Citation Nr: 18147251
Decision Date: 11/02/18	Archive Date: 11/02/18

DOCKET NO. 16-10 470
DATE:	November 2, 2018
REMANDED
Entitlement to service connection for a low back disability is remanded.
Entitlement to service connection for headaches is remanded.
REASONS FOR REMAND
The Veteran served on active duty from October 2004 to January 2006 with possible additional active duty time from July 2001 to November 2001.
While this case is being remanded, it is necessary to include a search for the Veteran’s complete military personnel files to include any state National Guard service records. The RO includes service dates of July 2001 to November 2001 in its August 2014 rating decision, but the file does not include any certificate of release or discharge (DD-214) from that period, nor are there any military personnel records in the file. While the file does contain some service treatment records from this period, those records alone are not sufficient to determine duty dates or status.
1. Entitlement to service connection for a low back disability is remanded.
The Board cannot make a fully-informed decision on the issue of service connection for a low back disability because the July 2014 VA examiner did not provide an opinion whether the Veteran’s current low back disability and right lower extremity radiculopathy was caused or aggravated by service. Therefore on remand, a supplemental medical opinion should be obtained that provides this opinion with an adequate rationale. 
2. Entitlement to service connection for headaches is remanded.
The Board cannot make a fully-informed decision on the issue of service connection for headaches because no VA examiner has opined whether the Veteran’s current headache disorder were caused or aggravated by her active service. The Veteran’s service treatment records show that the the Veteran complained of air quality and dust issues while on active duty and began to have head congestion and headaches. The Veteran also had allergic rhinitis while in service. On remand a VA examination should be provided to obtain a medical opinion to determine whether the Veteran’s current complains of headaches were caused or aggravated by her allergic rhinitis, head congestion or headaches during service. 
The matters are REMANDED for the following action:
1. Contact the National Personnel Records Center, Records Management Center and any other appropriate agency, to obtain the Veteran’s personnel and disciplinary records; specifically for, but not limited to, any records pertaining to the periods of July 2001 to November 2001, to include any National Guard service.
2. Then after completion of the foregoing, forward the claims file and copies of all pertinent records to an appropriate VA examiner to obtain a medical opinion for the Veteran’s low back disability. If the examiner determines that an opinion cannot be provided without an examination, one should be scheduled.
After reviewing the claims file, the examiner is asked to answer the following:
Is it at least as likely as not (50 percent probability) that any currently diagnosed back disability was incurred in or is otherwise related to service?
The examiner’s attention is directed to service treatment records dated (i) November 2001: “bilateral hip pain for 5 weeks – No trauma,” and; (ii) October 2004: “Problems with shoulder pain and back/hips.”
The examiner must provide reasons for any opinion given. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered.
3. Schedule the Veteran for a VA examination for the Veteran’s headaches claim. Forward the claims file and copies of all pertinent records to an appropriate VA examiner to obtain a medical opinion. After reviewing the claims file, the examiner is asked to answer the following:
Is it at least as likely as not (50 percent probability) that any currently diagnosed headache disorder was incurred in or is otherwise related to service? The examiner should consider the Veteran’s in-service complaints of air quality and dust issues.  
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The examiner must provide reasons for any opinion given. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered.
 
M.E. Larkin
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	Perkins, Michael