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 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. |
Created: February 13, 2026 01:43 AM
