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Update... Just checked Ebenefits and it shows am in PFN, but the weird thing is when I check under disabilities I have the following: PTSD New IU New Migraine INC PTSD INC The first 2 (PTSD & IU) were not there yesterday, they were just added. Any idea what that means??

OK so this is what happened today, I took my my PTSD DBQ and went to the VSO to ask her to submit it to the VARO. She looked at it and was reading everything and then said I don't think it will be a good idea to submit this DBQ to them now, I asked her and why is that? She said this one says you are 100% disabled because of your PTSD and the C&P doctor put you at 10%, that's a BIG JUMP from 10% to 100% don't you think so. Then she continued, C&P examiner was MD and your DBQ is from psychologist PHD. MD opinion will overweight that of psychologist PHD. I told her but this lady knows my condition because I've been in therapy with her for sometime, while the C&P examiner saw me for one hour and asked me only couple questions. She said it doesn't matter, if this DBQ from your psychologist recommended 50% or 70% then that would be more helpful for your case. I'm totally lost now and confused, any ideas please

Any idea about my eyes exam?? Anyone....

Thanks everyone for your help, So the TBI and PTSD exam concluded that my disability won't prevent me from working, while this one states otherwise, Do you this this eye exam will be enough to qualify me for TDIU?

Update.... So I was able to get a DBQ from a psychologist (Phd) outside the VA,. I've been in therapy with her for sometime now. Of course she didn't agree with the C&P psychiatrist (PTSD). C&P doctor advised 10% and this psychologist checked (TOTAL OCCUPATIONAL AND SOCIAL IMPAIRMENT). She also mentioned that she is basing her decision on my health history, current condition and after checking my military records, VA treatment records and my DD214 "she put this in remark section" I didn't send this new DBQ to the VA yet. I don't know how to proceed from here, should I send it now or wait for my claim to close and get the result then file NOD with this DBQ as a prove of my bad PTSD. Any help will be highly appreciated...

Thanks flores97 for your reply, This was a Psychiatrist, the main problem here is 90% of what she wrote was not said by me, andn I hate it when people put words in my mouth. I was thinking about trying to get a DBQ from outside the VA since no VA Psychiatrist or Psychologist will do this here. At the same time I'm thinking about contacting the patient advocate too. Any other advice will be highly appreciated Thanks in advance

I went to C&P exam for my IU, before submitting my claim for IU I was rated 50% PTSD, 50% vision, 30% Migraine and 10%TBI. I had my first C&P for Migraine which lasted 15-20 minutes, and then I had C&P exam for PTSD which took about one hour, 15 minutes she was on her phone talking to one of her patients and then she spend about 20 minutes trying to find my military records on her computer. Then she asked me 3 or 4 times about driving and I told her I don't drive anymore. Of course she didn't mention that on her report. Her other question was when I started service and I gave her my DD214. I also gave her a letter from VOC rehab which says I don't qualify for VOC Rehab because my health problems are too severe and again she didn't mention that. I gave her a DBQ from my neurologist which says I can't work but again she didn't mention anything about it, she just mentioned the medication that I'm taking and then wrote TBI has no effect on my social and occuptional life. For PTSD she mentioned the following: OCCUPATIONAL AND SOCIAL IMPAIRMENT DUE TO MILD OR TRANSIENT SYMPTOMS WHICH DECREASE WORK EFFICIENCY AND ABILITY TO PERFORMOCCUPATIONAL TASKS ONLY DURING PERIODS OF SIGNIFICANT STRESS, OR SYMPTOMS CONTROLLED BY MEDICATION Of course she didn't mention what every Psychiatrist and Psychogists that I visited the last 3 years wrote about my PTSD (severe PTSD). I still have vision C&P exam but I don't think this will go well too. Anyway, from what I red I think my PTSD rating will go down from 50% to 10%, I know some will say C&P is just a part of the claim and it doesn't have total effect on rating, that is WRONG C&P decides what rating you will get and the rater depends totally on what is mentioned in the C&P exam. My question is this, if I get a PTSD DBQ from outside the VA hospital (since no Psychiatrist in the VA will fill one) will that have any effect on my claim or it is too late now? Will DBQ filled out by a Psychologist have the same as one filled by Psychiatrist? Is there anything I can do to help my claim? Any advice will be highly appreciated

tdubya82 thanks for the link bronocovet: I don't agree with you. It's true that the doctor might know what's going on with the patient but sometimes they will avoid making a proper diagnoses ( because of claims).

Well, I'm asking this because that's what I was told by the C&P doctor. The strange thing is when I go to the VA for my headaches, dizziness, ED, or just because of feeling tired the answer will be it's TBI and you have to learn to adapt. So when it comes to treatment then it's TBI and I have to live with it but when it's C&P then it should be better by now because TBI is known to get better after a while. A liitle more about my condition; first we were hit by IED, then after few months a suicide bomber and after few week my best friend was shot by a sniper when we were on a mission. I'm currently rated at 10% for TBI. It was reduced from 40% to 10%. Dizziness was denied.

How true is it that TBI can only get better and never worst??

Need Dr. Sniger email address. Thanks in advance

Can I have Dr. Sniger email, please

Here is my TBI C&P which lasted 20 minutes only. I'm thinking of 0%-10%. Thanks in advance Muscle Injuries Disability Benefits Questionnaire Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file reviewed? [ ] Yes[X] No If no, check all records reviewed: [X] Veterans Health Administration medical records (VA treatment records) E-FOLDER ON VBMS. SECTION I: DIAGNOSIS -------------------- Does the Veteran now have or has he/she ever been diagnosed with a muscle injury? [X] Yes[ ] No Diagnosis #1: RESIDUALS OF CLOSED LEFT RIB FRACTURE Date of diagnosis: S/C Side affected: [ ] Right [X] Left [ ] Both SECTION II: HISTORY OF MUSCLE INJURY ------------------------------------ a. Does the Veteran have a penetrating muscle injury, such as a gunshot or shell fragment wound? [ ] Yes[X] No b. Does the Veteran have a non-penetrating muscle injury (such as a muscle strain, torn Achilles tendon or torn quadriceps muscle)? [X] Yes[ ] No c. Describe the history (including onset and course) of the Veteran's muscle injury: (brief summary): THIS EXAM IS FOR CURRENT STATUS OF S/C LEFT RIB FRACTURE. PATIENT SAYS HE GETS OCCASIONAL MILD PAIN IN LEFT RIB IF SITS TOO LONG BUT NO NEED OF MEDICINE. d. Dominant hand [X] Right[ ] Left[ ] Ambidextrous SECTION III: LOCATION OF MUSCLE INJURY -------------------------------------- 1. Shoulder girdle and arm -------------------------- Does the Veteran now have or has he/she ever had an injury to a muscle group of the shoulder girdle or arm? [ ] Yes[X] No 2. Forearm and hand ------------------- Does the Veteran now have or has he/she ever had an injury to a muscle group of the forearm or hand? [ ] Yes[X] No 3. Foot and leg --------------- Does the Veteran now have or has he/she ever had an injury to a muscle group of the foot or leg? [ ] Yes[X] No 4. Pelvic girdle and thigh -------------------------- Does the Veteran now have or has he/she ever had an injury to a muscle group of the pelvic girdle or thigh? [ ] Yes[X] No 5. Torso and neck ----------------- Does the Veteran now have or has he/she ever had an injury to a muscle group in the torso and/or neck? [ ] Yes[X] No 6. Additional conditions ------------------------ a. Does the Veteran have a history of rupture of the diaphragm with herniation? [ ] Yes[X] No b. Does the Veteran have a history of an extensive muscle hernia of any muscle, without other injury to the muscle? [ ] Yes[X] No c. Does the Veteran have a history of injury to the facial muscles? [ ] Yes[X] No SECTION IV: MUSCLE INJURY EXAM ------------------------------ 1. Scar, fascia and muscle findings ----------------------------------- a. Does the Veteran have any scar(s) associated with a muscle injury? [ ] Yes[X] No b. Does the Veteran have any known fascial defects or evidence of fascial defects associated with any muscle injuries? [ ] Yes[X] No c. Does the Veteran's muscle injury(ies) affect muscle substance or function? [ ] Yes[X] No 2. Cardinal signs and symptoms of muscle disability --------------------------------------------------- Does the Veteran have any of the following signs and/or symptoms attributable to any muscle injuries? [X] Yes[ ] No If yes, check all that apply, and indicate side affected, muscle group and frequency/severity. [X] Fatigue-pain If checked, indicate side affected: [ ] Right [X] Left [ ] Both Indicate muscle group(s) affected (I-XXIII) if possible: LEFT RIBS Indicate frequency/severity: [X] Occasional[ ] Consistent[ ] Consistent at a more severe level 3. Muscle strength testing -------------------------- Rate strength according to the following scale: 0/5 No muscle movement 1/5 Visible muscle movement, but no joint movement 2/5 No movement against gravity 3/5 No movement against resistance 4/5 Less than normal strength 5/5 Normal strength Shoulder abduction (Group III) Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Elbow flexion (Group V) Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Elbow extension (Group VI) Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Wrist flexion (Group VII) Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Wrist extension (Group VIII) Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Hip flexion (Group XVI) Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Knee flexion (Group XIII) Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Knee extension (Group XIV) Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle plantar flexion (Group XI) Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Ankle dorsiflexion (Group XII) Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 If other movements/muscle groups were tested, specify: THORACIC MUSCLE GROUPS. Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5 Does the Veteran have muscle atrophy? [ ] Yes[X] No SECTION V: OTHER ---------------- 1. Assistive devices -------------------- a. Does the Veteran use any assistive devices as a normal mode of locomotion, although occasional locomotion by other methods may be possible? [ ] Yes[X] No 2. Remaining effective function of the extremities -------------------------------------------------- Due to the Veteran's muscle conditions, is there functional impairment of an extremity such that no effective function remains other than that which would be equally well served by an amputation with prosthesis? (Functions of the upper extremity include grasping, manipulation, etc., while functions for the lower extremity include balance and propulsion, etc.) [ ] Yes, functioning is so diminished that amputation with prosthesis would equally serve the Veteran. [X] No 3. Other pertinent physical findings, complications, conditions, signs and/or symptoms ---------------------------------------------------------------------- Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms? [ ] Yes[X] No 4. Diagnostic Testing --------------------- a. Have imaging studies been performed and are the results available? [X] Yes[ ] No b. Is there x-ray evidence of retained metallic fragments (such as shell fragments or shrapnel) in any muscle group? [ ] Yes[X] No c. Were electrodiagnostic tests done? [ ] Yes[X] No d. Are there any other significant diagnostic test findings and/or results? [X] Yes[ ] No If yes, provide type of test or procedure, date and results (brief summary): Exam Date/Time 09/03/2014 Procedure Name CHEST 2 VIEWS, FRONTAL & LATERAL Impression No active lung disease. Report Cardiomediastinal silhouette is normal in size, shape and position. The lungs are clear bilaterally with sharp costophrenic angles and posterior recesses. The osseous structures and soft tissues are intact. 5. Functional impact -------------------- Does the Veteran's muscle injury(ies) impact his or her ability to work, such as resulting in inability to keep up with work requirements due to muscle injury(ies)? [ ] Yes[X] No 6. Remarks, if any: ------------------- THERE IS NO TENDERNESS AT SITE WHICH PATIENT MENTIONED HE HAD CLOSED RIB FRACTURE. THERE IS NO EVIDENCE OF OTHER RESIDUALS ON CURRENT EXAM. **************************************************************************** Headaches (including Migraine Headaches) Disability Benefits Questionnaire Indicate method used to obtain medical information to complete this document: [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file reviewed? [ ] Yes [X] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: If no, check all records reviewed: [ ] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [ ] Military separation examination [ ] Military post-deployment questionnaire [ ] Department of Defense Form 214 Separation Documents [X] Veterans Health Administration medical records (VA treatment records) [ ] Civilian medical records [ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service) [ ] No records were reviewed [X] Other: E-FOLDER ON VBMS. 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with a headache condition? [X] Yes [ ] No [X] Migraine including migraine variants Date of diagnosis: S/C 2. Medical History ------------------ a. Describe the history (including onset and course) of the Veteran's headache conditions (brief summary): THIS EXAM IS FOR CURRENT STATUS OF S/C HEADACHE DUE TO TBI. PATIENT SAYS HE GETS MILD CONSTANT HEADACHE IN BACK AND OCCASIONALLY GETS LEFT SIDE HEADACHE 4-5 TIMES A WEEK WHICH IS MILD TO MODERATE AND LAST FOR ABOUT AN AN HOUR AND SUBSIDE AFTER REST OR MEDICINE. b. Does the Veteran's treatment plan include taking medication for thediagnosed condition? [X] Yes [ ] No If yes, describe treatment (list only those medications used for the diagnosed condition): GABAPENTIN 600 MG PO TID 3. Symptoms ----------- a. Does the Veteran experience headache pain? [X] Yes [ ] No [X] Constant head pain [X] Pain localized to one side of the head b. Does the Veteran experience non-headache symptoms associated with headaches? (including symptoms associated with an aura prior to headache pain) [X] Yes [ ] No [X] Nausea [X] Sensitivity to light [X] Sensitivity to sound c. Indicate duration of typical head pain [X] Less than 1 day d. Indicate location of typical head pain [X] Left side of head 4. Prostrating attacks of headache pain --------------------------------------- a. Migraine / Non-Migraine- Does the Veteran have characteristic prostrating attacks of migraine / non-migraine headache pain? [ ] Yes [X] No 5. Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------------- a. Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above? [ ] Yes [X] No b. Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any conditions listed in the Diagnosis section above? [ ] Yes [X] No 6. Diagnostic testing --------------------- Are there any other significant diagnostic test findings and/or results? [X] Yes [ ] No If yes, provide type of test or procedure, date and results (brief summary): 9/23/2014 Unremarkable MRI of the brain. 7. Functional impact -------------------- Does the Veteran's headache condition impact his or her ability to work? [ ] Yes [X] No 8. Remarks, if any: ------------------- No remarks provided. **************************************************************************** Review Evaluation of Residuals of Traumatic Brain Injury (R-TBI) Disability Benefits Questionnaire * Internal VA or DoD Use Only* Indicate method used to obtain medical information to complete this document: [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes[X] No If no, check all records reviewed: [X] Veterans Health Administration medical records (VA treatment records) [X] Other: E-FOLDER ON VBMS. SECTION I: Diagnosis and medical history ---------------------------------------- 1. Diagnosis ------------ Does the Veteran now have or has he/she ever had a traumatic brain injury (TBI) or any residuals of a TBI? [X] Yes [ ] No [X] Traumatic brain injury (TBI) Date of diagnosis: S/C 2. Medical history ------------------ Describe the history (including onset and course) of the Veteran's TBI and residuals attributable to TBI (brief summary): THIS EXAM IS FOR CURRENT STATUS OF S/C TBI. PATIENT SAYS SINCE ABOUT AND YEAR GETTING DIZZINESS AND THINKS IT IS DUE TO TBI. SECTION II: Assessment of facets of TBI-related cognitive impairment and subjective symptoms of TBI ----------------------------------------------------------------------------- 1. Memory, attention, concentration, executive functions -------------------------------------------------------- [X] A complaint of mild memory loss (such as having difficulty following a conversation, recalling recent conversations, remembering names of new acquaintances, or finding words, or often misplacing items), attention, concentration, or executive functions, but without objective evidence on testing If the Veteran has complaints of impairment of memory, attention, concentration or executive functions, describe (brief summary): OCCASINALLY FORGETFULLNESS 2. Judgment ----------- [X] Normal 3. Social interaction --------------------- [X] Social interaction is routinely appropriate 4. Orientation -------------- [X] Always oriented to person, time, place, and situation 5. Motor activity (with intact motor and sensory system) -------------------------------------------------------- [X] Motor activity normal 6. Visual spatial orientation ----------------------------- [X] Normal 7. Subjective symptoms ---------------------- [X] Subjective symptoms that do not interfere with work; instrumental activities of daily living; or work, family or other close relationships. Examples are: mild or occasional headaches, mild anxiety If the Veteran has subjective symptoms, describe (brief summary): MILD HEADACHE, SUBJECTIVE DIZZINESS 8. Neurobehavioral effects -------------------------- [X] No neurobehavioral effects 9. Communication ---------------- [X] Able to communicate by spoken and written language (expressive communication) and to comprehend spoken and written language. 10. Consciousness ----------------- [X] Normal SECTION III: Additional residuals, other findings, diagnostic testing, functional impact and remarks ----------------------------------------------------------------------------- 1. Residuals ------------ Does the Veteran have any subjective symptoms or any mental, physical or neurological conditions or residuals attributable to a TBI (such as migraine headaches or Meniere's disease)? [X] Yes [ ] No 2. Other pertinent physical findings, scars, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------------- No answer provided. 3. Diagnostic testing --------------------- a. Has neuropsychological testing been performed? [ ] Yes [ ] No b. Have diagnostic imaging studies or other diagnostic procedures been performed? [ ] Yes [ ] No c. Has laboratory testing been performed? [ ] Yes [ ] No d. Are there any other significant diagnostic test findings and/or results? [ ] Yes [ ] No 4. Functional impact -------------------- No answer provided. 5. Remarks, if any: ------------------- No remarks provided. **************************************************************************** Ear Conditions (including Vestibular and Infectious Conditions) Disability Benefits Questionnaire Indicate method used to obtain medical information to complete this document: In-person examination Evidence review ----------------- Was the Veteran's VA claims file (hard copy paper C-file) reviewed: No Check all records reviewed: [X] Veterans Health Administration medical records (VA treatment records) [X] Other: E-FOLDER ON VBMS. 1. Diagnosis ------------ Does the Veteran now have or has he/she ever been diagnosed with an ear or peripheral vestibular condition? Yes Other diagnosis #1: SUBJECTIVE DIZZINESS/ VERTIGO BY HISTORY. Date of diagnosis: 2014 2. Medical history ------------------ Description of the history (including onset and course) of the Veteran's ear or peripheral vestibular condition: PATIENT SAYS HE STARTED GETTING DIZZINESS MANY TIME AGO BUT WENT TO DOCTOR FEW MONTHS AGO. SEEN PRIVATE ENT AND HE GAVE SOME MEDICINE. DIZZINESS IS INTERMITTENT LASTS FOR FEW MINUTES AND TAKES REST. NOT ALWAYS WITH HEADACHES. DURING ATTACK FEELS HE IS SPINNING AND MAY LOSE BALANCE. Does the Veteran's treatment plan include taking continuous medication for the diagnosed condition: Yes Medications used for the diagnosed condition: DON'T NO THE NAME BUT GIVEN BY PRIVATE ENT DOCTOR. 3. Vestibular conditions ------------------------ Does the Veteran have any of the following findings, signs or symptoms attributable to Meniere's syndrome (endolymphatic hydrops), a peripheral vestibular condition or another diagnosed condition from Section 1: No 4. Infectious, inflammatory and other ear conditions ---------------------------------------------------- Does the Veteran have any of the following findings, signs or symptoms attributable to chronic ear infection, inflammation, cholesteatoma or any of the diagnoses in Section 1: No 5. Surgical treatment --------------------- Has the Veteran had surgical treatment for any ear condition: No Does the Veteran have any residuals as a result of the surgery: No 6. Physical exam ---------------- External ear: Normal Ear canal: Normal Tympanic membrane: Normal Gait: Normal Romberg test: Normal or negative Dix Hallpike test (Nylen-Barany test) for vertigo: Normal, no vertigo or nystagmus during test Limb coordination test (finger-nose-finger): Normal 7. Tumors and neoplasms ----------------------- Does the Veteran have a benign or malignant neoplasm or metastases related to any of the diagnoses in the Diagnosis section: No 8. Other pertinent physical findings, complications, conditions, signs and/or symptoms ----------------------------------------------------------------------------- Does the Veteran have any scars (surgical or otherwise) related to any conditions or to the treatment of any conditions listed in the Diagnosis section above: No Does the Veteran have any other pertinent physical findings, complications, conditions, signs and/or symptoms related to any conditions in the Diagnosis section above: No 9. Diagnostic testing --------------------- Have diagnostic imaging studies or other diagnostic procedures been performed: Yes Magnetic resonance imaging (MRI) Date: 9/23/2014 Results: Unremarkable MRI of the brain. Has the Veteran had an audiogram: No Are there any other significant diagnostic test findings and/or results: No 10. Functional impact --------------------- Do any of the Veteran's ear or peripheral vestibular conditions impact his or her ability to work? No 11. Remarks, if any: No response provided --------------------- NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's application. **************************************************************************** Medical Opinion Disability Benefits Questionnaire Indicate method used to obtain medical information to complete this document: [ ] Review of available records (without in-person or video telehealth examination) using the Acceptable Clinical Evidence (ACE) process because the existing medical evidence provided sufficient information on which to prepare the DBQ and such an examination will likely provide no additional relevant evidence. [ ] Review of available records in conjunction with a telephone interview with the Veteran (without in-person or telehealth examination) using the ACE process because the existing medical evidence supplemented with a telephone interview provided sufficient information on which to prepare the DBQ and such an examination would likely provide no additional relevant evidence. [ ] Examination via approved video telehealth [X] In-person examination Evidence review --------------- Was the Veteran's VA claims file reviewed? No If no, check all records reviewed: [X] Veterans Health Administration medical records (VA treatment records) [X] Other: E-FOLDER ON VBMS. MEDICAL OPINION SUMMARY ----------------------- RESTATEMENT OF REQUESTED OPINION: a. Opinion from general remarks: CLAIMS FILE BEING SENT FOR REVIEW BY THE EXAMINER. **All evidence needed for review is available electronically through VBMS** The Veteran has filed a fully developed claim. Please expedite. Date of claim: 09/29/2014 Days pending: 22 Veteran has a power of attorney. Please send a courtesy copy of the exam notice letter to PARALYZED VETERANS OF AMERICA, INC. The Veteran will need to report for the following exam(s): DBQ NEURO TBI Review DBQ MUSC Muscle injuries ___________________________________________________________________________ DBQ MUSC Muscle injuries: Clinician: If using the ACE process to complete the DBQ, please explain the basis for the decision not to examine the Veteran, and identify the specific materials reviewed to complete the DBQ. Please review the Veteran's electronic folder in VBMS and state that it was reviewed in your report. The Veteran is service connected for residuals rib fracture which is currently evaluated at 0%. Please evaluate for the current level of severity of the Veteran's service connected disability. If the diagnosis rendered is different from the disability for which the Veteran is service connected, please indicate whether the Veteran's current diagnosis is a progression of the service connected disability or the original diagnosis was in error. *************************************************************************** DBQ NEURO TBI Review: Clinician: If using the ACE process to complete the DBQ, please explain the basis for the decision not to examine the Veteran, and identify the specific materials reviewed to complete the DBQ. Please review the Veteran's electronic folder in VBMS and state that it was reviewed in your report. ***The Veteran is service connected for traumatic brain injury with subjective memory impairment and headaches which is currently evaluated at 10%. Please evaluate for the current level of severity of the Veteran's service connected disability. If the diagnosis rendered is different from the disability for which the Veteran is service connected, please indicate whether the Veteran's current diagnosis is a progression of the service connected disability or the original diagnosis was in error. If the Veteran has a co-existing psychiatric condition, please state, to the extent possible, which emotional/behavioral signs and symptoms are part of a co-morbid mental disorder and which represent residuals of TBI. If it is impossible to make such a determination without speculation, please state so. *** The Veteran is claiming that his dizziness was proximately due to or the result of his service connected traumatic brain injury with subjective memory impairment and headaches. Opinion Requested: Is the Veteran's dizziness at least as likely as not (50 percent or greater probability) proximately due to or the result of his service connected traumatic brain injury with subjective memory impairment and headaches. Rationale must be provided in the appropriate section below. Your review is not limited to the evidence identified on this request form, or tabbed in the claims folder. If an examination or additional testing is required, obtain them prior to rendering your opinion. If not caused, but aggravated by service, please provide the following information: " The baseline manifestations of the aggravation which are due to the effects of the disease or injury. " The increased manifestations which, in your opinion, are proximately due to the service connected disability based on medical considerations. " The medical considerations supporting an opinion, that increased manifestations of a non-service connected disease or injury are proximately due to the service connected disability. =========================================== b. Indicate type of exam for which opinion has been requested: DIZZINESS/VERTIGO TYPE OF MEDICAL OPINION PROVIDED: [ MEDICAL OPINION FOR DIRECT SERVICE CONNECTION ] b. The condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. c. Rationale: AFTER REVIEWING E-FOLDER, VA TREATMENT RECORDS PATIENT COMPLAINED HAVING DIZZINESS/VERTIGO IN 2014 THAT IS SIX YEARS AFTER INSIDENT OF MILD TBI. THESE LONG TIME DELAY BETWEEN TBI INSIDENT AND SYMPTOMS ARE NOT CONSISTENT WITH PATTERN OF MILD TBI.

I really appreciate all the advice that I'm getting from everybody. Navywife, I filed for TBI increase and asked for dizziness to be added as secondary to TBI. Why I did this? Everytime I go to the VA hospital to complain about my dizziness or headaches or anything else, they will tell me it's all related to my TBI and I have to learn how to adapt to this new me. So I thought if TBI is causing all this mess why I'm rated at 10% only. That's what made do this, but like I said this examiner said i didn't complain from dizziness before, why I'm doing it now. The simple answer would be, because I have menier's but then if he already decided something even before seeing me then it would be hard to change even with evidence like the note from ENT specialist. I also don't think he was trying to test my reaction because from all these medication that I'm taking it's so hard to get a reaction from me. God bless you all and thanx again

I think the doctor was contracted by the VA. The reason that makes me think that I can't reopen this or appeal it, is because this guy was a doctor and as I know doctors wont contradict other doctors opinion (although this guy did). He said that since my discharge in 2008 I never mentioned anyhting about dizziness but now I'm having all these symptoms. That's not true because in 2009 while I was still in active duty I saw a doctor for my vertigo. Before that in 2006 I complained from vestibular tube dysfunction and it's mentioned in military record which I gave to him, and as he did with everything else gave it back to me. I'm thinking about asking the ENT specialist and the neurologist to fill a DBQ for me for menier's and migraine, hopefully both will agree. Will this help??