Disability Benefits Questionnaire (DBQ) - Muscle Injuries Completed Form Examples and Samples

View a detailed example of a filled Disability Benefits Questionnaire (DBQ) - Muscle Injuries. Learn how to accurately document muscle group involvement, functional findings, and clinical diagnoses for VA disability claims.
A screenshot showing a completed Disability Benefits Questionnaire (DBQ) for Muscle Injuries, highlighting the structured extraction of clinical data.

Source document used: Orthopedic Progress Note

Progress Note - Clinical Evaluation: Dr. Marcus Thorne, MD (Orthopedics, NPI: 1234567890, License: MD-998877, California). Exam Date: February 14, 2026. Patient: Arthur J. Miller, SSN 000-11-2222. The patient presented for a follow-up regarding his service-connected muscle injuries. He is a regular patient in our clinic. I performed an in-person physical examination today. I reviewed his service treatment records (2018-2022) and his recent private treatment records (2025). The veteran is right-hand dominant. Current diagnoses: Traumatic tear of the left quadriceps muscle (ICD-10: S76.112A) diagnosed on 05/12/2020 (Side: Left); Chronic strain of the right trapezius (ICD-10: M79.11) diagnosed on 11/02/2019 (Side: Right). He describes significant weakness in his left leg during long walks. Physical exam of the left thigh shows visible atrophy compared to the right (Left: 48cm vs Right: 52cm at max bulk). Strength testing reveals: Left knee flexion strength at 3/5, and left knee extension at 4/5. Right trapezius strength is 5/5. The patient reports occasional fatigue and pain in the left thigh muscles, which limits his ability to stand for more than 30 minutes, impacting his warehouse work duties. No retained metallic fragments found on current X-rays. He currently uses a cane for long-distance mobility on an occasional basis. No other pertinent physical findings or neoplasms noted. I have discussed these findings with the patient. Signed, Marcus Thorne, MD, 1500 Medical Plaza, Suite 400, Los Angeles, CA 90001. Phone: (555) 123-4567.