Amputations DBQ: Official VA Form

The public Amputations Disability Benefits Questionnaire records medical information for VA evaluation. The form itself provides its current questions, definitions, examination and clinician requirements. A completed form is evidence; it does not establish service connection or guarantee an evaluation.

Related Diagnostic Code Subjects

47 code subjects are associated with this form in this educational directory. These editorial subject associations are not official VA assignments, and the form may not be appropriate for every examination or claim.

• DC 5120: Complete amputation, upper extremity
• DC 5121: Above insertion of deltoid
• DC 5122: Below insertion of deltoid
• DC 5123: Above insertion of pronator teres
• DC 5124: Below insertion of pronator teres
• DC 5126: Five digits of one hand, amputation of
• DC 5127: Thumb, index, long and ring
• DC 5128: Thumb, index, long and little
• DC 5129: Thumb, index, ring and little
• DC 5130: Thumb, long, ring and little
• DC 5131: Index, long, ring and little
• DC 5132: Thumb, index and long
• DC 5133: Thumb, index and ring
• DC 5134: Thumb, index and little
• DC 5135: Thumb, long and ring
• DC 5136: Thumb, long and little
• DC 5137: Thumb, ring and little
• DC 5138: Index, long and ring
• DC 5139: Index, long and little
• DC 5140: Index, ring and little
• DC 5141: Long, ring and little
• DC 5142: Thumb and index
• DC 5143: Thumb and long
• DC 5144: Thumb and ring
• DC 5145: Thumb and little
• DC 5146: Index and long
• DC 5147: Index and ring
• DC 5148: Index and little
• DC 5149: Long and ring
• DC 5150: Long and little
• DC 5151: Ring and little
• DC 5152: Thumb, amputation of
• DC 5153: Index finger, amputation of
• DC 5154: Long finger, amputation of
• DC 5155: Ring finger, amputation of
• DC 5156: Little finger, amputation of
• DC 5160: Complete amputation, lower extremity
• DC 5161: Upper third, one-third of the distance from perineum to knee joint measured from perineum
• DC 5162: Middle or lower thirds
• DC 5163: With defective stump, thigh amputation recommended
• DC 5164: Amputation not improvable by prosthesis controlled by natural knee action
• DC 5165: At a lower level, permitting prosthesis
• DC 5166: Forefoot, amputation proximal to metatarsal bones (more than one-half of metatarsal loss)
• DC 5170: Toes, all, amputation of, without metatarsal loss or transmetatarsal, amputation of, with up to half of metatarsal loss
• DC 5171: Toe, great, amputation of
• DC 5172: Toes, other than great, amputation of, with removal of metatarsal head
• DC 5173: Toes, three or four, amputation of, without metatarsal involvement

Read The Form Before Arranging An Examination

Review who may complete the form, which conditions it includes or excludes, and whether testing is required. VA can still request a claim examination. Report actual findings; this reference does not provide suggested answers.

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