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VA Rating Assistant

DC 5025 · 38 CFR 4.71a

Fibromyalgia C&P Exam Prep

To evaluate the nature, severity, and functional impact of fibromyalgia for VA disability rating purposes under 38 CFR 4.71a, DC 5025. The examiner will determine whether you meet diagnostic criteria, document tender point findings, assess associated symptoms, and evaluate how your condition affects your daily functioning and ability to work.

Format:
Interview + Physical
Typical duration:
30-45 minutes
DBQ form:
Fibromyalgia (Fibromyalgia)
Examiner:
Rheumatologist or Physician

What the examiner evaluates

  • Presence and distribution of widespread musculoskeletal pain (bilateral, above and below waist, axial)
  • Number and location of tender points out of the 18 classic ACR tender point sites
  • Associated symptoms including fatigue, sleep disturbance, stiffness, paresthesias, headache, depression, anxiety, irritable bowel symptoms, Raynaud-like symptoms, and muscle weakness
  • Frequency of symptoms: episodic with exacerbations, present more than one-third of the time, or constant/nearly constant
  • Whether symptoms are precipitated by environmental or emotional stressors
  • Functional impact on work, daily activities, and quality of life
  • Current medications required to manage fibromyalgia symptoms
  • Use of assistive devices (canes, braces, walker, crutches, wheelchair)
  • Co-existing diagnosed conditions that may be secondary to fibromyalgia
  • History, onset, and course of the condition including any in-service connection

The examination will typically involve a seated interview followed by a physical tender point assessment. The examiner will apply approximately 4 kg of pressure (enough to blanch the thumbnail) to each of the 18 ACR tender point sites bilaterally. You should be wearing comfortable, accessible clothing. The examiner may also review your medical records prior to or during the examination. If the exam is conducted via telehealth, notify the examiner that a physical tender point assessment is required and cannot be fully replicated remotely. You have the right to request that the exam be recorded in most states.

Measurements and tests

Tender Point Assessment (ACR 18-Point Examination)

What it measures: Presence of pain at specific anatomical sites when moderate pressure (approximately 4 kg/cm-) is applied. The 18 classic tender point sites are: bilateral occiput (suboccipital muscle insertions), bilateral low cervical (anterior aspects of intertransverse spaces C5-C7), bilateral trapezius (midpoint of upper border), bilateral supraspinatus (above medial border of scapula), bilateral second rib (at second costochondral junction), bilateral lateral epicondyle (2 cm distal to epicondyle), bilateral gluteal (upper outer quadrant of buttocks), bilateral greater trochanter (posterior to trochanteric prominence), and bilateral knee (medial fat pad proximal to joint line).

What to expect: The examiner will press firmly on each of the 18 sites with their thumb or a pressure algometer. They will ask whether each site is painful - not just tender or uncomfortable. You should verbally confirm 'Yes, that is painful' or 'No, that is not painful' clearly for each site. Do not minimize your response. The examiner will indicate on the DBQ whether each bilateral site is positive and whether findings are bilateral.

Critical thresholds

  • 11 or more of 18 tender points positive (historic ACR 1990 criteria) Supports diagnosis; however, VA uses its own criteria for rating - the number and severity of positive tender points inform symptom frequency and functional impact ratings
  • Widespread pain plus associated symptoms present more than one-third of time Supports 20% rating under DC 5025
  • Widespread pain plus associated symptoms that are constant or nearly constant, or that produce marked limitation of daily activities Supports 40% rating under DC 5025

Tips

  • Do not brace or hold your breath during the exam - allow your natural pain response to occur
  • If a tender point is painful, say 'Yes, that is painful' clearly and distinctly
  • If you are having a better day than usual at the time of the exam, tell the examiner: 'This is not my typical day - on my worst days my pain is significantly more severe'
  • Mention any tender points you experience that are not formally tested if they affect your daily function
  • Report if the pressure causes referred pain or radiating discomfort beyond the point of contact

Pain considerations: Fibromyalgia tender point pain is characteristically allodynic - normal pressure causes disproportionate pain. If you experience severe pain with even light touch at tender point sites on your worst days, describe this to the examiner. Per DeLuca v. Brown, the examiner must also address functional limitations that occur during flare-ups and with repeated use over time, not only what is observed during the exam itself. Proactively describe how your pain changes with activity, stress, weather changes, and over the course of a day.

Functional Impact and Activity Limitation Assessment

What it measures: How fibromyalgia symptoms limit your ability to perform daily activities, maintain employment, and engage in personal care, mobility, and social functioning. The DBQ requires the examiner to describe functional impact for all conditions present.

What to expect: The examiner will ask open-ended questions about what you can and cannot do. They may ask about your ability to walk, climb stairs, lift objects, sit for prolonged periods, concentrate, sleep, and work. Be specific and use concrete examples. Do not give general answers like 'it hurts' - describe which activities you cannot complete and why.

Critical thresholds

  • Marked limitation of daily activities Key factor supporting 40% rating; document specific activities you cannot perform or can only perform with significant difficulty or pain
  • Moderate limitation of daily activities Supports 20% rating; symptoms present more than one-third of the time

Tips

  • Prepare a written list of activities you can no longer perform or have had to modify because of fibromyalgia
  • Include occupational impacts: missed workdays, inability to maintain employment, need for accommodations
  • Include social and recreational impacts: activities you have given up
  • Describe morning stiffness duration and how it affects your ability to start your day
  • Describe post-exertional malaise - how you feel the day after physical or mental exertion

Pain considerations: Per M21-1 and DeLuca v. Brown, the examiner must consider functional limitations during flare-ups and with repeated use, not just at the time of exam. Tell the examiner: 'After I do [activity], I experience a flare that lasts [duration] and I cannot function normally for [time period].'

Associated Symptoms Review

What it measures: The presence and severity of the constellation of symptoms commonly associated with fibromyalgia, including fatigue, sleep disturbances, stiffness, paresthesias, headache, depression, anxiety, irritable bowel symptoms, Raynaud-like symptoms, and muscle weakness. These are documented on the DBQ and directly influence rating level.

What to expect: The examiner will ask about each symptom category or check boxes on the DBQ. Be prepared to describe each symptom you experience in detail, including frequency, severity, and impact. Do not wait to be asked - if the examiner does not ask about a symptom you have, volunteer the information.

Critical thresholds

  • Multiple associated symptoms present constantly or nearly constantly Supports 40% rating; demonstrates pervasive functional impairment
  • Associated symptoms present more than one-third of time Supports 20% rating
  • Symptoms precipitated by environmental or emotional stressors Relevant to rating; demonstrates episodic nature and identifies triggers that worsen condition

Tips

  • Prepare descriptions of each symptom category before the exam: fatigue level (1-10), sleep quality, stiffness duration, numbness/tingling locations, headache frequency and severity
  • Note whether symptoms are worse with stress, weather changes, physical activity, or poor sleep
  • If you have been separately diagnosed with depression, anxiety, headaches, or IBS, note those diagnoses - they may be rated separately under M21-1 guidance
  • Document how fatigue impacts your cognitive function (fibro fog) and describe specific examples
  • If you use any assistive devices, bring them to the exam

Pain considerations: Fatigue in fibromyalgia is not ordinary tiredness - it is often described as profound exhaustion that is not relieved by rest. Muscle weakness in fibromyalgia can affect grip strength, the ability to carry objects, and the ability to sustain physical activity. Describe each of these in functional terms: 'I can only walk one block before I need to rest due to fatigue and pain.'

Rating criteria by percentage

40%

With widespread musculoskeletal pain and tender points, with or without associated symptoms, that are constant or nearly constant and that refractory to therapy.

Key symptoms

  • Widespread musculoskeletal pain present constantly or nearly constantly
  • Tender points present constantly or nearly constantly
  • Symptoms refractory (not responding adequately) to treatment
  • Marked limitation of daily activities
  • Fatigue that is constant or nearly constant
  • Sleep disturbances that are constant or nearly constant
  • Multiple associated symptoms (headache, depression, anxiety, IBS, paresthesias, Raynaud-like symptoms) present constantly or nearly constantly
  • Inability to maintain gainful employment due to symptoms

From 38 CFR: 38 CFR 4.71a, DC 5025: 40% - With widespread musculoskeletal pain and tender points, with or without associated symptoms, that are constant or nearly constant and refractory to therapy.

20%

With widespread musculoskeletal pain and tender points, with or without associated symptoms, that are present more than one-third of the time.

Key symptoms

  • Widespread musculoskeletal pain present more than one-third of the time
  • Tender points positive on examination
  • Episodic flare-ups occurring regularly
  • Associated symptoms present more than one-third of the time
  • Fatigue that affects daily function intermittently
  • Sleep disturbances occurring more than one-third of nights
  • Partial response to therapy
  • Moderate limitation of daily activities during symptomatic periods

From 38 CFR: 38 CFR 4.71a, DC 5025: 20% - With widespread musculoskeletal pain and tender points, with or without associated symptoms, that are present more than one-third of the time.

10%

With widespread musculoskeletal pain and tender points, with or without associated symptoms, that are episodic, present less than one-third of the time.

Key symptoms

  • Widespread musculoskeletal pain present less than one-third of the time
  • Episodic tender point pain
  • Associated symptoms mild or infrequent
  • Reasonable response to therapy
  • Minimal limitation of daily activities
  • Symptoms manageable with current medications

From 38 CFR: 38 CFR 4.71a, DC 5025: 10% - With widespread musculoskeletal pain and tender points, with or without associated symptoms, that are episodic, present less than one-third of the time.

Describing your symptoms accurately

Widespread Musculoskeletal Pain

How to describe it: Describe your pain as affecting multiple regions of your body simultaneously - both sides, above and below the waist, and in the spine or chest wall. Use specific anatomical language: 'I have pain in my neck, shoulders, upper back, lower back, hips, and legs - it is on both sides and it does not go away.' Describe the quality (burning, aching, stabbing, throbbing), intensity (use a 0-10 scale), and how it changes throughout the day and with activity.

Example: On my worst days, which occur approximately [X times per week/month], I wake up in severe pain rated 8-9 out of 10 across my entire body. My muscles feel like they have been bruised even without injury. I cannot lift my arms above my head, I cannot grip objects tightly, and walking to the bathroom requires significant effort. The pain is present from the moment I wake up and does not subside even after rest or medication.

Examiner listens for: The examiner is determining whether pain is truly 'widespread' per VA definition (bilateral, above and below waist, axial), how frequently it occurs, and whether it is refractory to treatment. They will note whether you describe constant versus episodic pain, as this directly determines the rating level.

Avoid: Do not say 'I manage' or 'It's not that bad today' without also describing your typical or worst-day experience. Do not minimize pain by saying 'I take medication and it helps some' without also describing residual limitations even with medication.

Fatigue

How to describe it: Describe fatigue as a pervasive, non-restorative exhaustion that is not relieved by sleep or rest. Differentiate it from ordinary tiredness: 'Even after 8 hours of sleep, I wake up feeling as though I did not sleep at all. By mid-morning, I am so fatigued that I cannot concentrate or complete basic tasks.' Describe the impact on your ability to work, maintain a household, and care for yourself.

Example: On my worst days, I cannot get out of bed before noon because of exhaustion. Even simple activities like showering or preparing a meal leave me completely depleted and I must rest for 1-2 hours afterward. I have had to stop working because I cannot sustain 8 hours of activity even in a sedentary job due to my fatigue.

Examiner listens for: The examiner is assessing whether fatigue is a present, documented associated symptom of your fibromyalgia and whether it contributes to limitation of daily activities. The DBQ has a specific checkbox for fatigue - ensure the examiner checks it if you experience it.

Avoid: Do not confuse fatigue with sleepiness - they are different. Do not say 'I'm tired sometimes' - describe the functional impact in terms of what you cannot do because of fatigue. Avoid saying 'I push through it' without describing the cost of pushing through (increased pain, worsened symptoms the next day).

Sleep Disturbances

How to describe it: Describe the nature of your sleep disturbance: difficulty falling asleep due to pain, frequent awakening due to pain or discomfort, non-restorative sleep (waking unrefreshed), or early morning awakening. Note how many nights per week are affected and the downstream functional impact.

Example: I wake up 3-5 times per night because the pain in my hips and shoulders becomes unbearable when I stay in one position. Even when I do sleep, I do not feel rested in the morning. I have had chronic non-restorative sleep for [X years] which makes my pain and fatigue significantly worse during the day.

Examiner listens for: Sleep disturbance is a specific checkbox on the DBQ and is a recognized associated symptom of fibromyalgia. The examiner will note whether it is present and how frequently. This symptom, in combination with others, supports higher rating levels when constant or nearly constant.

Avoid: Do not say 'I just don't sleep well' - be specific about the pattern, frequency, and the relationship to your fibromyalgia pain. Do not omit this symptom even if you use sleep aids, because the need for medication to manage symptoms is itself evidence of severity.

Stiffness

How to describe it: Describe morning stiffness in terms of duration and severity: 'Every morning I wake up with severe stiffness throughout my entire body that lasts approximately [X] hours before I can move normally. I cannot make a fist, turn my head fully, or bend over until the stiffness partially resolves.' Note whether stiffness also occurs after prolonged sitting or inactivity.

Example: On my worst days, my morning stiffness lasts 3-4 hours and I am unable to dress myself without assistance. I have to sit on the edge of the bed for 20-30 minutes before I can stand safely. After sitting at a table for more than 30 minutes, I become stiff and need several minutes to loosen up before I can walk.

Examiner listens for: Stiffness is a checked symptom on the DBQ. The examiner will note its presence and the description will be captured in the narrative fields. This is a DeLuca factor - stiffness that worsens with repeated use or prolonged positioning is relevant to functional loss assessment.

Avoid: Do not omit stiffness simply because it eventually resolves. The duration of morning stiffness (especially when it exceeds 1 hour) is medically significant. Do not say 'I'm a little stiff in the morning' - quantify the time and describe the functional limitations during that period.

Paresthesias and Neurological Symptoms

How to describe it: Describe numbness, tingling, burning sensations, or electric shock-like feelings in specific body regions. Note whether they are bilateral or unilateral, constant or intermittent, and whether they affect your ability to use your hands or walk safely.

Example: I regularly experience burning and tingling in both hands and feet that wakes me at night. During flare-ups, the numbness in my hands is severe enough that I drop objects and cannot button clothing or use a keyboard. The tingling in my feet makes me unsteady when walking on uneven surfaces.

Examiner listens for: Paresthesias are a specific checkbox on the DBQ and are a recognized associated symptom. If your paresthesias are severe enough to have received a separate neurological diagnosis, this may be separately ratable under M21-1 guidance.

Avoid: Do not dismiss paresthesias as 'just tingling.' Describe the functional impact - what tasks cannot be performed because of numbness or tingling. Note if you have had nerve conduction studies or neurological evaluations.

Cognitive Dysfunction (Fibro Fog)

How to describe it: Describe difficulties with concentration, memory, word-finding, and mental clarity: 'I experience significant cognitive fog that makes it difficult to follow conversations, complete multi-step tasks, or remember things from hour to hour. I frequently lose my train of thought mid-sentence and cannot retain new information reliably.'

Example: On my worst days, I cannot read more than a paragraph without losing comprehension. I forget whether I have taken my medications, miss appointments despite reminders, and cannot perform job duties that require sustained attention or problem-solving. My cognitive symptoms are as disabling as my physical pain.

Examiner listens for: While fibro fog is not a separately listed checkbox on the DBQ, it falls under the broader symptom description fields and supports functional impact documentation. If cognitive symptoms are severe and separately diagnosed (e.g., as a cognitive disorder), they may be separately ratable.

Avoid: Do not omit cognitive symptoms because you believe the exam is only about physical pain. Fibro fog is a well-documented component of fibromyalgia and is directly relevant to your ability to maintain gainful employment, which affects your overall disability rating.

Flare-Ups and Triggers

How to describe it: Describe what triggers your flare-ups, how often they occur, how long they last, and what happens during them. Common triggers include physical exertion, emotional stress, weather changes, illness, and poor sleep. During a flare: 'My pain escalates from a baseline of 4/10 to 8-9/10, I become unable to perform any physical activity, and I may be bedridden for 1-5 days.'

Example: My flare-ups occur approximately [X] times per month, last [X] days each, and are triggered by [stress, physical activity, cold weather, etc.]. During a flare, I cannot get dressed without help, I cannot drive, I cannot prepare food, and I require assistance with basic personal care. After the flare subsides, I am exhausted for several additional days.

Examiner listens for: The DBQ specifically asks whether symptoms are precipitated by environmental or emotional stressors (field _96). The examiner should document flare-up frequency and severity. Per DeLuca v. Brown, the examiner must address functional limitations during flare-ups even if you appear relatively well at the time of the exam.

Avoid: Do not allow the examiner to assess your condition only based on how you present on the day of the exam. Proactively state: 'Today is not representative of my worst days. I want to make sure you understand my condition as it is during a flare-up.' The VA rates your condition on its full range, not just your best days.

Common mistakes to avoid

Appearing 'too well' at the exam by dressing up, sitting without visible distress, or minimizing pain responses during tender point testing

Why: Examiners are trained to observe your presentation from the moment you enter the building. If you appear to function normally at the exam but claim severe disability at home, this inconsistency can undermine your credibility and result in a lower rating.

Do this instead: Present authentically. If you are having a relatively better day, explicitly tell the examiner: 'I want to be clear - today is a better day than usual. My typical experience and my worst days are significantly more severe than what you are observing right now.' Use the 'worst day' framework per M21-1 guidance.

Impact: 40% vs. 20% or lower

Failing to describe all associated symptoms because you assume the examiner will ask about everything

Why: The examiner may not thoroughly probe every symptom category. If a symptom is not documented on the DBQ, it does not exist for rating purposes. Unchecked boxes mean uncounted symptoms.

Do this instead: Before the exam, prepare a written list of every associated symptom you experience (fatigue, sleep disturbance, stiffness, paresthesias, headache, depression, anxiety, IBS, Raynaud-like symptoms, muscle weakness, fibro fog). Proactively mention each one. If the examiner does not address a symptom you experience, say: 'I also experience [symptom] - is that something you will document?'

Impact: All rating levels; particularly 40% requires multiple associated symptoms

Describing symptoms only as they are on the day of the exam rather than describing your worst-day and typical-day experiences

Why: VA ratings are based on the average and worst manifestations of your condition, not a single snapshot in time. An exam conducted on a low-pain day can result in a drastically undervalued rating.

Do this instead: Use the 'worst day' framework: 'On my worst days, which occur [X times per week/month], I experience [specific, concrete limitations]. On a typical day, I experience [baseline symptoms].' Bring a symptom diary or written statement documenting your condition over the past 3-6 months.

Impact: 40% vs. 10-20%

Saying symptoms are 'manageable' or 'controlled' with medication without describing residual limitations

Why: Statements like 'my medication helps' or 'I manage okay' can lead the examiner to underestimate severity. What matters is your functional level even with treatment, and whether treatment is adequate (i.e., whether your condition is refractory).

Do this instead: If medication provides only partial relief, say exactly that: 'Even with [medication names], my pain remains at a [X]/10 on typical days and [X]/10 on bad days. The medication takes the edge off but does not restore normal function.' If you have tried multiple medications without adequate relief, emphasize that your condition is refractory to therapy - a key criterion for the 40% rating.

Impact: 40% - refractory to therapy is a specific criterion

Not bringing documentation of separately diagnosed co-existing conditions to the exam

Why: Under M21-1, conditions separately diagnosed as secondary to fibromyalgia (e.g., depression, anxiety, IBS, headaches) may be rated separately in addition to the fibromyalgia rating. If the examiner does not document these as separate diagnoses, you may lose additional rating opportunities.

Do this instead: Bring a list of all diagnosed conditions with dates of diagnosis and treating providers. Clearly state: 'I have a separate diagnosis of [condition] that my doctor has attributed to my fibromyalgia. Is that something you can document in this exam?' Request that separately diagnosed conditions be noted in the DBQ's additional diagnosis fields.

Impact: Overall combined rating - separate secondary conditions each carry their own rating

Failing to describe functional impact in concrete, specific terms

Why: Vague statements like 'it hurts to do things' do not give the examiner enough information to document functional impairment accurately. The DBQ has specific fields for functional impact description that require specific details.

Do this instead: Describe functional impact in terms of: 'I cannot [specific activity] because [specific reason related to fibromyalgia symptoms].' Examples: 'I cannot stand at a kitchen counter for more than 10 minutes without severe pain.' 'I cannot lift more than 5 pounds without my symptoms worsening.' 'I have missed an average of [X] days of work per month due to flare-ups.'

Impact: All rating levels; functional impact documentation supports higher ratings

Not mentioning use of assistive devices or adaptive behaviors you have adopted

Why: The DBQ includes specific fields for assistive devices (canes, braces, walker, crutches, wheelchair). Use of assistive devices demonstrates functional limitation and supports higher ratings. Adaptive behaviors (avoiding stairs, using a shower chair, sitting rather than standing) also demonstrate impairment.

Do this instead: Bring any assistive devices to the exam. Explicitly tell the examiner about every device or adaptive aid you use, how often you use it, and why. Even if you use a device only during flare-ups, that is relevant and should be documented.

Impact: 20-40% range; supports functional impairment documentation

Not requesting that the examiner address DeLuca factors (pain with repeated use, flare-up limitations, fatigue, weakness, incoordination)

Why: Per DeLuca v. Brown (1995) and M21-1, the examiner must address functional limitations during flare-ups and with repeated use. If the examiner fails to address these, the exam may be inadequate and your claim could be remanded - delaying your rating.

Do this instead: If the examiner completes the physical assessment without asking about flare-ups or repeated-use limitations, politely say: 'Can you also document how my condition affects me during a flare-up and after repeated activity? I understand the VA requires that information to be in the exam report.' You can also bring a written statement describing these limitations to ensure they are part of the record.

Impact: All rating levels; required for complete and adequate C&P examination

Prep checklist

  • critical

    Obtain and review all relevant medical records

    Request copies of all records documenting your fibromyalgia diagnosis, treatment history, medications, specialist notes, and any lab work or imaging from your VA and private providers. Review these to identify gaps and ensure the examiner has access to them. Know your diagnosis date and the treating provider(s) who established the diagnosis.

    before exam

  • critical

    Write a detailed symptom diary covering the past 3-6 months

    Document your daily pain levels (0-10 scale), fatigue levels, sleep quality, flare-up frequency and duration, activities you could not perform, and any triggers. This diary provides objective evidence of symptom frequency (supporting 'more than one-third of the time' or 'constant or nearly constant' criteria) and can be submitted as supporting evidence.

    before exam

  • critical

    Prepare a written 'worst day' statement

    Write a 1-2 page description of what your worst days look like: when you wake up, what pain you experience, what activities you cannot perform, how long flare-ups last, and what triggers them. Bring this to the exam and, if the examiner will not read it during the exam, submit it to your VSO or directly to the VA as a supporting lay statement (VA Form 21-4138).

    before exam

  • critical

    List all current medications prescribed for fibromyalgia

    Write down the name, dosage, prescribing provider, and whether the medication provides adequate relief for each medication. Include medications you have tried and discontinued due to inadequate effect or side effects - this supports a finding that your condition is refractory to therapy (40% criterion). Include: duloxetine, pregabalin, gabapentin, milnacipran, cyclobenzaprine, amitriptyline, tramadol, NSAIDs, sleep aids, and any others.

    before exam

  • critical

    Prepare a list of separately diagnosed co-existing conditions

    List all conditions that have been separately diagnosed and that may be related to your fibromyalgia (depression, anxiety, IBS, migraine/headaches, chronic fatigue syndrome, PTSD, sleep disorders). Include the diagnosis date, treating provider, and current treatment. Under M21-1 guidance, these may be separately ratable in addition to your fibromyalgia rating.

    before exam

  • critical

    Prepare a functional impact statement describing what you cannot do

    List 10-15 specific activities you can no longer perform or must modify because of fibromyalgia. Be concrete: 'I cannot stand for more than 15 minutes without increasing pain to 8/10.' 'I cannot work a full day.' 'I require help with grocery shopping because carrying bags causes flare-ups.' Include household, occupational, recreational, and personal care impacts.

    before exam

  • recommended

    Identify your flare-up triggers and document their frequency

    The DBQ specifically asks whether symptoms are precipitated by environmental or emotional stressors. Prepare to describe: physical exertion triggers, stress triggers, weather triggers, sleep deprivation triggers, illness triggers, and any others. Note approximately how many flare-ups you have per month and the average duration.

    before exam

  • recommended

    Contact your VSO or accredited claims agent to review your claim file

    Ask your Veterans Service Organization (VSO), accredited claims agent, or VA-accredited attorney to review your C-file before the exam to ensure all relevant evidence is associated with your claim. Identify any evidence gaps that could be filled before the exam date.

    before exam

  • recommended

    Research your state's recording laws

    Most states permit one-party consent recording, meaning you can record the exam with only your own consent. Check your state's law and, if permitted, bring a recording device (phone or dedicated recorder). Inform the examiner at the start that you are recording. A recording protects your interests if the DBQ does not accurately capture what was discussed.

    before exam

  • recommended

    Wear comfortable, accessible clothing to the exam

    Wear loose-fitting clothing that allows easy access to tender point locations on your neck, shoulders, upper back, lower back, hips, elbows, and knees. Avoid tight clothing, high collars, or layers that would require removal. Comfortable clothing also helps you move naturally during the examination rather than compensating for restrictive garments.

    before exam

  • critical

    Do not take extra pain medication before the exam to reduce symptoms

    Attend the exam in your typical medicated state - do not take additional medication beyond your regular regimen in order to appear more comfortable. If you are more comfortable than usual due to your medication, tell the examiner: 'I have taken my regular medications, and even so, this is better than my typical day.' The examiner needs to assess your condition as it actually presents.

    day of

  • recommended

    Arrive early and observe your pain and mobility honestly

    Arrive 15-20 minutes early. Notice how you feel - your pain level, fatigue level, and any specific limitations you are experiencing that day. Be prepared to describe this honestly and to contrast it with your typical and worst-day experiences. Do not 'perform' for the examiner in either direction.

    day of

  • critical

    Bring all prepared documents and any assistive devices

    Bring your symptom diary, worst-day statement, medication list, functional impact statement, co-existing condition list, and any assistive devices (cane, brace, etc.) you use. While the examiner may not read all documents during the exam, having them available reinforces your credibility and allows you to reference specific details accurately.

    day of

  • optional

    Bring a support person if needed

    You have the right to bring a support person (family member, VSO, or advocate) to your C&P exam. A support person can observe the exam, take notes, and help you remember details afterward. Inform the examiner at the start that your support person is present. The support person should not answer questions on your behalf but may take notes.

    day of

  • critical

    Clearly affirm pain at each tender point when it is genuinely painful

    When the examiner presses on each of the 18 tender point sites, clearly say 'Yes, that is painful' if it is painful. Do not say 'a little' or 'sort of' if the pressure genuinely causes pain - say 'Yes, that is painful' without qualification. If it is not painful, say 'No.' Be honest - do not affirm pain at sites that are not painful.

    during exam

  • critical

    State that today may not represent your worst or typical experience

    At an appropriate point in the interview (usually when asked how you are doing or when describing your symptoms), clearly state: 'I want to make sure you understand that today is [better than usual/a typical day/worse than usual]. My symptoms on my worst days are significantly [more severe / as I described]. I want the exam to reflect my full range of symptoms, not just today.'

    during exam

  • critical

    Proactively address DeLuca factors if the examiner does not ask

    If the examiner does not ask about your condition during flare-ups, after repeated activity, or with prolonged use, volunteer this information: 'I also want to make sure you document how my symptoms change during a flare-up and after repeated physical activity - can I describe that?' The VA requires examiners to address these factors, and if they are not addressed, your exam may be inadequate for rating purposes.

    during exam

  • critical

    Describe each associated symptom proactively

    As the examiner works through the symptom checklist (fatigue, sleep disturbance, stiffness, paresthesias, headache, depression, anxiety, IBS, Raynaud-like symptoms, muscle weakness), provide a brief, specific description of each symptom you experience. Do not just answer 'yes' or 'no' - add: 'Yes, my fatigue is severe and occurs daily' or 'Yes, I have sleep disturbances approximately 5 nights per week.'

    during exam

  • critical

    Describe functional impact with specific examples

    When asked about what you can and cannot do, give concrete, specific examples: 'I cannot stand at the kitchen counter long enough to cook a meal.' 'I can walk approximately one block before pain forces me to stop and rest.' 'I have not been able to work since [date] because of my fibromyalgia.' Avoid vague statements - specificity is what gets documented.

    during exam

  • recommended

    Request clarification if the examiner asks a confusing question

    If you do not understand a question, ask for clarification: 'Could you rephrase that?' or 'Are you asking about my symptoms at their worst or on a typical day?' It is better to ask for clarification than to give an inaccurate answer that gets recorded in your DBQ.

    during exam

  • critical

    Write down everything you remember about the exam immediately afterward

    As soon as you leave the exam (in the parking lot if necessary), write down or dictate into your phone everything you remember: what the examiner said, what questions were asked, what you answered, whether the examiner checked all 18 tender points, whether DeLuca factors were addressed, and any concerns about the exam's adequacy. This record is important if you need to challenge the exam report.

    after exam

  • critical

    Request a copy of the completed DBQ

    You have the right to request a copy of the completed DBQ exam report through your VA MyHealtheVet portal, through a FOIA request, or through your VSO. Review the report carefully when it becomes available. If it contains inaccuracies, omissions of symptoms you described, or failure to address DeLuca factors, notify your VSO immediately - you may be able to request a supplemental exam.

    after exam

  • recommended

    Submit a personal statement (VA Form 21-4138) addressing any gaps

    If the exam did not fully capture your symptoms, functional limitations, flare-up frequency, or worst-day experience, submit a signed personal statement (VA Form 21-4138 or equivalent) to supplement the exam record. Submit it through your VSO or directly to the VA Evidence Intake Center promptly. Your statement becomes part of the record of evidence.

    after exam

  • recommended

    Follow up with your treating physician for a nexus or support letter if needed

    Ask your treating rheumatologist, primary care physician, or pain specialist to write a letter supporting your disability claim. This letter should address: the diagnosis, the severity and frequency of symptoms, the functional limitations caused by fibromyalgia, any secondary conditions caused by fibromyalgia, and whether your condition is refractory to therapy. A private physician's opinion can supplement or challenge an inadequate C&P exam.

    after exam

Your rights during a C&P exam

  • You have the right to record your C&P examination in most states under one-party consent recording laws - verify your state's law before the exam and inform the examiner if you are recording.
  • You have the right to bring a support person (family member, VSO representative, or advocate) to your C&P examination to observe and take notes.
  • You have the right to request a copy of the completed DBQ examination report through the VA's medical records release process or your MyHealtheVet portal.
  • You have the right to request a new or supplemental C&P examination if the original exam is inadequate - for example, if it fails to address DeLuca factors, does not examine all 18 tender point sites, or contains factual errors.
  • You have the right to submit lay statements (VA Form 21-4138) from yourself, family members, friends, coworkers, or other witnesses describing your symptoms and functional limitations - these are competent evidence.
  • You have the right to submit a private medical opinion (Independent Medical Examination or IMO) from a physician of your choosing to supplement or rebut the C&P examiner's opinion.
  • You have the right to be rated on the full range of your condition's severity, including your worst-day experience, not just your presentation on the day of the exam - per M21-1 guidance.
  • You have the right to appeal a rating decision you disagree with through the Supplemental Claim, Higher-Level Review, or Board of Veterans' Appeals lanes under the Appeals Modernization Act.
  • You have the right to free claims assistance from accredited Veterans Service Organizations (VSOs), VA-accredited claims agents, and VA-accredited attorneys - you do not need to navigate this process alone.
  • You have the right to separate ratings for conditions diagnosed secondary to your fibromyalgia (such as depression, anxiety, IBS, or headaches) in addition to your fibromyalgia rating, provided they are separately diagnosed - per M21-1, Part V, Subpart iii, Section F.
  • You have the right to have the benefit of the doubt applied in your favor when the evidence is in approximate balance - per 38 CFR 3.102, the VA must give you the benefit of the doubt when there is an equal amount of evidence for and against your claim.
  • You have the right to a Total Disability Rating based on Individual Unemployability (TDIU) if your fibromyalgia (alone or in combination with other service-connected conditions) prevents you from maintaining substantially gainful employment, even if your combined rating does not reach 100%.

Related conditions

Get a personalized prep packet

This guide covers what to expect for any veteran with this condition. If you have already uploaded your medical records, sign in to generate a packet that maps your specific symptoms to the DBQ fields your examiner will fill out.

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This C&P exam preparation guide is for educational purposes only and does not constitute legal, medical, or claims advice. Always consult with a qualified Veterans Service Organization (VSO) representative or VA-accredited attorney for guidance specific to your claim. Never exaggerate, minimize, or fabricate symptoms during a C&P examination.