Provider responsibility
A licensed provider completes the clinical findings, signs, and dates the questionnaire. A veteran should not fill in medical findings for the provider.
Hematologic and Lymphatic Conditions, Including Leukemia
This questionnaire is available for public use from VA and is completed by a licensed health care provider.
Official VA file
Open the current public questionnaire.
Confirm the PDF update date and instructions with the provider before the examination.
VA may still examine
VA may verify the information or request another examination. A privately completed DBQ does not guarantee a decision or percentage.
Private exam cost
VA states it does not reimburse private providers for completing a DBQ. A VA-requested compensation examination is generally provided at no cost.