The VA General Medical Exam, commonly known as a Compensation and Pension (C&P) exam, is a mandatory medical appointment in the disability claims process. The Department of Veterans Affairs (VA) uses this examination to gather comprehensive medical evidence about a veteran’s claimed condition. It is a no-cost assessment provided by either a VA clinician or a contracted provider to help determine a claim’s validity. The C&P exam significantly influences the final decision on a veteran’s eligibility for benefits.
The Purpose of the Examination in VA Claims
The C&P exam serves a specific purpose distinct from routine medical treatment, as the examiner does not provide prescriptions or therapy. The primary goal is to establish two critical factors for a successful disability claim. The first is service connection, which links the veteran’s current medical condition to their military service.
The examiner must provide an opinion on whether the disability was caused by, incurred during, or aggravated by active duty service. Another element is establishing the severity rating, which measures the functional limitation the condition causes. This rating directly correlates to the percentage the VA assigns, influencing the level of compensation and benefits received.
The examiner translates findings into objective medical evidence used by the VA to apply the Schedule for Rating Disabilities. This standardized process ensures the rating decision is based on a consistent evaluation of the disability’s impact on the veteran’s daily and occupational life. The C&P exam is an evidence-gathering tool designed to fulfill the VA’s legal “duty to assist” the veteran in developing their claim.
Preparing for the C&P Appointment
The process begins when the VA, or one of its contracted medical examination companies, sends the veteran a notification by mail, phone, or email. This notification provides the specific date, time, and location of the scheduled appointment. Upon receiving this notice, the veteran should confirm the details immediately to ensure they do not miss the exam, which could lead to a claim’s denial or delay.
Preparing a detailed, concise personal history of symptoms is highly recommended before attending the appointment. This history should focus on how the condition affects daily activities and work performance, providing concrete examples of functional limitations. While the examiner will have access to the veteran’s claims file (C-file), bringing copies of any private medical records that have not yet been submitted to the VA can ensure all relevant evidence is considered.
Veterans should also be prepared to discuss the onset and progression of their condition since leaving service. Clearly communicating the frequency and severity of symptoms helps the examiner accurately document the current state of the disability. The examination is not the time to minimize symptoms, but rather to be completely honest about the condition’s full impact.
What Happens During the Examination
The C&P examination is typically structured around three main components performed by the VA or contracted clinician. The first involves the examiner reviewing the veteran’s claims file, which contains all previously submitted medical records, service records, and lay evidence. This file review provides context and background for the claimed condition before the veteran is seen.
Next, the examiner conducts an interview, taking a detailed history of the veteran’s symptoms. This discussion focuses on the current functional impact of the disability, asking specific questions about pain, mobility, and the ability to perform daily tasks. The veteran’s description of their symptoms is translated into medical language and objective findings by the examiner.
The final part involves the physical or mental health assessment, which includes testing or observation. For example, a musculoskeletal assessment may involve measuring the range of motion in a joint using a goniometer. A mental health assessment involves structured questioning and observation of the veteran’s behavior. The clinician’s role is to objectively document these findings to support the severity rating.
The examination’s length is highly variable, ranging from a brief 15-minute assessment for a single condition to several hours for complex mental health claims. Regardless of the duration, the examiner’s observations and measurements are formally recorded to establish the medical evidence required for the VA’s rating process. Standardized protocols and worksheets are used to ensure consistency in the evaluation of different disabilities.
After the Exam: The Disability Benefits Questionnaire
Following the physical assessment and interview, the examiner completes the Disability Benefits Questionnaire (DBQ). The DBQ is a standardized form that translates medical findings from the C&P exam into a format addressing the VA’s rating criteria. There are over 70 different DBQ forms, each corresponding to a specific body system or condition.
The questionnaire uses a checklist format and standardized language to document the diagnosis, symptoms, severity, and functional limitations. This structured format helps ensure that the necessary medical details for rating are present and accurate. The DBQ also includes the examiner’s medical opinion on the nexus, or connection, between the current disability and the veteran’s military service.
Once completed, the examiner submits the DBQ directly to the VA for inclusion in the veteran’s claims file. The VA claims processor then uses this formal document, along with all other evidence, to determine the final disability rating. Veterans are entitled to request a copy of the completed C&P exam report and DBQ from the VA once it has been submitted, typically by submitting a Privacy Act or Freedom of Information Act request.