran's anemia (which is attributable to the arthritis condition) cause impairment of health?
  • If yes, describe the impairment, and also provide Complete Blood Count (CBC) under Section IX - Diagnostic Testing:
JOINT INVOLVEMENT (Section III)
  • 3A. Does the Veteran have any joint involvement (e.g., pain, limitation of motion, joint deformity) attributable to the arthritis condition?
  • If yes, indicate affected joints. Check all that apply: Cervical spine
  • Thoracolumbar spine
  • Sacroiliac joints
  • Right: Shoulder
  • Right: Elbow
  • Right: Wrist
  • Right: Hand/fingers
  • Right: Hip
  • Right: Knee
  • Right: Ankle
  • Right: Foot/toes
  • Left: Shoulder
  • Left: Elbow
  • Left: Wrist
  • Left: Hand/fingers
  • Left: Hip
  • Left: Knee
  • Left: Ankle
  • Left: Foot/toes
  • For all checked joints, describe involvement (brief summary):
SYSTEMIC INVOLVEMENT OTHER THAN JOINTS (Section IV)
  • 4A. Does the Veteran have any involvement of any body systems, other than joints, attributable to the arthritis condition?
  • If yes, indicate systems involved. Check all that apply: Opthalmological
  • Skin and mucous membranes
  • Hematological
  • Pulmonary
  • Cardiac
  • Neurological
  • Renal
  • Gastrointestinal
  • Vascular
  • Other
  • For all checked systems, describe involvement (brief summary). Also complete the appropriate questionnaire for each affected body system, if indicated.
  • 4B. Comments (if any):
INCAPACITATING AND NON-INCAPACITATING EXACERBATIONS (Section V)
  • 5A. Due to the arthritis condition, does the Veteran have exacerbations which are not incapacitating?
  • If yes, indicate frequency of non-incapacitating exacerbations per year (on average): 0 / 1 / 2 / 3 / 4 or more
  • Date of most recent non-incapacitating exacerbation:
  • Duration of most recent non-incapacitating exacerbation:
  • Describe non-incapacitating exacerbation:
  • 5B. Due to the arthritis condition, does the Veteran have exacerbations which are incapacitating?
  • If yes, indicate frequency of incapacitating exacerbations per year (on average): 0 / 1 / 2 / 3 / 4 or more
  • Indicate the total duration of incapacitation over the past 12 months: < 1 week / 1 week to < 2 weeks / 2 weeks to < 4 weeks / 4 weeks to < 6 weeks / 6 weeks or more
  • Date of most recent incapacitating exacerbation:
  • Duration of most recent incapacitating exacerbation:
  • Describe incapacitating exacerbation:
  • 5C. Is the Veteran's arthritis manifested by constitutional manifestations associated with active joint involvement which are totally incapacitating?
  • 5D. Is the Veteran's arthritis manifested by weight loss and anemia productive of severe impairment of health?
  • 5E. Is the Veteran's arthritis manifested by severely incapacitating exacerbations occurring four or more times a year, or a lesser number over prolonged periods?
  • 5F. Is the Veteran's arthritis manifested by symptom combinations productive of definite impairment of health, objectively supported by examination findings?
OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS, AND SCARS (Section VI)
  • 6A. Does the Veteran have any other pertinent physical findings, complications, conditions, signs, or symptoms related to any conditions listed in the diagnosis section above?
  • If yes, describe (brief summary):
  • 6B. Does the Veteran have any scars or other disfigurement of the skin related to any conditions, or to the treatment of any conditions, listed in the diagnosis section?
ASSISTIVE DEVICES (Section VII)
  • 7A. Does the Veteran use any assistive devices as a normal mode of locomotion, although occassional locomotion by other methods may be possible?
  • Wheelchair - Frequency of use: Occasional / Regular / Constant
  • Brace(s) - Frequency of use: Occasional / Regular / Constant
  • Crutch(es) - Frequency of use: Occasional / Regular / Constant
  • Cane(s) - Frequency of use: Occasional / Regular / Constant
  • Walker - Frequency of use: Occasional / Regular / Constant
  • Other: - Frequency of use: Occasional / Regular / Constant
  • 7B. If the Veteran uses any assistive devices, specify the condition, indicate the side, and identify the assistive device used for each condition:
REMAINING EFFECTIVE FUNCTION OF THE EXTREMITIES (Section VIII)
  • 8A. Due to the Veteran's arthritis condition, is there functional impairment of an extremity such that no effective function remains, other than that which would be equally well-served by an amputation with prosthesis?
  • If yes, indicate extremities for which this applies: Right upper
  • Left upper
  • Right lower
  • Left lower
  • 8B. For each checked extremity, identify the condition causing loss of function, describe loss of effective function and provide specific examples (brief summary):
DIAGNOSTIC TESTING (Section IX)
  • 9A. Have clinically relevant diagnostic imaging studies or other diagnostic procedures been performed or reviewed in conjunction with this examination?
  • Was arthritis documented?
  • X-ray - Area(s) imaged:
  • X-ray - Date:
  • X-ray - Results:
  • Other, specify: - Area(s) imaged:
  • Other, specify: - Date:
  • Other, specify: - Results:
  • 9B. Has clinically relevant laboratory testing been performed or reviewed in conjunction with this examination?
  • Erythrocyte sedimentation rate (ESR) - Date of test:
  • Erythrocyte sedimentation rate (ESR) - Results:
  • C-reaction protein - Date of test:
  • C-reaction protein - Results:
  • Rheumatoid factor (RF) - Date of test:
  • Rheumatoid factor (RF) - Results:
  • Anti-DNA antibodies - Date of test:
  • Anti-DNA antibodies - Results:
  • Antinuclear antibodies (ANA) - Date of test:
  • Antinuclear antibodies (ANA) - Results:
  • Anti-cyclic citrullinated peptide (ANTI - CCP) antibodies - Date of test:
  • Anti-cyclic citrullinated peptide (ANTI - CCP) antibodies - Results:
  • CBC - Date of test:
  • CBC - Results:
  • Hemoglobin:
  • Hematocrit:
  • White Blood cell count:
  • Platelets:
  • Uric acid test - Date of test:
  • Uric acid test - Results:
  • Other, specify: - Date of test:
  • Other, specify: - Results:
  • If any test results in this section are other than normal, include normal reference ranges for your facility.
  • 9C. Has the Veteran had a joint aspiration or synovial fluid analysis?
  • If yes, indicate joint aspirated, date and results:
  • 9D. Has the Veteran had a biopsy?
  • If yes, indicate area biopsied, date and results:
  • 9E. Are there any other clinically relevant diagnostic test findings or results related to the claimed condition(s) and/or diagnosis(es) that were reviewed in conjunction with this examination?
  • If yes, provide type of test or procedure, date, and results (brief summary):
  • 9F. If any test results are other than normal, indicate relationship of abnormal findings to diagnosed condition(s):
FUNCTIONAL IMPACT (Section X)
  • 10A. Regardless of the Veteran's current employment status, do the conditions listed in the diagnosis section impact his/her ability to perform any type of occupational task (such as standing, walking, lifting, sitting, etc.)?
  • If yes, describe the functional impact of each condition, providing one or more examples:
REMARKS (Section XI)
  • 11A. Remarks (if any - please identify the section to which the remark pertains when appropriate).

Rating Levels for DC 5002

The following tiers are reproduced from 38 CFR Part 4, the VA Schedule for Rating Disabilities. Toggle between the official VA criteria and a Plain English explanation.

Plain-English summaries are AI-generated to explain the official criteria. The official 38 CFR language is the binding legal standard. When in doubt, ask a VSO.

What the Board discussed in granted decisions for DC 5002

The themes below were extracted by clustering 500 grant-factor sentences from published Board of Veterans Appeals decisions for this diagnostic code. Frequencies indicate how often each theme appeared in the sample. This is a factual aggregate of the public record, not advice or strategy for any specific claim.

  1. 37% Benefit of the doubt doctrine cited in Board reasoning
    The Board noted the benefit of the doubt doctrine as part of its legal reasoning, either applying it in favor of the Veteran or finding it inapplicable because evidence was persuasively against the claim.
    185 of 500 sample sentences
  2. 29% Examiner nexus opinion recorded as at least as likely as not
    A VA or private examiner's opinion that a current disability was at least as likely as not related to, caused by, or aggravated by service or a service-connected condition was documented in the record.
    143 of 500 sample sentences
  3. 14% Evidence found in equipoise supporting grant
    The Board found the overall lay and medical evidence to be in approximate balance or relative equipoise on a material issue, resulting in a decision in the Veteran's favor.
    72 of 500 sample sentences
  4. 9% Secondary nexus opinion linking disability to service-connected condition
    An examiner or provider opined that a current disability was at least as likely as not proximately due to, the result of, or aggravated by an already service-connected disability.
    45 of 500 sample sentences
  5. 4% Rheumatoid arthritis or polyarthritis nexus to service documented
    Medical or lay evidence in the record addressed whether the Veteran's rheumatoid arthritis, polyarthritis, or related multi-joint condition was causally linked to military service or a service-connected condition.
    18 of 500 sample sentences
  6. 3% Bilateral knee disability nexus to service recorded
    Examiner opinions or lay evidence documented in the record supported a finding that the Veteran's bilateral knee conditions were at least as likely as not incurred in, caused by, or aggravated during military service.
    17 of 500 sample sentences
  7. 3% Preponderance of evidence found against claim; doctrine inapplicable
    The Board recorded that the weight of evidence persuasively stood against the claim, rendering the benefit of the doubt doctrine inapplicable and resulting in denial.
    16 of 500 sample sentences
  8. 1% Increased rating granted based on equipoise and credible symptom reports
    The Board found the evidence in approximate balance regarding severity criteria and, affording the Veteran the benefit of the doubt, assigned a higher disability rating based on documented symptom reports and examination findings.
    4 of 500 sample sentences
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Disclaimer: This page reproduces public Department of Veterans Affairs forms (DBQs) and verbatim text from 38 CFR Part 4 (the VA Schedule for Rating Disabilities). It is informational only and is not legal or medical advice. For guidance on a specific claim, contact a VA-accredited representative.