C&P Exam for Gastroesophageal reflux disease (DC 7206)

Read the C&P exam preparation guideWhat happens at the exam, what 38 CFR Part 4 requires the examiner to record, and what to bring.

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Diagnostic code: 7206Condition: Gastroesophageal reflux diseaseRegulation: 38 CFR § 4.114DBQ: DBQ GI Esophageal Disorders

Which form the examiner uses

For gastroesophageal reflux disease (DC 7206), the C&P examiner completes the following Disability Benefits Questionnaire (DBQ):

DBQ GI Esophageal Disorders (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 to expect at your C&P exam

Here is what the exam itself usually looks like for an esophageal condition. The examiner uses these steps to document severity against the rating criteria.

1Initial interview (history)

When your symptoms first started.
How often you have heartburn, acid reflux, or regurgitation.
Whether symptoms worsen after eating, when lying down, or at night.
Associated symptoms: chest pain, difficulty swallowing (dysphagia), chronic cough, sore throat, or a sour taste.
How symptoms affect your daily activities, sleep, and ability to work.
Treatments and medications tried (antacids, H2 blockers, proton pump inhibitors) and whether they helped.
Any complications: esophagitis, strictures, Barrett's esophagus, or aspiration pneumonia.
Smoking, alcohol, or dietary triggers, and family history.

2Physical examination

Vital signs (blood pressure, heart rate, respiratory rate, temperature).
Inspection of the chest and abdomen.
Listening to lung and bowel sounds.
Palpating the abdomen for tenderness, bloating, or discomfort.

3Diagnostic tests the examiner may rely on

These are usually already in your records rather than performed at the exam. The examiner reviews the results to gauge severity.

Upper endoscopy (EGD) what's this?

A thin camera passed through the mouth to look at the esophagus and stomach for inflammation, ulcers, strictures, or Barrett's esophagus.

Esophageal pH monitoring what's this?

Measures how often and how long stomach acid backs up into the esophagus, usually over 24 hours, to confirm reflux.

Esophageal manometry what's this?

Measures the pressure and coordination of the esophageal muscles and the lower esophageal sphincter (the valve that should keep acid down).

Barium swallow X-ray what's this?

An X-ray taken after drinking a chalky contrast liquid, showing reflux, narrowing, or how the esophagus moves.

Biopsy what's this?

If abnormal tissue is seen during endoscopy, a small sample is taken to check for Barrett's esophagus or other changes.

4Functional assessment

Impact on sleep quality and daily comfort.
Diet limitations and food restrictions.
Need for ongoing medication or medical care.
Frequency of flare-ups or incapacitating episodes.
Effect on employment and physical activity.

Test explainers open MedlinePlus (NIH National Library of Medicine), or Wikipedia where MedlinePlus has no matching page. This describes what happens and what is measured, not how to influence a result.

What the examiner records (full DBQ form)

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 esophageal conditions including gastroesophageal reflux disease (GERD), hiatal hernia, esophageal stricture, and other esophageal disorders.

How DC 7206 maps to this DBQ: for this diagnostic code specifically, the examiner typically completes sections I-III and V-VIII of this form. Section III is the condition-specific section for this code. Section IV covers an unrelated condition on this DBQ and is skipped.

7 of 8 sections apply to DC 7206 on this DBQ

DIAGNOSIS (Section I) MEDICAL HISTORY (Section II) SIGNS AND SYMPTOMS (Section III) OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS AND OR SYMPTOMS, AND SCARS (Section V) DIAGNOSTIC TESTING (Section VI) FUNCTIONAL IMPACT (Section VII) REMARKS (Section VIII)

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 condition(s) listed above
Hiatal hernia - ICD code / Date of diagnosis
Gastroesophageal reflux disease (GERD) - ICD code / Date of diagnosis
Paraesophageal hernia - ICD code / Date of diagnosis
Esophagus, stricture of - ICD code / Date of diagnosis
Esophagitis (specify type) - ICD code / Date of diagnosis
Barrett's esophagus - ICD code / Date of diagnosis
Mallory Weiss syndrome/tear - ICD code / Date of diagnosis
Esophageal motility disorder (select one if known) - ICD code / Date of diagnosis
Achalasia (cardiospasm) - ICD code / Date of diagnosis
Diffuse esophageal spasm - ICD code / Date of diagnosis
Corkscrew esophagus - ICD code / Date of diagnosis
Nutcracker esophagus - ICD code / Date of diagnosis
Other motor/motility disorders of the esophagus (specify type) - ICD code / Date of diagnosis
Esophageal rings (including Schatzki rings) - ICD code / Date of diagnosis
Disorder of esophageal mucosal webs - ICD code / Date of diagnosis
Disorder of esophageal mucosal folds - ICD code / Date of diagnosis
Esophagus impairment caused by systemic condition (specify condition) - ICD code / Date of diagnosis
Esophagus, diverticulum of, acquired - ICD code / Date of diagnosis
Pharyngoesophageal (Zenker's) diverticulum - ICD code / Date of diagnosis
Mid-esophageal diverticulum - ICD code / Date of diagnosis
Epiphrenic (distal esophagus) diverticulum - ICD code / Date of diagnosis
Esophageal cancer - ICD code / Date of diagnosis
Benign neoplasm of the esophagus (if checked specify) - ICD code / Date of diagnosis
Other esophageal condition(s) (specify) - ICD code / Date of diagnosis
1C. If there are additional diagnoses that pertain to esophageal disorders, list using above format

MEDICAL HISTORY (Section II)

2A. Describe the history, including onset and course, of the Veteran's esophageal condition(s). Brief summary
2B. Does the Veteran's treatment plan include taking daily prescribed medication for the diagnosed condition(s)?
If yes, list only those medications used for the diagnosed condition(s)

SIGNS AND SYMPTOMS (Section III)

3A. Does the Veteran have any of the following signs, symptoms, or treatment requirements due to any esophageal condition(s) (including GERD and hiatal hernia)?
Without daily symptoms
Without requirement for daily medication
Dysphagia (difficulty swallowing)
Requiring daily medication to control dysphagia
Documented history of esophageal stricture(s) (If checked indicate if recurrent or refractory)
Has the esophageal stricture(s) been recurrent or refractory?
Requiring dilatation (if checked indicate frequency and list most recent dates): No more than 2 times a year / 3 or more times a year
Was there dilatation utilizing steroids at least 1 time per year?
Date of dilatation (x3)
Requiring esophageal stent placement
Aspiration
Undernutrition
Substantial weight loss
Treatment with surgical correction
Treatment with a percutaneous esophago-gastrointestinal tube (PEG tube)
Other, symptom(s) specify
3B. Does the Veteran have Barrett's esophagus documented by pathologic diagnosis?
Specify severity of dysplasia: High-grade dysplasia / Low-grade dysplasia / No dysplasia
Did Barrett's esophagus cause esophageal stricture(s)?
Has the condition been resolved via surgery, radiofrequency ablation, or other treatment?
Surgery/procedure type and date (Barrett's esophagus)
3C. Did the Veteran have surgery or other procedure performed for an esophageal condition(s) (other than Barret's esophagus) or hiatal hernia?
Surgery/procedure type and date (3C)
3D. Does the Veteran have chronic complications of esophageal or hiatal hernia surgery?
Post-operative, asymptomatic
Requiring continuous total parenteral nutrition (TPN) for a period longer than 30 consecutive days in the last six months - Start date of TPN / Completion date of TPN or anticipated date of completion
Requiring continuous tube feeding for a period longer than 30 consecutive days in the last six months - Start date of tube feeding / Completion date of tube feeding or anticipated date of completion
Vomiting (if checked indicate frequency and if managed by medical treatment, oral dietary modification, or medication): Frequency - Less than 2 times a week / 2 or more times a week / Daily
Vomiting Treatment: No treatment / Managed by ongoing medical treatment / Vomiting despite medical treatment - Oral dietary modification / Medication / Other (specify)
Watery bowel movements (if checked indicate frequency): Less than 3 per day every day / 3-5 per day every day / 6 or more per day every day
Explosive bowel movements that are difficult to predict or control
Nausea (if checked indicate if managed by medical treatment): Managed by ongoing medical treatment?
Post-prandial (meal-induced) light-headedness (syncope) with sweating
Requirement for medications to specifically treat complications of upper GI surgery including dumping syndrome or delayed gastric emptying
Discomfort or pain within an hour of eating and requiring ongoing oral dietary modification
Other, symptom(s) specify (3D)

TUMORS AND NEOPLASMS (Section IV)

4A. Does the Veteran currently have, or has had, a benign or malignant neoplasm or metastases related to any condition in the diagnosis section?
4B. Is the neoplasm: Benign / Malignant
If malignant: Active / In remission
If malignant: Primary / Secondary (metastatic) - if secondary, indicate the primary site, if known
4C. Has the Veteran completed treatment or is the Veteran currently undergoing treatment for a benign or malignant neoplasm or metastases?
Treatment completed
Surgery - If checked, describe / Date(s) of surgery
Radiation therapy - Date of most recent treatment / Date of completion of treatment or anticipated date of completion
Antineoplastic chemotherapy - Date of most recent treatment / Date of completion of treatment or anticipated date of completion
Other therapeutic procedure - If checked, describe procedure / Date of most recent procedure
Other therapeutic treatment - If checked, describe treatment / Date of completion of treatment or anticipated date of completion
4D. Does the Veteran currently have any residuals or complications due to the neoplasm (including metastases) or its treatment, other than those already documented in the report above?
If yes, list residuals or complications (brief summary)
4E. 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 AND OR SYMPTOMS, AND SCARS (Section V)

5A. Does the Veteran have any other pertinent physical findings, complications, conditions, signs or symptoms related to any condition(s) listed in the diagnosis section above?
If yes, describe (brief summary)
5B. Does the Veteran have any scars or other disfigurement (of the skin) related to any condition(s) or to the treatment of any condition(s) listed in the diagnosis section?

DIAGNOSTIC TESTING (Section VI)

6A. Have clinically relevant diagnostic imaging studies or other diagnostic procedures been performed or reviewed in conjunction with this examination?
EGD - Date / Results
Upper GI radiographic studies - Date / Results
Barium swallow - Date / Results
MRI - Date / Results
CT - Date / Results
Biopsy, specify site - Date / Results
Other, specify - Date / Result
6B. Has clinically relevant laboratory testing been performed or reviewed in conjunction with this examination?
CBC - Date of test / Hemoglobin / Hematocrit / White blood cell count / Platelets
Other, specify - Date of test / Results
6C. 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)
6D. If any test result results are other than normal, indicate relationship of abnormal findings to diagnosed condition

FUNCTIONAL IMPACT (Section VII)

7A. 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 VIII)

8A. Remarks (if any - please identify the section to which the remark pertains when appropriate)

Rating Levels for DC 7206

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 7206

The counts below are aggregated from published Board of Veterans Appeals decisions for this diagnostic code, among issues the Board granted or denied (remanded issues are not included). 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 4643 granted decisions (6658 denied; 11301 decided total)
Service treatment records: appeared in 3011 granted decisions (5428 denied; 8439 decided total)
Buddy / lay statements: appeared in 2488 granted decisions (3318 denied; 5806 decided total)
Private medical opinion: appeared in 1839 granted decisions (1980 denied; 3819 decided total)
Nexus letter: appeared in 1354 granted decisions (801 denied; 2155 decided total)
Medical literature: appeared in 631 granted decisions (445 denied; 1076 decided total)

What the Board discussed in granted decisions for DC 7206

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.

34% Benefit of the doubt doctrine explained or applied
The Board cited, explained, or applied the benefit of the doubt doctrine, noting that when positive and negative evidence is in approximate balance or nearly equal, the claimant prevails.
171 of 500 sample sentences
16% Private medical nexus opinion cited for GERD or secondary condition
A private physician, nurse practitioner, or other non-VA clinician provided a nexus opinion finding a claimed condition at least as likely as not related to service or a service-connected disability.
82 of 500 sample sentences
14% VA examiner nexus opinion cited for GERD or secondary condition
A VA examiner opined that the Veteran's claimed condition was at least as likely as not incurred in service, caused by service, or secondary to a service-connected disability.
72 of 500 sample sentences
11% Benefit of the doubt doctrine found inapplicable, claim denied
The Board found the preponderance or persuasive weight of evidence against the claim, rendering the benefit of the doubt doctrine inapplicable and resulting in denial.
57 of 500 sample sentences
4% NSAID use from service-connected conditions linked to GERD
Medical opinions or Board findings noted that chronic NSAID use required for service-connected orthopedic or other conditions was at least as likely as not the cause or aggravating factor of GERD.
22 of 500 sample sentences
4% PTSD or psychiatric disability cited as nexus for GERD
Medical opinions or Board findings identified the Veteran's service-connected PTSD or other psychiatric disorder as at least as likely as not causing or aggravating GERD through mechanisms such as stress-related acid overproduction.
19 of 500 sample sentences
4% Evidence found in equipoise supporting service connection grant
The Board determined that the overall evidence of record was at least in relative equipoise on the nexus or continuity-of-symptomatology question, resolving the balance in the Veteran's favor.
18 of 500 sample sentences
3% Increased disability rating granted under benefit of the doubt
The Board afforded the Veteran the benefit of the doubt in rating severity, finding that the documented symptomatology more nearly approximated a higher percentage rating under the applicable diagnostic code.
15 of 500 sample sentences
3% In-service treatment records or symptoms cited as direct nexus
The Board noted documented in-service complaints, treatment for heartburn or acid reflux, or continuity of symptoms from service separation as supporting at least an equipoise finding for direct service connection.
14 of 500 sample sentences
2% Remand order for nexus opinion on GERD or related condition
The Board or AOJ directed a VA examiner to provide an opinion on whether the Veteran's GERD or related gastrointestinal condition was at least as likely as not related to service or a service-connected disability.
12 of 500 sample sentences
2% OSA, obesity, or intermediate-step condition linked to GERD nexus chain
Medical opinions or Board findings identified obstructive sleep apnea, obesity, or another intermediate service-connected condition as part of the causal chain connecting service or a service-connected disability to GERD.
10 of 500 sample sentences
2% Diabetes mellitus or metabolic condition cited as GERD nexus
Medical opinions noted that the Veteran's service-connected diabetes mellitus, including associated nerve impairment or medication use, was at least as likely as not the proximate cause of GERD.
8 of 500 sample sentences

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.