C&P Exam for Tympanic membrane, perforation of (DC 6211)
Which form the examiner uses
For tympanic membrane, perforation of (DC 6211), the C&P examiner completes the following Disability Benefits Questionnaire (DBQ):
- DBQ ENT Ear Conditions Including Vestibular and Infectious (public PDF on VA.gov)
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 ear conditions including vestibular conditions (Meniere's, peripheral vestibular disorders), infectious/inflammatory ear conditions, and surgical treatments. Hearing loss and tinnitus are evaluated on a separate examiner-only Audio DBQ.
How DC 6211 maps to this DBQ: for this diagnostic code specifically, the examiner typically completes sections I-III and VIII-XI 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. List the claimed condition(s) that pertain to this questionnaire: Note: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed above. If there is no diagnosis, if the diagnosis is different from a previous diagnosis for this condition, or if there is a diagnosis of a complication due to the claimed condition(s), explain your findings and reasons…
- 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 condition(s) listed above. (Explain your findings and reasons in the comments section) Meniere's syndrome or endolymphatic hydrops ICD Code: Date of diagnosis: Peripheral vestibular disorder ICD Code: Date of diagnosis: Benign Paroxysmal…
- 1C. If there are additional diagnoses that pertain to ear or peripheral vestibular conditions, list using above format Note: If the Veteran has hearing loss or tinnitus attributable to any ear condition listed above, a Hearing Loss and Tinnitus Questionnaire must ALSO be completed.
MEDICAL HISTORY (Section II)
- 2A. Describe the history (including onset, course, and treatment) of the Veteran's ear or peripheral vestibular conditions (brief summary):
- 2B. Does the Veteran's treatment plan include taking continuous medication for the diagnosed condition? Yes No If yes, list only those medications used for the diagnosed condition:
VESTIBULAR CONDITIONS (Section III)
- 3A. Does the Veteran have any of the following findings, signs, or symptoms attributable to Meniere's Syndrome (Endolymphatic Hydrops), a peripheral vestibular condition or another diagnosed condition from Section I? Yes No If yes, check all that apply: Hearing impairment with vertigo If checked, indicate frequency: Less than once a month
INFECTIOUS, INFLAMMATORY AND OTHER EAR CONDITIONS (Section IV)
- 4A. Does the Veteran have any of the following findings, signs or symptoms attributable to chronic ear infection, inflammation, cholesteatoma or any of the diagnoses listed in Section I? Yes No If yes, check all that apply: Swelling (external ear canal) If checked, describe: Dry and scaly (external ear canal)
- 4B. Does the Veteran have a benign neoplasm of the ear (other than skin only, such as keloid) that causes any impairment of function? Yes No If yes, describe impairment of function caused by this condition:
SURGICAL TREATMENT (Section V)
- 5A. Has the Veteran had surgical treatment for any ear condition? Yes No If yes, indicate type of surgery: Type of surgery: Date of surgery: Side affected: Right Left Both
- 5B. Does the Veteran have any residuals as a result of the surgery? Yes No If yes, describe:
PHYSICAL EXAM (Section VI)
- 6A. External ear: Exam of external ear not indicated Normal Deformity of auricle, with loss of less than one-third of the substance If checked, specify side: Right Left Deformity of auricle, with loss of one-third or more of the substance
- 6B. Ear canal: Exam of ear canal not indicated Normal Abnormal, describe:
- 6C. Tympanic membrane: Exam of tympanic membrane not indicated Normal Perforated tympanic membrane If checked, specify side affected: Right Left Evidence of a healed tympanic membrane perforation If checked, specify side affected: Right Left
- 6D. Gait: Exam of gait not indicated Normal Unsteady, describe: Other abnormality, describe:
- 6E. Romberg Test: Exam using this test not indicated Normal or negative Abnormal or positive for unsteadiness
- 6F. Dix Hallpike test (Nylen-Barany test) for vertigo: Exam using this test not indicated Normal, no vertigo or nystagmus during test Abnormal, vertigo or nystagmus during test, describe:
- 6G. Limb coordination test (finger-nose-finger): Exam using this test not indicated Normal Abnormal, describe:
TUMORS AND NEOPLASMS (Section VII)
- 7A. Does the Veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses in the diagnosis section? Yes No If yes, complete the following:
- 7B. Is the neoplasm: Benign Malignant Active In remission Primary Secondary (metastatic) (if secondary, indicate the primary site, if known):
- 7C. Has the Veteran completed treatment or is the Veteran currently undergoing treatment for a benign or malignant neoplasm or metastases? Yes No; watchful waiting If yes, indicate type of treatment the Veteran is currently undergoing or has completed (check all that apply): Treatment completed; currently in watchful waiting status Surgery If checked, describe: Date(s) of surgery:
- 7D. Does the Veteran currently have any residual conditions or complications due to the neoplasm (including metastases) or its treatment, other than those already documented in the report above? Yes No If yes, list residual conditions and complications (brief summary):
- 7E. If there are additional benign or malignant neoplasms or metastases related to any of the diagnoses in the diagnosis section, describe using the above format:
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 the 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? Yes No If yes, also complete the appropriate dermatological questionnaire.
- 8C. Comments, if any:
DIAGNOSTIC TESTING (Section IX)
- 9A. Have diagnostic imaging studies or other diagnostic procedures been performed? Yes No If yes, check all that apply: Magnetic resonance imaging (MRI) Date: Results: Computerized axial tomography
- 9B. Has the Veteran had an audiogram? Yes No If yes, attach or provide results: Note: If the Veteran has hearing loss or tinnitus, a hearing loss or tinnitus exam must also be completed.
- 9C. Are there any other 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 X)
- 10A. Do any of the Veteran's ear or peripheral vestibular conditions impact his or her ability to work? Yes No If yes, describe impact of each of the Veteran's ear or peripheral vestibular conditions, providing one or more examples:
REMARKS (Section XI)
- 11A. Remarks (if any)
Rating Levels for DC 6211
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.
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.