Updated on April 16, 2020 ~v20_1
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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)
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):
A1. INDICATE THE SINUSES/TYPE OF SINUSITIS CURRENTLY AFFECTED BY THE VETERAN'S CHRONIC SINUSITIS
(Check all that apply):
3. DOES THE VETERAN HAVE ANY OF THE FOLLOWING NOSE, THROAT, LARYNX OR PHARYNX CONDITIONS?
(If "Yes," complete Osteomyelitis Questionnaire)
Pain of affected sinus
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
(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):
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)
5 6 7 or more3 421
(open sinus surgery)
(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
Tenderness of affected sinus
B3. IS THERE COMPLETE OBSTRUCTION ON THE RIGHT SIDE DUE TO RHINITIS?
A7. HAS THE VETERAN HAD REPEATED SINUS-RELATED SURGICAL PROCEDURES PERFORMED?