C&P Exam for Hip, resurfacing or replacement (DC 5054)
Which form the examiner uses
For hip, resurfacing or replacement (DC 5054), the C&P examiner completes the following Disability Benefits Questionnaire (DBQ):
- DBQ MUSC Amputations (examiner-only DBQ. Link opens VA Find-A-Form search)
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 amputations of the upper and lower extremities, including fingers and toes.
How DC 5054 maps to this DBQ: for this diagnostic code specifically, the examiner typically completes sections I-III and VIII-XII of this form. Section III is the condition-specific section for this code. Sections IV-VII cover unrelated conditions on this DBQ and are skipped.
DIAGNOSIS (Section I)
- 1A. Has the Veteran had any amputations? Yes No
- 1B. If yes, provide only diagnoses that pertain to amputations. Amputation # 1 - ICD code - Date of amputation - Amputation # 2 - ICD code - Date of amputation - Amputation # 3 - ICD code - Date of amputation - Amputations
- 1C. If additional amputation(s) exist, list using above format.
MEDICAL HISTORY (Section II)
- 2A. Describe the history (including etiology and course) of each amputation listed above.
AMPUTATION(S) SITE(S) (Section III)
- 3A. Amputation(s) sites(s) (Indicate affected sites): Upper extremities (not including the fingers) Fingers Lower extremities (not including the toes) Toes For all checked sites, complete the corresponding sections below.
UPPER EXTREMITIES (NOT INCLUDING FINGERS) (Section IV)
- 4A. Does the Veteran have an amputation of either arm? Yes No If yes, indicate site and side affected. Check all that apply. Amputation is below insertion of deltoid Left Right Both Amputation is above insertion of deltoid Left Right Both Forequarter amputation (involving complete removal of the humerus along with any portion of the scapula) Left Right Both
- 4B. Indicate if the upper extremity amputation site allows the use of a suitable prosthetic appliance. Left Yes No NA Right Yes No NA
- 4C. Is there an amputation of either forearm? Yes No If yes, indicate site and side affected. Check all that apply. Amputation below insertion of pronator teres Left Right Both Amputation above insertion of pronator teres Left Right Both Amputation resulting in loss of use of the hand Left Right Both
FINGERS (Section V)
- 5A. Does the Veteran have an amputation of either thumb? Yes No If yes, indicate site and side affected. Check all that apply. Amputation at the distal joint or through the distal phalanx Left Right Both Amputation at the metacarpophalangeal joint or through the proximal phalanx Left Right Both Amputation with metacarpal resection Left Right Both
- 5B. Does the Veteran have an amputation of any fingers? Yes No If yes, indicate site and side affected. Check all that apply. Other (such as a fingertip amputation) please describe in Section VIII Amputation through the middle phalanx or at the distal joint Right index finger Right long finger Right ring finger Right little finger Left index finger Left long finger Left ring finger Left little…
LOWER EXTREMITIES (NOT INCLUDING THE TOES) (Section VI)
- 6A. Does the Veteran have an above the knee amputation of the thigh? Yes No If yes, indicate site and side affected. Check all that apply. Amputation of the middle or lower third Left Right Both Amputation of the upper third, one-third of the distance from the perineum to the knee joint, measured from the perineum Left Right Both Disarticulation (involving complete removal of the femur and…
- 6B. Indicate if the thigh amputation site allows the use of a suitable prosthetic appliance. Left Yes No NA Right Yes No NA Amputations
- 6C. Does the Veteran have a below or through the knee amputation of the lower leg, including forefoot? Yes No If yes, indicate site and side affected. Check all that apply. Amputation of the forefoot, which is proximal to the metatarsal bones (more than one-half of metatarsal loss) Left Right Both Amputation between the forefoot and knee, permitting prosthesis Left Right Both Amputation not…
- 6D. Indicate if the lower leg amputation site allows the use of a suitable prosthetic appliance. Left Yes No NA Right Yes No NA
TOES (Section VII)
- 7A. Does the Veteran have an amputation of any toes? Yes No If yes, indicate site and side affected. Check all that apply. Amputation of toes without metatarsal loss or transmetatarsal loss. Right great toe Right 2nd toe Right 3rd toe Right 4th toe Right little toe Left great toe Left 2nd toe Left 3rd toe Left 4th toe Left little toe Both great toes Both 2nd toes Both 3rd toes Both 4th toes Both…
OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS, AND SCARS (Section VIII)
- 8A. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any conditions listed in the diagnosis section above? Yes No If yes, describe (brief summary):
- 8B. 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 above? Yes No If yes, also complete the appropriate dermatological questionnaire.
ASSISTIVE DEVICES (Section IX)
- 9A. Does the Veteran use any assistive devices? Yes No If Yes, identify the assistive devices used. Check all that apply and indicate frequency. Wheelchair Frequency of use: Occasional Regular Constant Brace(s) Frequency of use: Occasional Regular Constant Amputations
- 9B. If the Veteran uses any assistive devices, specify the condition, indicate the side, and identify the assistive device used for each condition.
DIAGNOSTIC TESTING (Section X)
- 10A. Are there any significant diagnostic test findings and/or results? Yes No If yes, provide type of test or procedure, date and results - brief summary:
FUNCTIONAL IMPACT (Section XI)
- 11A. 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.)? Yes No If yes, describe the functional impact of each condition, providing one or more examples: Amputations
REMARKS (Section XII)
- 12A. Remarks (if any - please identify the section to which the remark pertains when appropriate).
Rating Levels for DC 5054
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.
Evidence cited in published BVA decisions for DC 5054
The counts below are aggregated from published Board of Veterans Appeals decisions for this diagnostic code. Each row reports how often a given evidence type was discussed in the decision text, broken down by outcome. This is a factual aggregate of the public record, not a prediction or recommendation about any specific claim.
- VA examination: appeared in 7 granted decisions (5 denied, 9 remanded; 21 total)
- Private medical opinion: appeared in 1 granted decision (1 denied, 0 remanded; 2 total)
- Service treatment records: appeared in 0 granted decisions (3 denied, 1 remanded; 4 total)
- Medical literature: appeared in 0 granted decisions (0 denied, 1 remanded; 1 total)
- Buddy / lay statements: appeared in 0 granted decisions (0 denied, 1 remanded; 1 total)
- Nexus letter: appeared in 0 granted decisions (1 denied, 0 remanded; 1 total)
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.