What this questionnaire covers
Records peritoneal adhesion history, manifestations, hospitalizations, diagnostic testing and functional effects.
Official instructions — page 1Peritoneal Adhesions DBQ
Records peritoneal adhesion history, manifestations, hospitalizations, diagnostic testing and functional effects.
Current public questionnaire
Download Peritoneal Adhesions DBQUpdated 2024-07-05 · v24_1
Use the appropriate condition questionnaire; identify evidence reviewed, complete the applicable findings and examiner certification, and follow the condition-specific instructions below. A form response does not itself establish service connection or a percentage.
Examiner requirements
The PDF is intended for the Veteran’s health care provider. Its general wording does not itself resolve specialty, state scope-of-practice or VA privileging requirements.
Instructions by section
Who completes it
The PDF is intended for the Veteran’s health care provider. Its general wording does not itself resolve specialty, state scope-of-practice or VA privileging requirements.
Official instructions — page 1Identify the evidence reviewed
Identify the records reviewed and the date range. Answer the examination-method and clinical-relationship questions from what actually occurred.
Official instructions — page 1Complete the examiner’s certification
The examiner certifies that the information is accurate, complete and current. Complete the signature, date, specialty, contact, National Provider Identifier and medical-license fields requested on the original form.
Official instructions — page 4Review scope
Editorial comparison of this description and revision label with the original questionnaire; not full regulatory mapping or professional review.
Instruction comparison: 2026-10-04. Per-record provider-intent and certification passages compared; full text automatically scanned for examiner-role restrictions. Named mental-health restrictions and selected testing passages separately read. Not a complete clinical instruction or examiner-qualification audit.