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SINUSITIS/RHINITIS AND OTHER CONDITIONS OF THE NOSE, THROAT, (U.S. Department of Veterans Affairs)

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Updated on April 16, 2020 ~v20_1
Page 1 of 8
Sinusitis/Rhinitis and other Conditions of the Nose, Throat, Larynx and Pharynx DBQ
Released March 2021
SINUSITIS/RHINITIS AND OTHER CONDITIONS OF THE NOSE, THROAT,
LARYNX AND PHARYNX DISABILITY BENEFITS QUESTIONNAIRE
NAME OF PATIENT/VETERAN PATIENT/VETERAN'S SOCIAL SECURITY NUMBER
Note - 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. VA may obtain additional medical information, including an examination, if necessary, to complete VA's review of the
veteran's application. VA reserves the right to confirm the authenticity of ALL questionnaires completed by providers. It is intended that this questionnaire will be completed
by the Veteran's provider.
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.
Are you completing this Disability Benefits Questionnaire at the request of:
Veteran/Claimant
Other: please describe
Are you a VA Healthcare provider?
Is the Veteran regularly seen as a patient in your clinic?
Yes No
Yes No
Was the Veteran examined in person?
Yes No
If no, how was the examination conducted?
Please identify the evidence reviewed (e.g. service treatment records, VA treatment records, private treatment records) and the date range.
Evidence reviewed:
EVIDENCE REVIEW
No records were reviewed
Records reviewed
Updated on April 16, 2020 ~v20_1
Page 2 of 8
Sinusitis/Rhinitis and other Conditions of the Nose, Throat, Larynx and Pharynx DBQ
Released March 2021
1B. IF YES, SELECT THE VETERAN'S CONDITION (check all that apply)
1C. IF THERE ARE ADDITIONAL DIAGNOSES THAT PERTAIN TO THE SINUSES, NOSE, THROAT, LARYNX, OR PHARYNX CONDITION(S), LIST USING ABOVE FORMAT:
APHONIA
2. DESCRIBE THE HISTORY
(including onset and course) OF THE VETERAN'S SINUS, NOSE, THROAT, LARYNX, OR PHARYNX CONDITION:
PHARYNGEAL INJURY
(Describe):
ANATOMICAL LOSS OF PART OF NOSE
(Complete Scars Benefits Questionnaire in
lieu of this questionnaire)
CHRONIC LARYNGITIS
GRANULOMATOUS RHINITIS
LARYNGEAL STENOSIS
LARYNGECTOMY
BACTERIAL RHINITIS
NON-ALLERGIC RHINITIS
ALLERGIC RHINITIS
CHRONIC SINUSITIS
DEVIATED NASAL SEPTUM
(Traumatic)
BENIGN OR MALIGNANT NEOPLASM OF SINUS,
NOSE, THROAT, LARYNX OR PHARYNX
1A. DOES THE VETERAN NOW HAVE OR HAS HE OR SHE EVER BEEN DIAGNOSED WITH A SINUS, NOSE, THROAT, LARYNX OR PHARYNX CONDITION?
(This is
the condition the Veteran is claiming or for which an exam has been requested.)
SECTION I - DIAGNOSIS
NOYES
Other diagnosis #2
Other diagnosis #1
OTHER
(specify)
ICD Code: Date of diagnosis:
Date of diagnosis:ICD Code:
ICD Code:
ICD Code:
ICD Code:
Date of diagnosis:ICD Code:
Date of diagnosis:
Date of diagnosis:ICD Code:
Date of diagnosis:
Date of diagnosis:ICD Code:
Date of diagnosis:
Date of diagnosis:
ICD Code: Date of diagnosis:
Date of diagnosis:ICD Code:
ICD Code:
ICD Code:
ICD Code: Date of diagnosis:
Date of diagnosis:ICD Code:
Date of diagnosis:
Date of diagnosis:ICD Code:
SECTION II - MEDICAL HISTORY
Updated on April 16, 2020 ~v20_1
Page 3 of 8
Sinusitis/Rhinitis and other Conditions of the Nose, Throat, Larynx and Pharynx DBQ
Released March 2021
(If "Yes," provide the total number of non-incapacitating episodes over the past 12 months):
NOTE - For VA purposes, an incapacitating episode of sinusitis means one that requires bed rest and treatment prescribed by a physician.
A2. DOES THE VETERAN CURRENTLY HAVE ANY FINDINGS, SIGNS OR SYMPTOMS ATTRIBUTABLE TO CHRONIC SINUSITIS?
A3. HAS THE VETERAN HAD NON-INCAPACITATING EPISODES OF SINUSITIS CHARACTERIZED BY HEADACHES, PAIN AND PURULENT DISCHARGE OR
CRUSTING IN THE PAST 12 MONTHS?
(If "No," proceed to Section IV) (If "Yes," check all that apply):
Chronic sinusitis detected only by imaging studies (See Diagnostic Testing Section)
SECTION III - NOSE, THROAT, LARYNX OR PHARYNX CONDITIONS
PART A - SINUSITIS
Episodes of sinusitis
(If "Yes," check all that apply)
PANSINUSITIS
A5. HAS THE VETERAN HAD SINUS SURGERY?
A6. IF VETERAN HAS HAD RADICAL SINUS SURGERY, DID CHRONIC OSTEOMYELITIS FOLLOW THE SURGERY?
3 or more
(If "Yes," specify type of surgery):
(Type of procedure, sinuses operated on and side(s)):
(Date(s) of surgery (if repeated sinus surgery, provide all dates of surgery)):
Near constant sinusitis (If checked, describe frequency):
Headaches
SPHENOID
A1. INDICATE THE SINUSES/TYPE OF SINUSITIS CURRENTLY AFFECTED BY THE VETERAN'S CHRONIC SINUSITIS
(Check all that apply):
2
3. DOES THE VETERAN HAVE ANY OF THE FOLLOWING NOSE, THROAT, LARYNX OR PHARYNX CONDITIONS?
(If "Yes," complete Osteomyelitis Questionnaire)
Pain of affected sinus
FRONTAL ETHMOIDMAXILLARYNONE
Purulent discharge
FOR ALL CHECKED CONDITIONS, DESCRIBE:
A4. HAS THE VETERAN HAD INCAPACITATING EPISODES OF SINUSITIS REQUIRING PROLONGED
(4 to 6 weeks) OF ANTIBIOTICS TREATMENT IN THE PAST
12 MONTHS?
(If "Yes," provide the total number of incapacitating episodes of sinusitis requiring prolonged (4 to 6 weeks) of antibiotic treatment over the past 12 months):
1
NO
YES
Sinusitis
Rhinitis
Larynx or pharynx condition
Tumors or neoplasms
Other nose, throat, larynx or pharynx conditions, pertinent physical findings or scars due to nose, throat, larynx or pharynx conditions.
(If checked, complete Part F below)
Deviated nasal septum (traumatic)
NOYES
Other (describe):
NOYES
5 6 7 or more3 421
NO
YES
Radical
(open sinus surgery)
NO
YES
Endoscopic
Other:
NO
YES
(If checked, complete Part E below)
(If checked, complete Part D below)
(If checked, complete Part C below)
(If checked, complete Part B below)
(If checked, complete Part A below)
B1. IS THERE GREATER THAN 50% OBSTRUCTION OF THE NASAL PASSAGE ON BOTH SIDES DUE TO RHINITIS?
B2. IS THERE COMPLETE OBSTRUCTION ON THE LEFT SIDE DUE TO RHINITIS?
PART B - RHINITIS
NOYES
YES NO
Crusting
Tenderness of affected sinus
B3. IS THERE COMPLETE OBSTRUCTION ON THE RIGHT SIDE DUE TO RHINITIS?
NO
YES
A7. HAS THE VETERAN HAD REPEATED SINUS-RELATED SURGICAL PROCEDURES PERFORMED?
YES NO
Updated on April 16, 2020 ~v20_1
Page 4 of 8
Sinusitis/Rhinitis and other Conditions of the Nose, Throat, Larynx and Pharynx DBQ
Released March 2021
Granulomatous rhinitis
Other granulomatous infection
(Describe):
B6. DOES THE VETERAN HAVE ANY OF THE FOLLOWING GRANULOMATOUS CONDITIONS?
(If "Yes," check all that apply)
Rhinoscleroma Wegener's granulomatosis Lethal midline granuloma
YES NO
SECTION III - NOSE, THROAT, LARYNX OR PHARYNX CONDITIONS (Continued)
PART C - LARYNX AND PHARYNX CONDITIONS
(If "Yes," describe):
(If "Yes," assess for upper airway obstruction with pulmonary function testing to include Flow-Volume Loop, and provide results in Diagnostic
Testing Section)
(If "Yes," check all that apply)
Thickening of vocal chords
(If checked, does the Veteran have any residuals of the partial laryngectomy?)
Nodules of vocal chords
Submucous infiltration of vocal chords
C2. HAS THE VETERAN HAD A LARYNGECTOMY?
C1. DOES THE VETERAN HAVE CHRONIC LARYNGITIS?
Vocal chord polyps
(If "Yes," does the Veteran have any of the following symptoms due to chronic laryngitis?)
C3. DOES THE VETERAN HAVE LARYNGEAL STENOSIS, INCLUDING RESIDUALS OF LARYNGEAL TRAUMA (unilateral or bilateral)?
(If "Yes," specify)
Total laryngectomy
Partial laryngectomy
Hoarseness
(If checked, describe frequency):
NOYES
NOYES
Other (describe):
NO
YES NO
YES
NOYES
C4. DOES THE VETERAN HAVE COMPLETE ORGANIC APHONIA?
Constant inability to speak above a whisper
Constant inability to communicate by speech
(If "Yes," check all that apply)
YES NO
Other (describe):
C5. DOES THE VETERAN HAVE INCOMPLETE ORGANIC APHONIA?
(If "Yes," check all that apply)
(If "Yes," describe reason for tracheostomy and potential for decannulation):
Hoarseness (If checked, describe frequency):
YES NO
C6. HAS THE VETERAN HAD A PERMANENT TRACHEOSTOMY?
YES NO
Inflammation of vocal cords
Inflammation of mucous membrane
Thickening of vocal chords
Nodules of vocal chords
Submucous infiltration of vocal chords
Vocal chord polyps
Other (describe):
Inflammation of vocal cords
Inflammation of mucous membrane
B4. IS THERE PERMANENT HYPERTROPHY OF THE NASAL TURBINATES?
B5. ARE THERE NASAL POLYPS?
NO
YES
YES NO
PART B - RHINITIS (Continued)
Updated on April 16, 2020 ~v20_1
Page 5 of 8
Sinusitis/Rhinitis and other Conditions of the Nose, Throat, Larynx and Pharynx DBQ
Released March 2021
C8. DOES THE VETERAN HAVE VOCAL CHORD PARALYSIS OR ANY OTHER PHARYNGEAL OR LARYNGEAL CONDITIONS?
(If "Yes," describe):
NOYES
PART C - LARYNX AND PHARYNX CONDITIONS
SECTION III - NOSE, THROAT, LARYNX OR PHARYNX CONDITIONS (Continued)
(If "Yes," check all findings, signs and symptoms that apply):
Obstruction of the pharynx
Absence of the soft palate secondary to granulomatous disease
Paralysis of the soft palate
Absence of the soft palate secondary to trauma
Absence of the soft palate secondary to chemical burn
YES
NO
Other (describe):
C7. HAS THE VETERAN HAD AN INJURY TO THE PHARYNX?
Obstruction of the nasopharynx
Stricture of the nasopharynx
Stricture of the pharynx
Swallowing difficulty
Nasal regurgitation
Speech impairment
D2. IS THE VETERAN'S DEVIATED SEPTUM TRAUMATIC?
PART D - DEVIATED NASAL SEPTUM (TRAUMATIC)
D1. IS THERE AT LEAST 50% OBSTRUCTION OF THE NASAL PASSAGE ON BOTH SIDES DUE TO TRAUMATIC SEPTAL DEVIATION?
NOYES
NOYES
PART E - TUMORS AND NEOPLASMS
BENIGN
E1. DOES THE VETERAN HAVE A BENIGN OR MALIGNANT NEOPLASM OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN THE DIAGNOSIS SECTION?
MALIGNANT
(If "Yes," complete the following section)
E3. HAS THE VETERAN COMPLETED TREATMENT OR IS THE VETERAN CURRENTLY UNDERGOING TREATMENT FOR A BENIGN OR MALIGNANT NEOPLASM OR
METASTASES?
(If "Yes," indicate type of treatment the Veteran is currently undergoing or has completed (check all that apply)):
E2. IS THE NEOPLASM:
NOYES
NO; WATCHFUL WAITINGYES
Other therapeutic treatment
Treatment completed; currently in watchful waiting status
(Date of completion of treatment or anticipated date of completion):
(Date of completion of treatment or anticipated date of completion):
(Date(s) of surgery):
Surgery (If checked, describe):
(Date of most recent procedure):
(Date of completion of treatment or anticipated date of completion):
(If checked, describe procedure):
Other therapeutic procedure
Radiation therapy
(Date of most recent treatment):
(Date of most recent treatment):
Antineoplastic chemotherapy
(If checked, describe treatment):
D3. IS THERE COMPLETE OBSTRUCTION ON LEFT SIDE DUE TO TRAUMATIC SEPTAL DEVIATION?
NOYES
D4. IS THERE COMPLETE OBSTRUCTION ON RIGHT SIDE DUE TO TRAUMATIC SEPTAL DEVIATION?
NOYES
E4. DOES THE VETERAN CURRENTLY HAVE ANY RESIDUAL CONDITIONS OR COMPLICATIONS DUE TO THE NEOPLASM (including metastases) OR ITS
TREATMENT, OTHER THAN THOSE ALREADY DOCUMENTED IN THE REPORT ABOVE?
(If "Yes," list residual conditions and complications (brief summary)):
NOYES
Updated on April 16, 2020 ~v20_1
Page 6 of 8
Sinusitis/Rhinitis and other Conditions of the Nose, Throat, Larynx and Pharynx DBQ
Released March 2021
PART E - TUMORS AND NEOPLASMS (Continued)
E5. IF THERE ARE ADDITIONAL BENIGN OR MALIGNANT NEOPLASMS OR METASTASES RELATED TO ANY OF THE DIAGNOSES IN THE DIAGNOSIS SECTIONI,
DESCRIBE USING THE ABOVE FORMAT:
PART F - OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS, SYMPTOMS, AND SCARS
SECTION III - NOSE, THROAT, LARYNX OR PHARYNX CONDITIONS (Continued)
F1. DOES THE VETERAN HAVE ANY OTHER PERTINENT PHYSICAL FINDINGS, COMPLICATIONS, CONDITIONS, SIGNS OR SYMPTOMS RELATED TO THE
CONDITIONS LISTED IN THE DIAGNOSIS SECTION ABOVE?
NO
YES NO
YES
F3. COMMENTS, IF ANY:
IF YES, ALSO COMPLETE VA FORM 21-0960F-1, SCARS/DISFIGUREMENT.
LOCATION: MEASUREMENTS: length cm X width cm.
IF NO, PROVIDE LOCATION AND MEASUREMENTS OF SCAR IN CENTIMETERS.
NOTE: If there are multiple scars, enter additional locations and measurements in Comment section below. It is not necessary to also complete a Scars DBQ.
NO
IF YES, ARE ANY OF THESE SCARS PAINFUL OR UNSTABLE; HAVE A TOTAL AREA EQUAL TO OR GREATER THAN 39 SQUARE CM (6 square inches); OR
ARE LOCATED ON THE HEAD, FACE OR NECK? (
An "unstable scar" is one where, for any reason, there is frequent loss of covering of the skin over the scar.)
YES
F2. 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?
IF YES, DESCRIBE (brief summary):
F4. DOES THE VETERAN HAVE LOSS OF PART OF THE NOSE OR OTHER SCARS OF THE NOSE EXPOSING BOTH NASAL PASSAGES?
F5. DOES THE VETERAN HAVE LOSS OF PART OF THE NOSE OR OTHER SCARS CAUSING LOSS OF PART OF ONE ALA?
F6. DOES THE VETERAN HAVE LOSS OF PART OF THE NOSE OR OTHER SCARS CAUSING ANY OTHER DISFIGUREMENT?
NO
YES
NOYES
NOYES
Updated on April 16, 2020 ~v20_1
Page 7 of 8
Sinusitis/Rhinitis and other Conditions of the Nose, Throat, Larynx and Pharynx DBQ
Released March 2021
NOTE - If testing has been performed and reflects the Veteran's current condition, repeat testing is not required. Specific diagnostic testing is not required for many
conditions, but if performed, record in this section.
4B. HAS ENDOSCOPY BEEN PERFORMED?
SECTION IV - DIAGNOSTIC TESTING
Benign
4E. ARE THERE ANY OTHER SIGNIFICANT DIAGNOSTIC TEST FINDINGS AND/OR RESULTS?
Malignant
4A. HAVE IMAGING STUDIES OF THE SINUSES OR OTHER AREAS BEEN PERFORMED?
Describe results:
Is the Flow-Volume Loop compatible with upper airway obstruction?
FEV-1 less than 40% predicted
(If "Yes," check all that apply):
Results: Pre-malignant
4C. HAS THE VETERAN HAD A BIOPSY OF THE LARYNX OR PHARYNX?
FEV-1 of 40 to 55% predicted
4D. HAS THE VETERAN HAD PULMONARY FUNCTION TESTING TO ASSESS FOR UPPER AIRWAY OBSTRUCTION DUE TO LARYNGEAL STENOSIS?
FEV-1 of 56 to 70% predicted
FEV-1 of 71 to 80% predicted
If "Yes," indicate results:
NO
YES NO
YES NO
YES NO
YES NO
YES
NOYES
(If "Yes," check all that apply)
X-rays:
Other:
Nasal endoscopy
Laryngeal endoscopy
Bronchoscopy
Other endoscopy
Computed tomography (CT)
Magnetic resonance imaging (MRI)
Date:
Date:
Date:
Date:
Date:
Date: Results:
Results:Date:
Results:
Results:Date:
Results:
Results:
Results:
Results:
(If "Yes," complete the following):
Site of biopsy: Date:
(If "Yes," provide type of test or procedure, date and results (brief summary)):
Updated on April 16, 2020 ~v20_1
Page 8 of 8
Sinusitis/Rhinitis and other Conditions of the Nose, Throat, Larynx and Pharynx DBQ
Released March 2021
5B. REMARKS (If any)
SECTION VII - PHYSICIAN'S CERTIFICATION AND SIGNATURE
5A. DOES THE VETERAN'S SINUS, NOSE, THROAT, LARYNX OR PHARYNX CONDITION IMPACT HIS OR HER ABILITY TO WORK?
(If "Yes," describe impact of each of the veteran's sinus, nose, throat, larynx or pharynx conditions, providing one or more examples):
YES NO
SECTION V - FUNCTIONAL IMPACT AND REMARKS
CERTIFICATION - To the best of my knowledge, the information contained herein is accurate, complete and current.
7C. DATE SIGNED
7E. NATIONAL PROVIDER IDENTIFIER (NPI) NUMBER
7B. PHYSICIAN'S PRINTED NAME7A. PHYSICIAN'S SIGNATURE
7D. PHYSICIAN'S PHONE AND FAX NUMBERS
NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the application.
7F. PHYSICIAN'S ADDRESS
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SINUSITISRHINITIS AND OTHER CONDITIONS OF THE NOSE, THROAT, (U.S. Department of Veterans Affairs)

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Completed 7 November 2021

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