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It collects patient/provider identifiers, examination context, and evidence review details, including types of records and date ranges. 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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 completed questionnaires. It is intended that this questionnaire will be completed by the Veteran's healthcare provider. |  |  |  |  |  |\n| Are you completing this Disability Benefits Questionnaire at the request of: |  |  |  |  |  |\n|  | Veteran/Claimant |  |  |  |  |\n|  | Third party (please list name(s) of organization(s) or individual(s)) |  |  |  | |\n| | Other: please describe | |  |  |  |\n| Are you a VA Healthcare provider?  Yes  No\u003Cbr>Is the Veteran regularly seen as a patient in your clinic?  Yes  No\u003Cbr>Was the Veteran examined in person?  Yes  No |  |  |  |  |  |\n| If no, how was the examination conducted? |  |  | |  |  |\n| EVIDENCE REVIEW |  |  |  |  |  |\n| Evidence reviewed:\u003Cbr> No records were reviewed\u003Cbr> Records reviewed\u003Cbr>Please identify the evidence reviewed (e.g. service treatment records, VA treatment records, private treatment records) and the date range.\u003Cbr>|  |  |  |  |  |\n| SECTION I -DIAGNOSIS |  |  |  |  |  |\n| Note: These are condition(s) for which an evaluation has been requested on an exam request form (Internal VA) or for which the Veteran has requested medical evidence be provided for submission to VA. |  |  |  |  |  |\n| 1A. List the claimed condition(s) that pertain to this questionnaire:\u003Cbr>|  |  |  |  |  |\n|  |  |  |  |  |  |\n\nFoot Conditions, Including Flatfoot (Pes Planus) Disability Benefits Questionnaire  \nUpdated on: 2024-09-03 ~v24_2 Page 1 of 16  \n\n| Note: These are the diagnoses determined during this current evaluation of the claimed condition(s) listed above. If there is no diagnosis, if the diagnosis is different from a previous diagnosis for this condition, or if there is a diagnosis of a complication due to the claimed condition, explain your findings and reasons in comments section. Date of diagnosis can be the date of the evaluation if the clinician is making the initial diagnosis, or an approximate date determined through record review or reported history. |  |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| 1B. Select diagnoses associated with the claimed condition(s) (check all that apply):\u003Cbr> The Veteran does not have a current diagnosis associated with any claimed conditions listed above. (Explain your findings and reasons in comments section.) |  |  |  |  |  |  |  |  |  |  |\n| Note: If any condition is checked below, complete all of Section 1, Section 2, and also the applicable Section(s) 3 through 11 with which the condition is most associated.\u003Cbr>Diagnosis: Side affected: ICD Code: Date of diagnosis: |  |  |  |  |  |  |  |  |  |  |\n| | Flat foot (pes planus) Plantar fasciitis |  |  Right\u003Cbr> Right |  Left\u003Cbr> Left\u003Cbr>|  Both\u003Cbr> Both\u003Cbr>|  | Right:   Left:\u003Cbr>Right: Left: |  |  |  |\n| | Morton's neuroma\u003Cbr>Metatarsalgia Hammer toes\u003Cbr>Hallux valgus\u003Cbr>Hallux rigidus\u003Cbr>Acquired pes cavus (claw foot)\u003Cbr>Malunion/nonunion of tarsal/ metatarsal bones Foot injury(ies), specify: |  |  Right\u003Cbr> Right\u003Cbr> Right\u003Cbr> Right\u003Cbr> Right\u003Cbr> Right\u003Cbr> Right\u003Cbr> Right |  Left\u003Cbr> Left\u003Cbr> Left\u003Cbr> Left\u003Cbr> Left\u003Cbr> Left\u003Cbr> Left\u003Cbr> Left\u003Cbr>|  Both\u003Cbr> Both\u003Cbr> Both\u003Cbr> Both\u003Cbr> Both\u003Cbr> Both\u003Cbr","cbCaifIFhMLvpj78","https://ap.wps.com/l/cbCaifIFhMLvpj78","pdf",4050622,"English","# Evidence Review\n## Section I - Diagnosis\n## Diagnosis Selection","[{\"question\":\"Who is expected to complete this disability benefits questionnaire?\",\"answer\":\"It is intended to be completed by the Veteran’s healthcare provider, with the Veteran applying for VA disability benefits.\"},{\"question\":\"What information is collected about the examination request and examination status?\",\"answer\":\"The form asks whether it is completed at the request of the Veteran/claimant, a third party, or other; whether the examiner is a VA healthcare provider; whether the Veteran is regularly seen; and whether the Veteran was examined in person.\"},{\"question\":\"What clinician documentation is used to support the claimed foot conditions?\",\"answer\":\"The clinician must review evidence (or state that no records were reviewed), identify the evidence type and date range, and provide diagnoses determined during the current evaluation, with diagnosis dates and supporting explanation in comments when needed.\"}]","Foot Conditions, Including Flatfoot (Pes Planus) Disability Benefits Questionnaire - Updated on 2024-09-03 | PDF",6]