Chapter 02 - General Instructions

2.01 - Identity of Pensioner

The identity of the pensioner must be established and his signature obtained, if feasible, on any document containing his own description of his symptoms. Particulars of height, weight, date of birth, and other physical features are to be recorded on each occasion and compared with previous records.

2.02 - History and Current Symptoms

History and previous symptoms must be recorded fully when application for entitlement is made. At subsequent examinations for the re- assessment of disability, care must be taken to record a fair and full account of the symptoms, attributed by the pensioner or the examiner to a pensioned condition, with the use of leading questions, if necessary. This would include an account of medical or hospital treatment and interference with work and other activities. The onset of a new disability or aggravation of a pensioned condition by recent injury should be noted.

2.03 - Physical Examination

1. The record should describe the loss or impairment of function, and evidence of remaining function, even if these are also described in current reports by other examiners.
2. The effects of non-pensioned conditions must be described;
   1. when they may be confused with the pensioned condition; and
   2. when entitlement is claimed, or may be claimed.
3. Apart from obtaining data, the Medical Officer is not required to carry out a complete functional enquiry or general physical examination at each review, as these services are provided in Canada through publicly-supported medical plans.
4. Examination by a Medical Specialist is often required for diagnosis and description of the progress of the disability. This will be done through Treatment Services of the Department, as a rule, but non- departmental Specialists in other communities may be employed in the interests of economy or convenience or for other reasons. The SDMO in requesting an examination and report should state the purpose and indicate Veterans Affairs Canada requirements. It is essential to have on record the history, clinical and laboratory findings on which the Specialist's opinion is based.
5. In assessing disability, the provisions of the Table of Disabilities as well as the provisions of the Pension Act shall, in the words of section 2… "be liberally construed and interpreted, etc…". The exercise of good judgement and careful attention to all relevant information are essential.
6. The Table of Disabilities exists only to assist Veterans Affairs Canada in fulfilling its responsibilities. It does not offer final or absolute values.