Reference: 38 CFR 4.104

Hypertension: Evidence & DBQ

What documentation clarifies the criteria

Evidence

Evidence that may clarify the published criteria

Medical and treatment records

May document diagnosis, dated blood pressure readings, treatment history, and any noted causing condition.

Diagnosis or treatment alone does not establish a percentage without confirmed readings.

Blood pressure log

May preserve dated diastolic and systolic readings across multiple days, supporting the predominant-reading pattern Note (1) requires.

A log should record observed readings. It should not assign a percentage.

Medication history

May show continuous antihypertensive medication use, supporting the minimum-evaluation pathway when paired with a documented diastolic-100-or-more history.

Medication use alone, without the paired diastolic history, does not establish the minimum-evaluation pathway.

Hypertension Disability Benefits Questionnaire

Organizes diagnosis, confirmation of readings on multiple days, current blood pressure values, continuous-medication history, and related findings.

A DBQ organizes evidence but does not issue the final VA decision.

DBQ

What a hypertension examination commonly documents

The official Hypertension DBQ gathers structured medical information for VA. It directly asks about Note (1)'s multi-day confirmation requirement. The examiner does not issue the final benefits decision. Describe the actual reading pattern honestly; do not exaggerate, minimize, or rehearse an outcome.

Current or historical hypertension diagnosis
Confirmation that readings were taken two or more times on at least three different days
Current diastolic and systolic blood pressure values
Continuous-medication history for blood pressure control
Related heart or kidney findings when documented

Preparation

What to have nearby

Confirmed blood pressure readings
Have dated readings from three or more different days nearby, since a single reading is not sufficient under Note (1).
Current diastolic and systolic values
Note the predominant, not just the highest single, reading for each.
History of diastolic pressure 100 or more, if applicable
This matters together with a continuous-medication requirement for the minimum-evaluation pathway.
Continuous-medication history
Document ongoing antihypertensive treatment separately from a one-time or as-needed prescription.
Any documented causing condition
Note (2)'s aortic insufficiency or hyperthyroidism causation exception is a separate, disclosed but unautomated pathway.

NextTerminologyPlain-English definitions of the terms used

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