Ankle Conditions Disability Benefits Questionnaire (DBQ) Completed Form Examples and Samples

View detailed examples of a completed VA Ankle Conditions Disability Benefits Questionnaire (DBQ). Our filled samples demonstrate how to document conditions like chronic instability, arthritis, and limited range of motion to support a successful VA disability claim.
Ankle Conditions Disability Benefits Questionnaire (DBQ) has a complex Form Complexity Index of 75/100 — Instafill’s AI completes it in under a minute.
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Completed sample of a VA Ankle Conditions Disability Benefits Questionnaire (DBQ) for a veteran with chronic instability and arthritis.

Ankle Conditions DBQ Example – Chronic Instability & Arthritis

How this form was filled:

This is a detailed example of a completed VA Ankle Conditions DBQ for a veteran with right ankle chronic instability and post-traumatic arthritis. It demonstrates how to document medical evidence, including limited range of motion, positive instability tests, painful motion, and functional loss, to support a VA disability claim.

Information used to fill out the document:

  • Veteran's Name: John A. Smith
  • Date of Exam: 2026-03-10
  • Diagnosis: Right Ankle Chronic Instability; Right Ankle Post-Traumatic Arthritis
  • Right Ankle Dorsiflexion: 10 degrees (Normal: 20)
  • Right Ankle Plantar Flexion: 35 degrees (Normal: 45)
  • Pain on Motion: Yes, for both dorsiflexion and plantar flexion.
  • Ankle Instability: Yes, positive anterior drawer test for the right ankle.
  • Functional Impact: Difficulty walking on uneven surfaces; cannot stand for more than 30 minutes without significant pain.
  • Flare-ups: Occur 2-3 times per month, lasting 2-3 days, causing significant pain and requiring use of a cane.
  • Imaging Results: X-ray from 2026-01-20 shows moderate joint space narrowing and osteophytes, consistent with arthritis.
  • Medical Opinion: The veteran's ankle condition is 'at least as likely as not' (50% or greater probability) caused by the in-service injury.

What this filled form sample shows:

  • Clear documentation of a service-connected diagnosis for the right ankle.
  • Precise range of motion (ROM) measurements that demonstrate functional loss compared to normal values.
  • Specific notation of painful motion, a critical component for VA rating considerations.
  • Evidence of clinical instability confirmed by a physical exam test.
  • Detailed description of flare-ups and their impact on daily functioning, including the need for an assistive device.

Form specifications and details:

Form Name: Ankle Conditions Disability Benefits Questionnaire (DBQ)
VA Form Number: 21-0960M-2
Use Case: Veteran with chronic right ankle instability and arthritis resulting from a service injury.
Categories: benefit forms, DBQ forms, disability benefits forms, disability forms
Created: February 13, 2026 01:43 AM
Completed sample of a VA Ankle Conditions Disability Benefits Questionnaire (DBQ) for a veteran with chronic instability and arthritis.