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MKAH
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Posts posted by MKAH
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43 minutes ago, GBArmy said:
You are already getting comp for tinnitus and hearing, so Diagnostic code 6205, in addition to those, a rating for peripheral vestibular disorder (DC 6204) is still on the table. Occasional dizziness is rated at 10%.Your VA doc wants to connect it as a symptom of tinnitus. Since you already have the disability, no additional rating (pyramiding). You need a good IMO from a hearing specialist that says it is separate from tinnitus and attributable to PVD. You don't have headaches with all this going on? If you do, that would be rated separately also. As for TDIU, it might be easier to obtain, and the lawyers may want to go that route, but if you can get by scheduler, it still may be preferable. You can go for the TDIU if it doesn't work out, but you'll not be able to work. I'm hoping, and you are too, that someday you may improve enough to go back to gainful employment. Just trying to point out options for you.
Thanks GBArmy
Thank you again for all the great advice. I'll keep everyone up to date on any changes or updates.
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2 hours ago, GBArmy said:
MKAH Hey brother, if you are actually at 94 rounded down to 90%, I would try really, really hard to find one more disability. Just one more 10% might push you to 95 therefore 100 scheduler. Obviously much better , and you could still work no problem. Google your disabilities and find out if you may have symptoms that might result in a secondary. For example, GERD can be secondary to many meds taken to help with PTSD. Look up the symptoms of GERD and see if you have any issues with swallowing, acid reflux, etc. See https://cck-law.com/blog/va-disability-benefits-for-gerd/ (diagnostic code 7346). This is just an example. Maybe you have something else you can connect secondary. Note that you need the symptoms current diagnosis, the med has to be on record for causing the distress, AND you have a nexus from a doc that says it caused your GERD. I'd go this route first before the TDIU path.
The only thing that I feel might be possible is i have a sever balance (vertigo) problem. The VA treated me for Menieres Disease, however I still suffer from daily imbalance which has been well documented in my VA health record.
The C&P physician that performed my migraine claim, commented to me that she was entering a notation that she thought my vertigo was a result of my Tinnitus. In a few more weeks, me and my attorney I will see the Migraine C&P and determine if this information is sufficient to move forward with a new claim for vertigo, or file for TDUI un employability for combined 10% tinnitus, 50% hearing loss and 50% migraines. As I mentioned before, I have not been able to work due to my SC disabilities since 3 Jan 2016. -
6 hours ago, Hucast21 said:
Congrats!
May I ask how long did it take you from BVA hearing (if you had one) to decision?
Hi Hucast21,
See the timeline below for the Migraine claim.
Looks roughly like:
6 months for the claim to first denial
10 months for the denial SOC on the NOD
6 months for BVA approval
10 months for the RO to perform a C&P
3 weeks for RO to rate disability and send me notification via E-Benefits.I called the VA "Peggy" on the 800 number. She said from her view, I will be receiving multiple retro payments, but they are still in the approval process.
My PTSD claim has been ongoing since 11/14/15. I have received a C&P via a remand from the BVA for the PTSD (see below link). However, I am still waiting for the RO to determine service connection or not.
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VA sent you a claim decision
on July 12, 2018 -
VA received your Notice of Disagreement
on July 30, 2018 -
VA sent you a Statement of the Case
on May 28, 2019 -
VA received your Form 9
on June 14, 2019 -
Your appeal was sent to the Board of Veterans’ Appeals
on July 20, 2019 -
Board of Veterans’ Appeals made a decision
on January 09, 2020
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2 hours ago, 63Charlie said:
Congrats.
If you aren't currently working due to your service connected disabilities, and have not previously filed for TDIU, you may want to consider filing immediately a VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability.
Thanks for the reply 63Charlie,
On Monday, I will be calling my attorney (Woods & Woods) to discuss this. I have not worked since 3 Jan 2016 due to my SC disabilities. We will likely file the 21-8940 ASAP as my remaining claim for PTSD, if determined to be SC, would be rated at 70% best case scenario. This combination would bring me to SC of 94% rounded down to 90%.
Thank you for the Form number.
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4 hours ago, pacmanx1 said:
Congratulations!
Don't you love when a plan come together?
Hopefully that PTSD claim will push you closer to that 100% rating scheduler or TDIU.
Sorry that you are going through what you are going through.
Try to keep some of the retro for rainy days, you never know what will happen.
Thank you very much.
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25 minutes ago, GBArmy said:
MKAH Conrats! That's super. Yes; it can take a while to get your back pay. The higher amounts take more time because more hoops in the signature circuit. And each one is a little different, but sometimes it is in a couple of spaced out deposits. If you get a big chunk of $ like that; pay some bills and just sit on it a while. It is a lot easier to spend it than to get it.
Thanks for the reply GBArmy,
I was surprised that VA.gov shows nothing regarding this specific claim for Migraines (a BVA grant, ordering a C&P which happened about 2.5 weeks ago and the RO rating happening today)?
My last claim pending is PTSD. A remand by the BVA for a C&P (which occurred about six months). The RO must still be working on (waiting to get to it) to determine service connection or not, then possible rating.
Thank you for the kind words
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Hello everyone,
Today I was on Ebenifits and saw that my Migraine claim had updated to 50%, bringing me up to 80% total. VA.gov shows no information on this claim..?
I did some quick math and backpay will be about 22,068, less 500 for doctor exam and letter, and 4,413 for my attorney = 17,154.
Anyway, I have not seen a direct deposit so I presume that large amounts take a little longer to process?
********************************************************************************************************************************
Total Combined DisabilityYou have a 80% final degree of disability. This percentage determines the amount of benefit pay you will receive.
Add Disabilities
Submit a claim to make any updates to the disabilities that you believe are related to your military service.
Rated Disabilities
Disability Rating Decision Related To Effective Date tinnitus 10% Service Connected 03/08/2011 migraines (previously addressed as headaches)
50% Service Connected 08/01/2017 bilateral hearing loss 50% Service Connected 02/11/2016 -
On 6/1/2019 at 4:35 AM, broncovet said:
I suggest you think of it as a "5 to 10 year" commitment, not unlike that of marriage
The marriage reference is funny but true
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UPDATE:
A few months ago I received a BVA decision; “Entitlement for headaches, to include as secondary to service-connected tinnitus, is granted. Resolving all reasonable doubt, in favor of the veteran, the evidence is at least in equipoise that the veteran’s headaches are caused or aggravated by his service-connected tinnitus.”
Sine this BVA notification letter, I have been patiently waiting for the RO to rate the service connection. Today (3/28/2020) I received a phone call from a company that schedules C&P exams for the VA. She confirmed that they were conducting a C&P for the SC headaches grant and will be using a contractor. She also said the C&P will likely be performed within the next 60 days or sooner.
Anyway, finally to my question:
Since I have severe headaches so frequently, I have found it difficult to keep a journal or record of them as I have seen mentioned in the HADIT forums for some time now.
A few years ago, I did have write a spreadsheet spanning about three weeks, which contained dates, times, diet, activity, severity and length of vertigo which included headaches.
#1) Is it too late to start tracking them starting now, so I can provide the C&P doctor / examiner with the most recent information?
#2) Should I also provide the C&P examiner the vertigo / headache tracking form, even though its several years old?
I just want to have what is needed so that the C&P doctor / examiner does not have to guess or me trying to describe from memory.
Thank You
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I am curious if RO operations with the exception of walk in traffic, will remain active considering the recent Coronavirus polices? Eg; BVA appeal decision ratings, C&P reviews, etcetera.
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1 hour ago, pete992 said:
You should get a decision letter most likely before these sites are updated to inform/ask you if you want to continue your appeal
Hi Pete,
I did a letter from the BVA judge that ruled in favor of service connection (see below) . It's my understanding that my file is now back at the Regional Office to determine a percentage..if any?
This is the meat and potatoes of that specific decision:
These matters come before the Board of Veterans' Appeals (Board) on appeal from a July 2018 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO).
After the SOC was issued in May 2019, VA treatment records and a private DBQ and medical opinion pertinent to the Veteran's headache claim were associated with the claims file. However, as the claim of entitlement to service connection for headaches, to include as secondary to service-connected tinnitus, is being granted, and that is a full grant of the benefit sought on appeal as to that issue, the Board finds no prejudice with proceeding with the adjudication of that claim.Interestingly, the Regional office is also in possession of what seems to be a favorable C&P for PTSD, that was ordered by a BVA judge via remand. I'm wondering if the RO is looking at both the Headache & PTSD claims in conjunction with my current service connected hearing loss & tinnitus to determine a combined service connection percentage?
Thank you for your reply.
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Thanks Richard.
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Years ago I filed a BVA PTSD appeal which was update as follows:
Disability compensation appeal updated on June 4, 2019
Status: The Board made a decision on your appeal
Issue on appeal: Service connection, Post-traumatic stress disorder
Submitted on: September 20, 20160
View detailsIn the view details section, it was a C&P remand request.
On August 98th, 2019 the C&P was conducted and the exam information (DBQ or C&P ???) was sent to the local (Oakland California RO) for review. I expect another year or two before I hear anything.
My question is:
VA.gov still shows the claims as GREEN and not closed but a decision being made. Since Ebennie's shows nothing other than an AB8 letter showing not service connected from years ago, will VA.gov update or will Ebennies update with whatever decision is ultimately made from this point forward?Thank You
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I was reading the BVA decision and it contained this line. What specifically does " and that is a full grant of the benefit sought on appeal" mean?
If the entire BVA decisaion of needed, I can provided is?
THX
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
These matters come before the Board of Veterans' Appeals (Board) on appeal from a July 2018 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO).
After the SOC was issued in May 2019, VA treatment records and a private DBQ and medical opinion pertinent to the Veteran's headache claim were associated with the claims file. However, as the claim of entitlement to service connection for headaches, to include as secondary to service-connected tinnitus, is being granted, and that is a full grant of the benefit sought on appeal as to that issue, the Board finds no prejudice with proceeding with the adjudication of that claim.
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
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I got the printed BVA decision. The law Judge approved the service connection Tension Headaches as a secondary condition of Tinitus. The decision letter from the BVA contained lots of physician notes & detail which is very similar to what GBArmy pointed out regarding severity.
GBArmy's comment: "headaches 5 x week and have to lie down 5 X week. Migraines/headaches under diagnostic code 8100 states that migraines are rated on symptoms of frequency, severity and prostrating. You also say you have to lay down in a dark room due to the severity."
Anyway, the letter did not specify a rating or start date, so I reached out to my VA attorney which is handling my case. Woods & Woods, They said the BVA has sent the Judges Grant to the Oakland RO and they will rate it and determine a start date. She said the current BVA approved appeals rating time, is about 120 days and I will likely see a deposit before a notification of increase (if any).
Is it just me, or does this process seem somewhat convoluted and inefficient?
Anyway, I am genuinely grateful to be closer to the end of this process.
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41 minutes ago, GBArmy said:
MKHA I am not a medical expert by any means. But your argument is that you have headaches 5 x week and have to lie down 5 X week. Migraines/headaches under diagnostic code 8100 states that migraines are rated on symptoms of frequency, severity and prostrating. You also say you have to lay down in a dark room due to the severity. Your history meets a level for 50% IMO. Expect a low-ball rating, even on appeal is what I would think the VA will try. For your sake, I hope i'm wrong. But they don't like to give out 50% ratings.
Thank You for your opinion GBArmy. I'll let you know how it turns out.
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GB Army,
Here is a redacted version of the brief my attorney submitted to the BVA for the appeal for headaches.
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UPDATE:
My appeal for PTSD also included an appeal for Migraines / Sleep Apnea
This morning on Vets.gov I see the following (I highlighted the most interesting parts):
"See past eventsJuly 12, 2018 – January 09, 2020Current statusThe Board made a decision on your appealThe Board of Veterans’ Appeals sent you a decision on your appeal. Here’s an overview:GrantedThe judge granted the following issue:Service connection, MigrainesIf this decision changes your disability rating or your eligibility for VA benefits, you should see this change made in 1 to 2 months.DeniedThe judge denied the following issue:Service connection, Sleep apneaPlease see your decision for more details.This appeal is now closed--------------------------------------------------------------------------------------------------------------------------------------------------However, I looked at my rating in Eebenefits and it does not appear to have been updated yet (see below).
-----------------------------------------------------------------------------------------------------------------------------------------------------Disability Rating Decision Related To Effective Date tinnitus 10% Service Connected 03/08/2011 bilateral hearing loss 50% Service Connected 02/11/2016 headaches Not Service Connected post traumatic stress disorder (PTSD) Not Service Connected PTSD - Personal Trauma
sleep condition Not Service Connected I guess I'll have to wait for a while to get the letter in the mail?
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On 11/4/2019 at 5:04 PM, GBArmy said:
... Since you are already at 60%, you will be rated higher, but if not enough to get you scheduler to 100% you can request TDIU for a 100% if they don't do it automatically. ...
Hi GBArmy,
After reading your post again, I just noticed that in my profile information I had not specified my 60% total Service Connection as: 10% Tinnitus & 50% Bilateral Hearing loss. I have now corrected that in my Profile/Interest section.
I have read the VA requirements for TDIU and am still a bit unclear on the single vs multiple percentages required to meet the policy. Based on the above line item description of my combined SC's, is TDIU still possible?
Thank You
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Thanks for the replies, I found the setting at this location:
Click on your username drop down control:
navigate to "account settings" located at the link below:
https://community.hadit.com/settings/
then navigate to the right middle of the screen and look for "Edit Profile":
Other Settings
then select Edit Profile
Boom!
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Hi everyone. I was looking over my account today and noticed a number of -My Attachments- files. I can't figure out how to delete them?
Years ago I added some photos of myself and wife that I would like to remove if possible?
Thanks in advance
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Hello everyone,
Thank you for all the replies. I thought I would answer a question which is not included in the original information I provided.
a. About two months after filing my claim, back in late 2015 I was weened off of narcotics & alcohol with Naltrexon and put on traditional mental health medications. Since then I have not been able to, and have not worked at all. My social security earnings statement since 2015, confirms zero earnings.
(It's shameful for me to admit, but narcotics and booze allowed me to get out and at least hold down a job. However, at the direction and insistence of VA mental health staff, I completely stopped all narcotic drugs and was RX'd every conceivable psychiatric medication. Unfortunately, I now have great difficulty in any public place. The Rx meds just don't work that well for me).Thank you again for all your replies
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I am completely at a loss as to what it all means and just want it all to end. The more interesting parts I highlighted with BOLD text, to make reading easier.
I am currently 60% SC with hearing loss/tinutus.Any insight would be great.
Thank You
***************** see below *****************
Medical Opinion
Disability Benefits Questionnaire
LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX): SOCIAL SECURITY
NUMBER/FILE NUMBER:TODAY’S DATE:
MARK XXXXX XXX-XX-XXXX 08/09/2019
HOME ADDRESS: EXAMINING LOCATION AND ADDRESS:
XXXXXXXXXXX
Redding, CA 96001VES
HOME TELEPHONE:
XXXXXXXXXX
CONTRACTOR: VES NUMBER: VA CLAIM NUMBER:
VES 22619376754
IMPORTANT - THE DEPARTMENT OF VETERANS AFFAIRS (VA) WILL NOT PAY OR REIMBURSE ANY EXPENSES OR
COST INCURRED IN THE PROCESS OF COMPLETING AND/OR SUBMITTING THIS FORM. PLEASE READ THE
PRIVACY ACT AND RESPONDENT BURDEN INFORMATION ON REVERSE BEFORE COMPLETING FORM.
NOTE TO PHYSICIAN - The Veteran is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will
consider the information you provide on this questionnaire as part of their evaluation in processing the Veteran’s claim.
For the Claimed Compensation Condition of - ACQUIRED PSYCHIATRIC DISORDER TO INCLUDE MAJOR
DEPRESSIVE DISORDER AND OBSESSIVE COMPULSIVE DISORDER
ACCEPTABLE CLINICAL EVIDENCE (ACE)
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
[] Not requested [] No records were reviewed
[] VA claims file (hard copy paper C-file)
[X] VA e-folder (VBMS or Virtual VA)
[] CPRS
[] Other (please identify other evidence reviewed):
Evidence comments:
The veteran's file was reviewed.
STATEMENT OF VETERAN RECEIPT DATE 1/26/16
BVA DECISION RECEIPT DATE 6/4/19- (REMAND ORDER)
VAMC TX RECS RECEIPT DATE 5/28/19Medical Opinion Name: MARK XXXXXXX
Disability Benefits Questionnaire VA Claim Number:Page 2 of 5 Contractor: VES
SERVICE TREATMENT RECORDS RECEIPT DATE 2/22/16
SERVICE TREATMENT RECORDS RECEIPT DATE 3/25/11
STRESSOR STATEMENT RECEIPT DATE 3/10/16
PERSONNEL RECS RECEIPT DATE 2/22/16
PERSONNEL RECS RECEIPT DATE 2/22/16
BUDDY STATEMENTS WITH RECEIPT DATES, 2/28/19, 12/27/16, 12/19/16, 6/20/16, 6/6/16, 5/9/16, 1/26/16, 3/24/11, 3/10/11,
3/3/11
SECTION I - DEFINITIONS
Aggravation of preexisting nonservice-connected disabilities. A preexisting injury or disease will be considered to have been
aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a
specific finding that the increase in disability is due to the natural progress of the disease.
Aggravation of nonservice-connected disabilities. Any increase in severity of a nonservice-connected disease or injury that isproximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-
connected disease, will be service connected.SECTION II – RESTATEMENT OF REQUESTED OPINION
2A. Insert requested opinion from general remarks:
THE EXAMINER IS ADVISED THAT THE VETERAN IS COMPETENT TO ATTEST TO OBSERVABLE SYMPTOMS. IF
THERE IS A MEDICAL BASIS TO SUPPORT OR DOUBT THE VETERANS REPORTS OF SYMPTOMATOLOGY, THE
EXAMINER SHOULD PROVIDE A FULLY REASONED EXPLANATION.
PLEASE NOTE THIS IMO IS TO ACKNOWLEDGE THAT RECORDS HAVE BEEN REVIEWED AS WELL AS
ADDRESSING ANY ADDITIONAL QUESTIONS NOTED AT THE BOTTOM OF THE DBQ.
POTENTIALLY RELEVANT EVIDENCE:
STATEMENT OF VETERAN RECEIPT DATE 1/26/16
BVA DECISION RECEIPT DATE 6/4/19- (REMAND ORDER)
VAMC TX RECS RECEIPT DATE 5/28/19
SERVICE TREATMENT RECORDS RECEIPT DATE 2/22/16
SERVICE TREATMENT RECORDS RECEIPT DATE 3/25/11
STRESSOR STATEMENT RECEIPT DATE 3/10/16
PERSONNEL RECS RECEIPT DATE 2/22/16
PERSONNEL RECS RECEIPT DATE 2/22/16
BUDDY STATEMENTS WITH RECEIPT DATES, 2/28/19, 12/27/16, 12/19/16, 6/20/16, 6/6/16, 5/9/16, 1/26/16, 3/24/11, 3/10/11,
3/3/11
2B. Indicate type of exam for which opinion has been requested (e.g. skin diseases):
Mental Disorder DBQ
SECTION III – MEDICAL OPINION FOR DIRECT SERVICE
CONNECTION
Choose the statement that most closely approximates the etiology of the claimed condition.3A. [] The claimed condition was at least as likely as not (50 percent or greater probability) incurred in or caused by the claimed in-
service injury, event, or illness.Provide rationale in section c.
3B. [] The claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service
injury, event, or illness.
Provide rationale in section c.
3C. Rationale:Medical Opinion Name: MARK ******
Disability Benefits Questionnaire VA Claim Number:Page 3 of 5 Contractor: VES
SECTION IV - MEDICAL OPINION FOR SECONDARY SERVICE
CONNECTION
4A. [] The claimed condition is at least as likely as not (50 percent or greater probability) proximately due to or the result of the
Veteran’s service connected condition.
Provide rationale in section c.
4B. [] The claimed condition is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran’s
service connected condition.
Provide rationale in section c.
4C. Rationale:
SECTION V - MEDICAL OPINION FOR AGGRAVATION OF A
CONDITION THAT EXISTED PRIOR TO SERVICE
5A. [] The claimed condition, which clearly and unmistakably existed prior to service, was aggravated beyond its natural progression
by an in-service injury, event, or illness.
Provide rationale in section c.
5B. [] The claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated
beyond its natural progression by an in-service injury, event, or illness.
Provide rationale in section c.
5C. Rationale:
SECTION VI - MEDICAL OPINION FOR AGGRAVATION OF A
NONSERVICE CONNECTED CONDITION BY A SERVICE CONNECTED
CONDITION
6A. Can you determine a baseline level of severity of (claimed condition/diagnosis) based upon medical evidence available prior to
aggravation or the earliest medical evidence following aggravation by (service connected condition)?
[] Yes [] No
If “Yes” to question 6A, answer the following:
I. Describe the baseline level of severity of (claimed condition/diagnosis) based upon medical evidence available prior to
aggravation or the earliest medical evidence following aggravation by (service connected condition):
II. Provide the date and nature of the medical evidence used to provide the baseline:
III. Is the current severity of the (claimed condition/diagnosis) greater than the baseline?
[] Yes [] No
If yes, was the Veteran’s (claimed condition/diagnosis) at least as likely as not aggravated beyond its natural progression by
(insert “service connected condition”)?
[] Yes (provide rationale in section 6B.)
[] No (provide rationale in section 6B.)
If “No” to question 6A, answer the following:Medical Opinion Name: MARK ******
Disability Benefits Questionnaire VA Claim Number:Page 4 of 5 Contractor: VES
I. Provide rationale as to why a baseline cannot be established (e.g. medical evidence is not sufficient to support a determination of
baseline level of severity):
II. Regardless of an established baseline, was the Veteran’s (claimed condition/diagnosis) at least as likely as not aggravated beyond
its natural progression by (insert “service connected condition”)?
[] Yes (provide rationale in section 6B.)
[] No (provide rationale in section 6B.)
6B. Provide rationale:
SECTION VII - OPINION REGARDING CONFLICTING MEDICAL
EVIDENCE
7. I have reviewed the conflicting medical evidence and am providing the following opinion:
Is there a need for the Veteran to follow up with his/her primary care provider regarding any life threatening findings in this
examination (not limited to claimed condition(s))?
[] Yes [X] No
Additional Question 1: PLEASE PROVIDE AN OPINION AS TO WHETHER IT IS AT LEAST AS LIKELY AS NOT (50
PERCENT OR GREATER PROBABILITY) THAT THE VETERANS MAJOR DEPRESSIVE
DISORDER AND OBSESSIVE COMPULSIVE DISORDER WERE INCURRED DURING, CAUSED
BY OR ARE OTHERWISE RELATED TO HIS ACTIVE SERVICE.Answer Question 1: It is at least as likely as not (50 percent or greater probability) that the veterans major depressive disorder
and obsessive compulsive disorder were incurred during, caused by or are otherwise related to his active
service.Additional Question 2: PLEASE PROVIDE YOUR MEDICAL RATIONALE.
Answer Question 2: The veteran had no prior history of mental health issues before serving in the military. He reported learning
the value of routine and ritual while serving and reported this seemed to become maladaptive in response to
stress. He reported becoming very depressed after leaving the service and being unable to pursue a career
in medicine. He appears to have developed Obsessive Compulsive Disorder and Major Depressive
Disorder in response to an in-service stressor (MST.) Though there are not apparently sufficient markers to
support a claim for PTSD due to MST, the evidence in the record and presented by the veteran appear
sufficient to this examiner to conclude that a serious stressor occurred during his service in Germany. This
stressor appears to be the proximate cause of his subsequent Major Depressive Disorder and Obsessive
Compulsive Disorder. The Obsessive Compulsive Disorder appears to have developed as a way to maintain
control and ensure that he could not be victimized again and the Major Depressive Disorder developed
when his experience prevented him pursuing further education.SECTION VIII - PHYSICIAN'S CERTIFICATION AND SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.8A. PHYSICIAN’S SIGNATURE:
8B. PHYSICIAN’S PRINTED NAME: JAMIE L. XXXXXXX, PsyDMedical Opinion Name: MARK *******
Disability Benefits Questionnaire VA Claim Number:
Page 5 of 5 Contractor: VESMental Disorders (other than PTSD and Eating Disorders) – DSM V
Disability Benefits Questionnaire
LAST NAME, FIRST NAME, MIDDLE NAME (SUFFIX): SOCIAL SECURITY NUMBER: TODAY’S DATE:
MARK XXXXXX XXX-XX-XXXX 08/09/2019
HOME ADDRESS: EXAMINING LOCATION AND ADDRESS:
XXXXXXXXXXXXXXX,
Redding, CA 96001VES
HOME TELEPHONE:
XXX-XXX-XXXX
CONTRACTOR: VES NUMBER: VA CLAIM NUMBER:
VES 22619376754
Your patient is applying to the U.S. Department of Veterans Affairs (VA) for disability benefits. VA will consider the information
you provide on this questionnaire as part of their evaluation in processing the Veteran’s claim. Please note that this questionnaire is for
disability evaluation, not for treatment purposes. This evaluation should be based on DSM-5 diagnostic criteria.
NOTE: If the Veteran experiences a mental health emergency during the interview, please terminate the interview and obtain help,
using local resources as appropriate. You may also contact the Veterans Crisis Line at 1-800-273-TALK (8255). Stay on the Crisis
Line until help can link the Veteran to emergency care.NOTE: In order to conduct an initial examination for mental disorders, the examiner must meet one of the following criteria: a board-
certified or board-eligible psychiatrist; a licensed doctorate-level psychologist; a doctorate-level mental health provider under theclose supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist; a psychiatry resident
under close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist; or a clinical or
counseling psychologist completing a one-year internship or residency (for purposes of a doctorate-level degree) under close
supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist.
In order to conduct a review examination for mental disorders, the examiner must meet one of the criteria from above, OR be a
licensed clinical social worker (LCSW), a nurse practitioner, a clinical nurse specialist, or a physician assistant, under close
supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist.
This Questionnaire is to be completed for both initial and review mental disorder(s) claims.
For the Claimed Compensation Condition of - ACQUIRED PSYCHIATRIC DISORDER TO INCLUDE MAJOR
DEPRESSIVE DISORDER AND OBSESSIVE COMPULSIVE DISORDER
Is this DBQ being completed in conjunction with a VA21-2507, C&P Examination request?
[X] Yes [] No
If no, how was the examination completed (check all that apply)?
[] In-person examination
[] Records reviewed
[] Other, please specify:
Comments:
SECTION I: DIAGNOSIS
1. DIAGNOSIS
1A. Does the Veteran now have or has he or she ever been diagnosed with a mental disorder(s)?Mental Disorders Disability Benefits Questionnaire Name: MARK ******
Page 2 of 7 VA Claim Number:
Contractor: VES[X] Yes [] No
ICD code: F33
NOTE: If the Veteran has a diagnosis of an eating disorder, complete the Eating Disorders Questionnaire, in lieu of this
questionnaire.
NOTE: If the Veteran has a diagnosis of PTSD, the Initial PTSD Questionnaire must be completed by a VHA staff or VA contract
examiner in lieu of this questionnaire.
If the Veteran currently has one or more mental disorders that conform to DSM-5 criteria, provide all diagnoses:
Mental Disorder Diagnosis #1:
Major Depressive Disorder, Severe, Recurrent
ICD code: F33
Comments, if any:
Mental Disorder Diagnosis #2:
Obsessive Compulsive Disorder
ICD code: F42
Comments, if any:
Mental Disorder Diagnosis #3:
ICD code:
Comments, if any:
If additional diagnoses, list using above format:
1B. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI):
None relevant
ICD code:
Comments, if any:
2. DIFFERENTIATION OF SYMPTOMS
2A. Does the Veteran have more than one mental disorder diagnosed?
[X] Yes [] No
(If “Yes,” complete the following question 2B)
2B. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis?
[X] Yes [] No [] Not applicable (N/A)
(If “No,” provide reason):
(If “Yes,” list which symptoms are attributable to each diagnosis and discuss whether there is any clinical association between
these diagnoses):
His obsessional rituals and compulsions are due to his Obsessive Compulsive Disorder. His suicidal ideation and prominent
depressed mood are due to his Major Depressive Disorder.Mental Disorders Disability Benefits Questionnaire Name: MARK *******
Page 3 of 7 VA Claim Number:
Contractor: VES
There is a clinical association as the disorders tend to exacerbate each other.
2C. Does the Veteran have a diagnosed traumatic brain injury (TBI)?
[] Yes [X] No [] Not shown in records reviewed
Comments, if any:
(If “Yes,” complete the following question 2D)
2D. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis TBI and any non-TBI mental health
diagnosis?
[] Yes [] No [X] Not applicable
(If “No,” provide reason):
(If “Yes,” list which symptoms are attributable to each diagnosis TBI and which symptoms are attributable to a non-TBI mental
health diagnosis):
3. OCCUPATIONAL AND SOCIAL IMPAIRMENT
3A. Which of the following best summarizes the Veteran’s level of occupational and social impairment with regards to all mental
diagnoses? (Check only one)
[] No mental disorder diagnosis
[] A mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and
social functioning or to require continuous medication
[] Occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform
occupational tasks only during periods of significant stress, or; symptoms controlled by medication
[] Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform
occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation
[] Occupational and social impairment with reduced reliability and productivity
[X] Occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking
and/or mood
[] Total occupational and social impairment
3B. For the indicated level of occupational and social impairment, is it possible to differentiate which impairment is caused by each
mental disorder?
[] Yes [X] No [] Not applicable
(If “No,” provide reason):
The symptoms and relative impairment overlap and exacerbate each other to such an extent that differentiation is not possible.
(If “Yes,” list which occupational and social impairment is attributable to each diagnosis):
3C. If a diagnosis of TBI exists, is it possible to differentiate which occupational and social impairment indicated above is caused by
the TBI?
[] Yes [] No [X] Not applicable
(If “No,” provide reason):
(If “Yes”, list which impairment is attributable to TBI and which is attributable to any non-TBI mental health diagnosis):Mental Disorders Disability Benefits Questionnaire Name: MARK *******
Page 4 of 7 VA Claim Number:
Contractor: VESSECTION II: CLINICAL FINDINGS:
1. EVIDENCE REVIEW
Evidence reviewed (check all that apply):
[] Not requested
[] VA claims file (hard copy paper C-file)
[X] VA e-folder
[] CPRS
[] Other (please identify other evidence reviewed):[] No records were reviewed
Evidence Comments:
The veteran's file was reviewed.
STATEMENT OF VETERAN RECEIPT DATE 1/26/16
BVA DECISION RECEIPT DATE 6/4/19- (REMAND ORDER)
VAMC TX RECS RECEIPT DATE 5/28/19
SERVICE TREATMENT RECORDS RECEIPT DATE 2/22/16
SERVICE TREATMENT RECORDS RECEIPT DATE 3/25/11
STRESSOR STATEMENT RECEIPT DATE 3/10/16
PERSONNEL RECS RECEIPT DATE 2/22/16
PERSONNEL RECS RECEIPT DATE 2/22/16
BUDDY STATEMENTS WITH RECEIPT DATES, 2/28/19, 12/27/16, 12/19/16, 6/20/16, 6/6/16, 5/9/16, 1/26/16, 3/24/11, 3/10/11,
3/3/11
2. HISTORY
NOTE: Initial examinations require pre-military, military, and post-military history. If this is a review examination only indicate any
relevant history since prior exam.
2A. Relevant Social/Marital/Family history (pre-military, military, and post-military) :
Pre-military
He reported being raised in an intact family until age 8 when his parents divorced. He initially lived with his mother, but was
then raised by his father. He reported having strict, but fair parents. He has an older sister. He reported having good relationships
with his family growing up. He endorsed an abuse attempt by a stepbrother, but denied anything actually occurred.
Military
He denied any changes to his marital or family status while in the service.
Post-military
He met his wife after he was discharged and they married in 1989. He had daughters born in 1994 and 1997.
2B. Relevant Occupational and Educational history (pre-military, military, and post-military):
Pre-military
He graduated high school before joining.
Military
He was an Army medic.
Post-military
He did not continue his education following the military. He got his EMT license and worked at a waterpark for 13 years.2C. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-
military):Mental Disorders Disability Benefits Questionnaire Name: MARK XXXX
Page 5 of 7 VA Claim Number:
Contractor: VESPre-military
He denied any personal or family mental health history.
Military
He reported feelings of guilt and self-blame following the reported MST.
Post-military
He reported feeling distrustful of others. He has a hard time being around strangers. He reported beginning to have rituals and
processes in the military. This appears to have come about due to his blaming himself for having poor judgment and being
victimized. He is currently in therapy for PTSD and takes prazosin, duloxetine, and trazadone. He reported being irritable with
his family. He reported feeling sad and disappointed with himself since leaving the service. He endorsed frequent suicidal
ideation and has been placed on two psychiatric holds due to danger to self.
2D. Relevant Legal and Behavioral history (pre-military, military, and post-military)
Pre-military
He denied any disciplinary issues
Military
He denied any disciplinary issues.
Post-military
He denied any legal issues
2E. Relevant Substance Abuse history (pre-military, military, and post-military)
Pre-military
He denied any substance abuse issues.
Military
He denied any excessive substance use.
Post-military
He reported a history of taking micro doses of narcotic medication to function on a day to day basis. He reported a history of
alcohol abuse up until a few years ago. He currently only drinks a few times per year. He no longer uses narcotic medication.
2F. Other, if any:
SECTION III: SYMPTOMS
For VA rating purposes, check all symptoms that actively apply to the Veteran’s diagnoses
[X] Depressed mood
[X] Anxiety
[X] Suspiciousness
[X] Panic attacks that occur weekly or less often
[] Panic attacks more than once a week
[] Near-continuous panic or depression affecting the ability to function independently, appropriately and effectively
[X] Chronic sleep impairment
[] Mild memory loss, such as forgetting names, directions or recent events
[] Impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete
tasks
[] Memory loss for names of close relatives, own occupation, or own name
[] Flattened affect
[] Circumstantial, circumlocutory or stereotyped speechMental Disorders Disability Benefits Questionnaire Name: MARK *******
Page 6 of 7 VA Claim Number:
Contractor: VES[] Speech intermittently illogical, obscure, or irrelevant
[] Difficulty in understanding complex commands
[] Impaired judgment
[] Impaired abstract thinking
[] Gross impairment in thought processes or communication
[X] Disturbances of motivation and mood
[] Difficulty in establishing and maintaining effective work and social relationships
[X] Difficulty in adapting to stressful circumstances, including work or a work like setting
[] Inability to establish and maintain effective relationships
[X] Suicidal ideation
[X] Obsessional rituals which interfere with routine activities
[] Impaired impulse control, such as unprovoked irritability with periods of violence
[] Spatial disorientation
[] Persistent delusions or hallucinations
[] Grossly inappropriate behavior
[] Persistent danger of hurting self or others
[] Neglect of personal appearance and hygiene
[] Intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene
[] Disorientation to time or place
SECTION IV: BEHAVIORAL OBSERVATIONS
He was alert and oriented. His affect was dysthymic and congruent with the conversation. He communicated his ideas clearly. He
denied any current suicidal or homicidal ideation. He denied any perceptual disturbance. There were no cognitive or memory deficits
apparent during the interview.
SECTION V: OTHER SYMPTOMS
5. Does the Veteran have any other symptoms attributable to mental disorders that are not listed above?
[] Yes [X] No
(If “Yes,” describe):
SECTION VI: COMPETENCY
Is the Veteran capable of managing his or her financial affairs?
[X] Yes [] No
(If “No”, explain):
SECTION VII: REMARKS
Remarks (Including any testing results), if any:
Additional comments regarding suicidal ideation, if any:
In the text box below please provide specific details on whether you feel the veteran is considered to be a current imminent risk
(active ideation with current plan and/or intent) or increased but not current imminent risk (no current plan or intent to take
action) of harm to him/herself.
NOTE: If you believe the veteran is a current imminent risk please contact your local authorities (police, 911, etc) and document
in the Remarks section that you have done so.
He reported feeling frequent suicidal ideation without intent. He denied any current plan or intent. He discussed protective
factors including his concern about negatively impacting his family.
[] I believe this Veteran/Service Member should be considered a CURRENT IMMINENT RISK.
[X] I believe this Veteran/Service Member should be considered an INCREASED but not current imminent risk.
[] I do not believe this Veteran/Service Member should be considered a current imminent or increased risk.Mental Disorders Disability Benefits Questionnaire Name: MARK *******
Page 7 of 7 VA Claim Number:
Contractor: VES
Please advise whether the Veteran was equipped with the VA crisis line (800-273-TALK):
He was provided the crisis line.
Is there a need for the Veteran to follow up with his/her primary care provider regarding any life threatening findings in this
examination (not limited to claimed condition(s))?
[] Yes [X] No
SECTION VIII: PSYCHIATRIST/PSYCHOLOGIST/EXAMINER
CERTIFICATION AND SIGNATURE
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.8A. PSYCHIATRIST/PSYCHOLOGIST/EXAMINER
SIGNATURE:
8B. PSYCHIATRIST/PSYCHOLOGIST/EXAMINERPRINTED NAME:
Migraine Claim approved at 50% today after BVA remand
in VA.gov Questions (formerly E-Benefits)
Posted
Thank you sir. I am going to give myself the weekend to unwind a bit. This process has been very draining and difficult for me, as I expect it has been for other disabled Veterans?