How to Fill Out and Submit the VA DBQ for GERD (Form 21-0960G-1)

The VA’s Disability Benefits Questionnaire for GERD is the Esophageal Conditions DBQ, a free PDF form your physician completes to translate reflux symptoms into the specific clinical findings the VA uses to assign a rating. Since May 19, 2024, GERD has its own diagnostic code — 7206 — with criteria built around documented esophageal strictures and swallowing difficulty rather than the older subjective language.¹ Getting the DBQ completed by a doctor who understands those updated criteria — and who has the imaging and procedure records in front of them — is where most GERD claims are won or lost.

Which Form to Download

The form you want is the Esophageal Conditions (Including Gastroesophageal Reflux Disease (GERD), Hiatal Hernia, and Other Esophageal Disorders) Disability Benefits Questionnaire, available as a PDF from the VA’s public DBQ page under the Gastrointestinal section, listed as “Esophageal Disorders.”²³ The current version was updated in mid-2024 to match the new rating criteria.

If you’ve seen references to “VA Form 21-0960L-2” in older guides, that number belonged to a retired version. The VA no longer uses the 21-0960 numbering for public DBQs. A separate Intestinal Conditions DBQ exists for lower gastrointestinal issues, so double-check that you have the esophageal form, not the intestinal one. Print it and bring it to your appointment, or email the PDF directly to your physician ahead of time.

How GERD Is Rated Under Diagnostic Code 7206

The DBQ’s checkboxes correspond directly to the rating tiers, so it helps to know them before your appointment. The VA rates GERD under DC 7206 in 38 C.F.R. § 4.114 on a scale from 0 to 80 percent, and every tier above zero hinges on documented esophageal strictures — narrowing of the esophagus that makes swallowing difficult.⁴

0 percent: documented history of GERD without daily symptoms or need for daily medication.
10 percent: documented esophageal strictures that require daily medication to control difficulty swallowing, but otherwise asymptomatic.
30 percent: recurrent strictures causing difficulty swallowing that require dilation no more than twice per year.
50 percent: recurrent or refractory strictures requiring dilation three or more times per year, steroid-assisted dilation at least once per year, or placement of an esophageal stent.
80 percent: recurrent or refractory strictures with aspiration, undernutrition, or substantial weight loss, combined with surgical correction or a feeding tube (PEG tube).

Two clinical definitions drive the higher tiers. A “recurrent” stricture is one that cannot stay at its target diameter for more than four weeks after a dilation. A “refractory” stricture is one where the target diameter cannot be reached at all despite at least five dilation sessions performed at two-week intervals.⁴ Your doctor needs to document to these benchmarks, not to general impressions.

The practical consequence is significant. A GERD rating above 0 percent now requires objective proof of strictures confirmed by barium swallow, CT scan, or upper endoscopy.⁴ Symptom descriptions alone — heartburn frequency, regurgitation, nighttime disruption — will not move the rating without imaging or procedure findings showing structural damage. If your prior evidence was gathered under the old DC 7346 criteria that referenced “prostrating attacks” and “considerable impairment of health,” you likely need updated testing that speaks to the new standard.¹

Evidence to Bring to the Appointment

The DBQ asks the examiner to confirm diagnoses based on clinical findings, not just your description of symptoms. Give your physician the raw data in hand.

Diagnostic Testing

The regulation specifically requires stricture findings to be documented by barium swallow, CT scan, or EGD.⁴ Without at least one of these studies, your doctor cannot check the boxes that support a compensable rating. Gather these records if they exist:

Upper endoscopy (EGD) reports. The DBQ notes that findings of “erythema, ulcers and/or strictures” on EGD support a GERD diagnosis.²
Barium swallow studies showing narrowing and swallowing function.
Dilation records — dates, frequency, whether steroids were used, whether the stricture recurred. These are critical for the 30 and 50 percent tiers.
Surgical or stent records, required for the 50 and 80 percent tiers.
24-hour pH monitoring, which strengthens the clinical picture even though the regulation does not require it.
Weight records. The 80 percent tier requires “substantial weight loss,” defined as involuntary loss exceeding 20 percent of baseline weight sustained for three months.²

If you’ve had multiple dilations, prepare a simple chronological list with dates and outcomes. It prevents your doctor from digging through hundreds of pages during a short appointment.

Medications

The DBQ asks whether your treatment plan includes daily prescribed medication. A GERD diagnosis can be established clinically by showing that reflux symptoms improve with proton pump inhibitors, H2 receptor antagonists, or antacids.² Bring a current medication list and pharmacy records showing how long you’ve been on each drug. This is especially relevant for the 10 percent tier.

What the DBQ Asks

Knowing the structure of the form lets you prepare to discuss each section rather than hoping the doctor asks the right questions.

Diagnosis and History

The examiner first confirms whether you have a current diagnosis — GERD, hiatal hernia, esophageal stricture, or another esophageal disorder — then documents when symptoms started and how the condition has progressed. Your treatment timeline and imaging dates matter most here.

Signs, Symptoms, and Complications

The form has checkboxes for the specific findings that map to each rating tier:²

Dysphagia and whether it requires daily medication.
Esophageal strictures confirmed by barium swallow, CT, or EGD.
Dilation history, including frequency, use of steroids, and whether strictures are recurrent or refractory.
Stent placement.
Aspiration of food or liquid into the airway.
Undernutrition from insufficient intake or the body’s inability to absorb nutrients.
Substantial weight loss as defined above, with reduced ability to perform self-care or work tasks.
Surgical correction of strictures or placement of a PEG tube.

Each box corresponds to a rating tier, so accuracy here controls the outcome. Make sure supporting records are in the file before the appointment.

Functional Impact

The final section asks whether your condition affects your ability to perform occupational tasks. This is where the doctor can add narrative beyond checkboxes. Be specific with what you tell them: “flare-ups lasting two to three hours prevent me from completing an eight-hour shift twice per week” carries far more weight than “it limits my daily activities.”

Connecting GERD to Your Service

A completed DBQ alone will not get you benefits. The VA also needs evidence connecting your GERD to military service, and there are two paths.

Direct Service Connection

Direct connection means your GERD started during or was caused by active duty. You’ll need service treatment records showing symptoms or a diagnosis in service, plus a medical opinion linking your current condition to that in-service event. Records of treatment for chronic heartburn, epigastric pain, or reflux during service strengthen this path.

Secondary Service Connection

Many GERD claims succeed as secondary conditions. Under 38 C.F.R. § 3.310, a disability that is “proximately due to or the result of a service-connected disease or injury” qualifies for service connection.⁵ The most common route involves NSAIDs. If you take ibuprofen, naproxen, or a similar drug for a service-connected musculoskeletal condition, and that medication caused or worsened your GERD, you can claim GERD as secondary to that medication use. SSRIs prescribed for service-connected PTSD or depression can also contribute to reflux by relaxing the lower esophageal sphincter.

To document the link, pull your VA pharmacy records showing the duration and frequency of the medication, along with provider notes showing when digestive symptoms started relative to when the medication was prescribed.

Filing and Submitting

Consider an Intent to File First

Before the DBQ is even in hand, consider submitting an intent to file. This sets a potential effective date for your benefits — if the VA later approves your claim, you may receive retroactive payments back to the date the intent was processed. You have one year after filing the intent to submit your completed claim.⁶ Only one intent to file can be active at a time, and it becomes inactive once you file the completed claim.

Private Physician or C&P Exam

You have two options for getting the DBQ completed. The VA may schedule a Compensation and Pension exam where a VA-contracted physician fills out the form after examining you. Alternatively, your own doctor can complete the public Esophageal Conditions DBQ. A private physician who has treated your GERD for years may produce a more thorough form because they already know your history and imaging results. The findings carry the same weight either way; what matters is accuracy and completeness.

Where to Send It

You can upload a completed private DBQ and supporting evidence through the VA’s online claim status tool if you have a pending claim.⁷ The VA’s QuickSubmit tool through AccessVA accepts uploads as well. For paper submissions, mail to:

Department of Veterans Affairs
Claims Intake Center
PO Box 4444
Janesville, WI 53547-4444⁸

You have up to one year from the date the VA receives your claim to submit evidence. But if you fail to provide evidence or respond to VA requests within 30 days, the VA may decide your claim early based on whatever is already in the file.⁷ Submit as soon as your DBQ and records are ready.

If the Claim Is Denied

A denial isn’t the end. Within one year of the decision you have two main options, and the choice depends on whether you have new evidence.

File a Supplemental Claim using VA Form 20-0995 if you have new and relevant evidence, such as a recent endoscopy showing strictures, updated dilation records, or a stronger nexus letter. “New” means information not previously submitted; “relevant” means it tends to prove or disprove a matter at issue.⁹ This is the right path when your original DBQ was incomplete or your condition has worsened.

Request a Higher-Level Review if you believe the VA misjudged the evidence already on file and you have nothing new to add. A more senior reviewer examines the existing record for error or a difference of opinion. No new evidence can be submitted with this option. You can request an informal conference (a phone call with the reviewer to point out specific errors), but you’re limited to one, and it isn’t a hearing. You also cannot request a Higher-Level Review of a previous Higher-Level Review or Board Appeal on the same issue.¹⁰ If that first review doesn’t go your way, your next step is either a Supplemental Claim with new evidence or an appeal to the Board of Veterans’ Appeals.

1
Federal Register. Schedule for Rating Disabilities: The Digestive System
2
U.S. Department of Veterans Affairs. Esophageal Conditions Disability Benefits Questionnaire
3
Department of Veterans Affairs. Public Disability Benefits Questionnaires – Compensation
4
eCFR. 38 CFR 4.114 – Schedule of Ratings – Digestive System
5
eCFR. 38 CFR 3.310 – Disabilities That Are Proximately Due To, or Aggravated By, Service-Connected Disease or Injury
6
Veterans Affairs. Your Intent To File a VA Claim
7
Veterans Affairs. Upload Evidence To Support Your Disability Claim
8
Veterans Affairs. How To File a VA Disability Claim
9
U.S. Department of Veterans Affairs. VA Form 20-0995, Decision Review Request: Supplemental Claim
10
Veterans Affairs. Higher-Level Reviews