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C&P Exam Prep: Leukemia
DBQ Overview
Interview + Physical- Form Name
- Hematologic_and_Lymphatic_Conditions_Including_Leukemia
- Form Code
- Hematologic_and_Lymphatic_Conditions_Including_Leukemia
- Page Count
- 10
- Examiner Type
- Hematologist or Oncologist
- Estimated Duration
- 30-45 minutes
- Exam Format
- Interview + Physical
What to Expect During Your Exam
Exam Overview
To evaluate the current severity, treatment requirements, and functional impact of leukemia for VA disability compensation purposes under 38 CFR 4.117, DC 7703. The examiner will document disease status (active vs. remission), treatment history and current regimen, laboratory values, and any complications or residual effects.
What the examiner evaluates:
- Specific leukemia type (CLL, CML, AML, ALL, hairy cell, chronic granulocytic, etc.)
- Disease status: active, in remission, or in treatment phase
- Current and prior treatment modalities (chemotherapy, biologic therapy, myelosuppressive therapy, interferon, transplant)
- Frequency and severity of infections secondary to immunosuppression
- Blood count laboratory values (CBC with differential, platelet count, hemoglobin, hematocrit, RBC, WBC)
- Bone marrow or peripheral blood stem cell transplant history
- Whether continuous biologic or myelosuppressive therapy is required
- Functional limitations and impact on daily life and employment
- Comorbidities and secondary conditions related to leukemia or its treatment
Exam is typically conducted in person by a hematologist or oncologist. Bring all oncology and hematology records. The examiner will review laboratory values and treatment records in detail. You have the right to request recording of the exam in most states - confirm your state law before the appointment.
Typical duration: 30-45 minutes
Complete Blood Count (CBC) with Differential
White blood cell count, red blood cell count, hemoglobin, hematocrit, platelet count, and WBC differential - all critical for leukemia rating criteria
What to expect:
Blood draw results from recent labs (within 90 days preferred). Examiner will review most recent values and document them on the DBQ. Bring printed copies of your most recent lab reports.
Key thresholds:
- WBC significantly elevated or suppressed — Helps establish active disease vs. remission and supports treatment necessity documentation
- Platelet count at or below 30,000 — Supports higher-severity ratings related to thrombocytopenic complications
- Platelet count 30,001-50,000 — Intermediate severity marker for rating purposes
- Hemoglobin severely reduced — Supports anemia as a complication requiring separate or combined evaluation
Tips:
- Bring the actual printed lab reports - do not rely solely on the examiner having access to records
- If your counts fluctuate, bring labs showing your worst values in the past 12 months
- Note the date of each lab draw clearly so the examiner can document the date alongside each value
- If you require growth factor support to maintain counts, bring documentation of that treatment
Pain considerations: Laboratory values alone do not capture the full functional burden. Be prepared to verbally describe fatigue, weakness, and functional limitations associated with abnormal blood counts.
Bone Marrow Biopsy or Aspiration Results
Bone marrow cellularity, blast percentage, and disease activity - central to confirming remission status or active disease
What to expect:
Examiner will review pathology reports. Bring copies of all bone marrow biopsy results with dates and findings.
Key thresholds:
- Residual or recurrent disease on biopsy — Supports active disease classification and highest-tier ratings
- Complete remission on biopsy — May affect rating level - ensure treatment burden and residual symptoms are fully documented even in remission
Tips:
- Bring the full pathology report, not just a summary
- If biopsy showed remission but you are still on continuous therapy, emphasize that treatment is ongoing
- Note how the biopsy procedure itself affects you - pain, recovery time, anxiety
Pain considerations: Bone marrow biopsies are painful procedures. Accurately describe the procedural burden and recovery to your examiner as part of your overall treatment narrative.
Molecular and Genetic Markers (e.g., BCR-ABL for CML, FISH, PCR)
Minimal residual disease, chromosomal abnormalities, and treatment response at the molecular level
What to expect:
Examiner may review molecular testing results to determine remission depth (e.g., complete molecular response) and to classify CML phase (chronic, accelerated, blast).
Key thresholds:
- Detectable BCR-ABL or other molecular marker despite therapy — Indicates continued disease activity even if CBC appears normal; supports ongoing treatment necessity
- Undetectable molecular marker on continuous targeted therapy — May support 'apparent remission on continuous molecularly targeted therapy' classification for CML
Tips:
- Bring all molecular monitoring test results with dates
- For CML veterans, document whether you are on continuous tyrosine kinase inhibitor (TKI) therapy and whether discontinuation has been attempted or is medically inadvisable
- If your oncologist has stated that lifelong therapy is required, ask for a written statement to that effect
Pain considerations: Side effects of TKIs and targeted therapies (fatigue, musculoskeletal pain, fluid retention, GI symptoms) should be described in detail as part of your overall symptom picture.
Rating Criteria Breakdown
| Rating % | Criteria | Key Symptoms |
|---|---|---|
| 100% | Active leukemia - active disease requiring treatment, including active disease during treatment phase, or active disease requiring bone marrow or peripheral blood stem cell transplant. Under 38 CFR 4.117 and General Rating Formula for Hematologic and Lymphatic Conditions, a 100% rating applies to active leukemia requiring continuous biologic therapy or myelosuppressive therapy, or requiring bone marrow/stem cell transplant. Note: A minimum 1-year 100% rating is assigned following transplant. |
CFR: Active leukemia requiring continuous biologic therapy or myelosuppressive therapy = 100%. Active disease requiring bone marrow or stem cell transplant = 100% (minimum 1 year post-transplant). CML in apparent remission on continuous molecularly targeted therapy is rated under the CML criteria which may still yield 100% if continuous therapy is required. |
| 100% | CML (Chronic Myeloid/Myelogenous Leukemia) in apparent remission on continuous molecularly targeted therapy - still rated 100% if continuous molecularly targeted therapy (e.g., TKI such as imatinib, dasatinib) is required to maintain remission. Rate intermittent myelosuppressive therapy or molecularly targeted therapy at lower levels. |
CFR: CML in apparent remission on continuous molecularly targeted therapy = 100%. CML requiring intermittent myelosuppressive or molecularly targeted therapy = lower rating. See also DC 7703 cross-reference to General Rating Formula for Hematologic Conditions. |
| 60% | Leukemia in remission but requiring intermittent treatment - includes intermittent myelosuppressive therapy, intermittent molecularly targeted therapy, requiring intermittent use of myeloid growth factors, or infections recurring on average at least once every three months per 12-month period. Also applies to CLL or other B-cell leukemia complete remission with residual functional impact at this level. |
CFR: Leukemia in remission requiring intermittent myelosuppressive or molecularly targeted therapy = 60%. Infections recurring on average at least once every three months per 12-month period = 60%. Requiring intermittent myeloid growth factors = 60%. |
| 30% | Leukemia in remission with residual lower-level treatment requirements - includes continuous medication (e.g., antibiotics) for infection control, infections recurring on average at least once per 12-month period, or requiring continuous medication but not myelosuppressive/biologic therapy. Functional limitations are present but less severe. |
CFR: Leukemia in remission requiring continuous medication such as antibiotics for infection control = 30%. Infections recurring on average at least once per 12-month period = 30%. |
| 0% | Leukemia in complete remission with no current treatment requirements and no significant residual symptoms - asymptomatic with no medication required for control of the condition. Note: A non-compensable (0%) rating is still service-connected, preserving future claims for worsening and establishing eligibility for certain VA benefits. |
CFR: Asymptomatic leukemia in remission requiring no treatment = 0% (non-compensable but service-connected). Veterans should still document any residual effects of prior treatment, as these may support a higher evaluation. |
100% Active leukemia - active disease requiring treatment, includ ...
Active leukemia - active disease requiring treatment, including active disease during treatment phase, or active disease requiring bone marrow or peripheral blood stem cell transplant. Under 38 CFR 4.117 and General Rating Formula for Hematologic and Lymphatic Conditions, a 100% rating applies to active leukemia requiring continuous biologic therapy or myelosuppressive therapy, or requiring bone marrow/stem cell transplant. Note: A minimum 1-year 100% rating is assigned following transplant.
Key Symptoms
- Active leukemia confirmed by laboratory or biopsy
- Currently undergoing chemotherapy, immunotherapy, biologic therapy, or myelosuppressive therapy
- Requiring or having undergone bone marrow or peripheral blood stem cell transplant
- Severe fatigue precluding even light manual labor
- Recurrent serious infections requiring hospitalization
- Profound cytopenias (severe anemia, thrombocytopenia, neutropenia)
- Complete functional impairment
CFR: Active leukemia requiring continuous biologic therapy or myelosuppressive therapy = 100%. Active disease requiring bone marrow or stem cell transplant = 100% (minimum 1 year post-transplant). CML in apparent remission on continuous molecularly targeted therapy is rated under the CML criteria which may still yield 100% if continuous therapy is required.
100% CML (Chronic Myeloid/Myelogenous Leukemia) in apparent remis ...
CML (Chronic Myeloid/Myelogenous Leukemia) in apparent remission on continuous molecularly targeted therapy - still rated 100% if continuous molecularly targeted therapy (e.g., TKI such as imatinib, dasatinib) is required to maintain remission. Rate intermittent myelosuppressive therapy or molecularly targeted therapy at lower levels.
Key Symptoms
- On continuous TKI or targeted therapy with no interruption
- Molecular monitoring ongoing (PCR, FISH testing)
- Side effects of continuous therapy (fatigue, fluid retention, GI distress, musculoskeletal pain)
- Unable to discontinue therapy without risk of relapse as documented by oncologist
CFR: CML in apparent remission on continuous molecularly targeted therapy = 100%. CML requiring intermittent myelosuppressive or molecularly targeted therapy = lower rating. See also DC 7703 cross-reference to General Rating Formula for Hematologic Conditions.
60% Leukemia in remission but requiring intermittent treatment - ...
Leukemia in remission but requiring intermittent treatment - includes intermittent myelosuppressive therapy, intermittent molecularly targeted therapy, requiring intermittent use of myeloid growth factors, or infections recurring on average at least once every three months per 12-month period. Also applies to CLL or other B-cell leukemia complete remission with residual functional impact at this level.
Key Symptoms
- Leukemia in remission but requiring intermittent chemotherapy or targeted therapy
- Infections recurring on average at least once every three months per 12-month period
- Requiring intermittent myeloid growth factors (G-CSF, GM-CSF) to maintain counts
- Requiring 1-3 blood or platelet transfusions per 12-month period
- Significant fatigue limiting work capacity to light manual labor only
- Residual immunosuppression with documented recurrent infections
CFR: Leukemia in remission requiring intermittent myelosuppressive or molecularly targeted therapy = 60%. Infections recurring on average at least once every three months per 12-month period = 60%. Requiring intermittent myeloid growth factors = 60%.
30% Leukemia in remission with residual lower-level treatment re ...
Leukemia in remission with residual lower-level treatment requirements - includes continuous medication (e.g., antibiotics) for infection control, infections recurring on average at least once per 12-month period, or requiring continuous medication but not myelosuppressive/biologic therapy. Functional limitations are present but less severe.
Key Symptoms
- Leukemia in confirmed remission
- Requiring continuous medication such as prophylactic antibiotics for infection control
- Infections recurring on average at least once per 12-month period but less frequently than every 3 months
- Some fatigue affecting capacity for heavy labor but able to perform light work
- Residual effects of prior treatment (neuropathy, fatigue, immune compromise)
CFR: Leukemia in remission requiring continuous medication such as antibiotics for infection control = 30%. Infections recurring on average at least once per 12-month period = 30%.
0% Leukemia in complete remission with no current treatment req ...
Leukemia in complete remission with no current treatment requirements and no significant residual symptoms - asymptomatic with no medication required for control of the condition. Note: A non-compensable (0%) rating is still service-connected, preserving future claims for worsening and establishing eligibility for certain VA benefits.
Key Symptoms
- Complete remission confirmed
- No ongoing treatment required
- No recurrent infections
- No significant functional limitations attributable to leukemia
- Laboratory values within normal limits
CFR: Asymptomatic leukemia in remission requiring no treatment = 0% (non-compensable but service-connected). Veterans should still document any residual effects of prior treatment, as these may support a higher evaluation.
How to Describe Your Symptoms
Fatigue and Energy Level
How to describe:
Describe fatigue as it affects your worst days - not your average or best days. Quantify how many hours per day you can be active before exhaustion, whether you need daytime naps, and how fatigue has changed your work capacity, household functioning, and social participation. Use concrete comparisons (e.g., 'Before leukemia I could work 8-hour shifts; now I am exhausted after 2 hours of light activity').
Worst-day example:
“On my worst days - which occur approximately 2-3 times per week - I am unable to get out of bed for more than 4 hours total. I cannot drive, prepare meals, or perform basic household tasks without needing to lie down. The fatigue is not relieved by rest and has been present continuously since beginning chemotherapy.”
What the examiner listens for:
Frequency and duration of severe fatigue episodes, impact on employment and activities of daily living, whether fatigue is treatment-related or disease-related or both, and any objective documentation such as employer accommodations or reduced work hours.
Understatements to avoid:
Saying 'I get a little tired' or 'I manage okay' when you are actually unable to sustain full-time employment or normal daily activities. Do not minimize fatigue because you are still functional on good days.
Infection History and Frequency
How to describe:
Provide a specific accounting of every infection in the past 12 months - dates, type of infection (e.g., pneumonia, bacteremia, UTI, cellulitis), treatment required (outpatient antibiotics vs. hospitalization), and duration of illness. The rating criteria specifically hinge on infection frequency (once per 12 months = 30%; once every 3 months = 60%; hospitalizations 1-2 times = higher tier; 3+ hospitalizations = highest tier).
Worst-day example:
“In the past 12 months I have had four infections: a hospitalization for pneumonia in January lasting 5 days, an outpatient URI requiring antibiotics in April, a skin infection requiring IV antibiotics in July, and a fever of unknown origin requiring emergency evaluation and hospitalization in October. I take prophylactic antibiotics daily and still experience recurring infections.”
What the examiner listens for:
Exact number of infections, whether hospitalization was required, what organisms were involved, whether prophylactic antibiotics are ongoing, and whether immunocompromise from leukemia or its treatment is documented as the cause of recurrent infections.
Understatements to avoid:
Forgetting to mention infections that seemed minor at the time, or omitting ER visits that did not result in overnight hospitalization. Also do not fail to mention that you are on continuous prophylactic antibiotics - this alone supports a 30% rating floor.
Treatment Burden and Current Regimen
How to describe:
Describe every current medication and procedure related to your leukemia treatment - oral targeted therapy (TKIs), IV chemotherapy cycles, biologic injections, growth factor injections, blood or platelet transfusions, and monitoring procedures. Specify whether treatment is continuous (daily, weekly) or intermittent (monthly, quarterly cycles). Describe side effects that affect daily functioning.
Worst-day example:
“I take imatinib 400mg daily without interruption. I cannot discontinue this medication without my oncologist's guidance because doing so risks disease progression. I receive monthly blood draws and quarterly molecular monitoring. Side effects include daily nausea, fluid retention in my legs, muscle cramps that wake me at night 3-4 times per week, and chronic fatigue that limits me to approximately 4 hours of productive activity per day.”
What the examiner listens for:
Whether therapy is continuous vs. intermittent, the specific drugs and doses, whether therapy is myelosuppressive or biologic, side effect burden, frequency of monitoring visits, and whether the veteran's oncologist has documented the medical necessity of ongoing treatment.
Understatements to avoid:
Saying 'I just take a pill every day' when that pill is a continuous molecularly targeted therapy required to maintain remission - this distinction is critical for CML rating at 100%. Always specify the drug name and document that it is continuous and cannot be stopped.
Functional Impact on Work and Daily Life
How to describe:
Describe specifically what you can and cannot do as a result of your leukemia, treatment side effects, and associated symptoms. Address physical labor capacity, cognitive functioning (chemo brain), emotional health, ability to maintain employment, and any accommodations or job changes made because of your condition.
Worst-day example:
“I was a construction foreman prior to my leukemia diagnosis. I have been unable to return to physical labor since beginning treatment. I currently work part-time as a desk clerk - 20 hours per week maximum - because fatigue and frequent medical appointments prevent full-time work. I have lost over 40 pounds. I am unable to lift more than 10 pounds, cannot stand for more than 30 minutes without needing to sit, and have cognitive difficulties remembering instructions and completing complex tasks.”
What the examiner listens for:
Occupational impact, activities of daily living limitations, cognitive effects, whether the veteran meets the criteria for 'symptoms preclude other than light manual labor' or 'symptoms preclude even light manual labor,' and the overall functional burden documented on the DBQ's impact section.
Understatements to avoid:
Underreporting cognitive effects (chemo brain), emotional/psychiatric impact, or changes in employment. Do not say you are 'doing fine at work' if you have had to reduce hours, change jobs, or receive accommodations.
Transplant History and Post-Transplant Status
How to describe:
If you have undergone bone marrow or peripheral blood stem cell transplant, provide exact dates of hospital admission, transplant date, and hospital discharge. Describe the ongoing post-transplant monitoring, immunosuppressive medications required post-transplant, graft-versus-host disease (GVHD) if present, and any complications or residual effects.
Worst-day example:
“I underwent allogeneic bone marrow transplant on [date] and was hospitalized for 47 days. Since discharge I have required continuous immunosuppressive therapy for graft-versus-host disease affecting my skin and GI tract. I attend transplant clinic monthly. I remain profoundly immunocompromised and have been hospitalized twice in the past year for infections. I am unable to work and require assistance with daily activities.”
What the examiner listens for:
Exact transplant dates, type of transplant (autologous vs. allogeneic, bone marrow vs. peripheral blood), whether a minimum 1-year 100% rating period applies, current post-transplant treatment requirements, and any GVHD complications requiring separate evaluation.
Understatements to avoid:
Failing to bring hospital admission and discharge records for the transplant. Also do not fail to mention GVHD - it may be a separately ratable condition or may support continuation of high-level ratings beyond the initial post-transplant period.
Common Mistakes to Avoid
Describing symptoms on your average or best day rather than your worst day
VA rating criteria under M21-1 guidance require evaluation of the condition at its worst - describing only average functioning systematically underrepresents your actual disability level
Instead: Explicitly state 'On my worst days, which occur [frequency]...' and describe the full severity of those episodes. Bring a symptom diary or journal documenting bad days with dates.
Impact: All levels - particularly the difference between 60% and 100%
Failing to specify whether treatment is continuous or intermittent
For CML and other leukemias, the distinction between continuous and intermittent therapy is the single most important factor separating a 100% rating from a 60% rating under the rating schedule
Instead: Explicitly state 'I take [drug name] every day without interruption' or 'I receive IV chemotherapy in cycles every [X] weeks.' Bring medication bottles, pharmacy printouts, and infusion records. Ask your oncologist for a letter confirming continuous therapy is medically required.
Impact: Difference between 60% and 100%
Not bringing printed lab results to the exam
The DBQ requires specific documented laboratory values including WBC, WBC differential, RBC count, hemoglobin, hematocrit, and platelet count with dates. If the examiner cannot access your records electronically, these fields may be left blank or estimated.
Instead: Print or download your most recent CBC with differential, your worst CBC results from the past 12 months, and any bone marrow or molecular monitoring results. Organize them chronologically in a folder.
Impact: All levels - missing lab values can prevent accurate rating
Not reporting all infections, including those treated outpatient
The rating criteria specifically count infection frequency per 12-month period. Veterans often forget minor infections treated with antibiotics, but these count toward the threshold for 30% vs. 60% ratings.
Instead: Before the exam, review your records and create a written list of every infection episode in the past 12 months with approximate dates, symptoms, treatment (antibiotic course vs. ER visit vs. hospitalization), and duration.
Impact: Difference between 30% and 60%
Downplaying remission status without documenting treatment burden
Veterans sometimes assume that being 'in remission' means they are not disabled, when in fact continuous therapy required to maintain remission (especially for CML on TKIs) still warrants 100% rating under the rating schedule
Instead: Even if your oncologist says you are in remission, document every medication, every side effect, every monitoring appointment, and every treatment that is ongoing. Remission on continuous therapy is not the same as no disability.
Impact: Difference between 0% and 100%
Forgetting to mention transplant hospitalization dates
Post-transplant rating requires documentation of the exact hospitalization dates. A minimum 1-year 100% rating follows transplant, but only if the dates are documented in the DBQ. Missing dates may result in the evaluator being unable to assign this rating.
Instead: Bring copies of the hospital admission and discharge paperwork for your transplant hospitalization. The DBQ specifically asks for date of hospital admission and date of discharge after transplant.
Impact: 100% (post-transplant minimum rating period)
Not addressing secondary conditions separately
Leukemia treatment can cause peripheral neuropathy, avascular necrosis, cardiac toxicity, secondary cancers, cognitive impairment, and other conditions that may be separately ratable as secondary service-connected disabilities - dramatically increasing combined rating
Instead: List every health condition you have developed since your leukemia diagnosis or treatment. Ask your treating providers to document the relationship between those conditions and your leukemia or its treatment. File secondary claims for each one.
Impact: Combined rating - indirect impact across all rating levels
Prep Checklist
Before Your Exam
Day Of
During the Exam
After the Exam
Your Rights During a C&P Exam
- You have the right to request a copy of the completed DBQ examination report after it is finalized - submit a request through your VSO or via FOIA to the VA Regional Office.
- In most states, you have the right to record your C&P examination - research your state's consent laws and inform the examiner at the start of the exam that you will be recording.
- You have the right to submit a personal statement (VA Form 21-4138) clarifying or correcting the record if you believe the DBQ does not accurately reflect your condition.
- You have the right to submit a private medical opinion or Nexus letter from your own treating oncologist or hematologist to supplement or rebut the C&P examination findings.
- You have the right to bring a VSO representative, accredited claims agent, or accredited attorney to your C&P examination as an observer (though they may not participate in the examination itself - confirm current VA policy).
- You have the right to request a new C&P examination if you believe the original examination was inadequate - this is typically raised through a Higher-Level Review or Supplemental Claim.
- You have the right to a Higher-Level Review, Supplemental Claim, or Board of Veterans Appeals review if you disagree with the rating decision that follows this examination - each pathway has specific evidence and procedural requirements.
- You have the right to have all relevant evidence in your VA claims file reviewed before a rating decision is made - ensure your oncology records, lab results, and supporting letters are submitted to your claims file before the exam.
- You have the right to request an earlier effective date if evidence shows your leukemia was service-connected prior to the date of your claim - work with a VSO or accredited representative to evaluate potential earlier effective dates.
- Under the PACT Act, veterans with certain leukemia diagnoses (particularly AML, ALL, and CLL) who were exposed to burn pits, Agent Orange, or certain radiation exposures may have presumptive service connection - confirm your presumptive eligibility with a VSO before your exam.
Related Conditions
- Chronic Myeloid Leukemia (CML) Specific leukemia subtype rated under DC 7703 with unique criteria for continuous molecularly targeted therapy and apparent remission on TKI therapy
- Chronic Lymphocytic Leukemia (CLL) Specific leukemia subtype rated under DC 7703; CLL staging (Rai Stage 0 = asymptomatic) affects rating level selection on the DBQ
- Myelodysplastic Syndromes (MDS) DC 7725 MDS that progresses to leukemia is evaluated as leukemia under DC 7703; also rated under the General Rating Formula for Hematologic Conditions
- Polycythemia Vera DC 7704 if polycythemia vera undergoes leukemic transformation, it is evaluated as leukemia under DC 7703
- Aplastic Anemia DC 7716 shares treatment modalities (bone marrow transplant, immunosuppressive therapy, growth factors) with leukemia; may be a comorbid or secondary condition
- Peripheral Neuropathy Frequently develops as a secondary condition due to chemotherapy neurotoxicity (vincristine, taxanes, platinum agents); separately ratable as a secondary service connected disability
- Immune Thrombocytopenia (ITP) DC 7681 may develop secondary to leukemia or its treatment; platelet count thresholds are shared rating criteria elements; separately ratable
- Acquired Hemolytic Anemia DC 7671 may develop as a complication of CLL or treatment; separately ratable under the hematologic rating schedule
- Secondary Malignancy Treatment related secondary cancers (e.g., therapy related MDS or AML from prior chemotherapy or radiation) may be separately ratable as secondary service connected conditions
- Depression and Anxiety (Cancer-Related) Mental health conditions secondary to a leukemia diagnosis are common and separately ratable under 38 CFR 4.130; file separately for maximum combined disability rating
- Graft-Versus-Host Disease (GVHD) Develops following allogeneic bone marrow or stem cell transplant; multi organ manifestations (skin, GI, liver, lungs) are separately ratable as secondary service connected conditions following leukemia treatment
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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.