VA Disability Claim Help | GVC4Vets — 100,000+ Veterans Served

GVC4Vets
Global Vets Consulting LLC — Tampa, FL
DPA Assessment

Disability Questionnaire(s)
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***IMPORTANT***
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Veteran Information
Legal Name
N/A

Required First
Required Middle
Required Last

**Please enter the name that your VA records reflect, including SUFFIX if applicable
Social Security Number *
N/A

***PLEASE VERIFY THAT YOUR SSN IS CORRECT***
Phone *
N/A

### ### ####
Email *
N/A

**Please use the same email you have on file with GVC4Vets to ensure your documents are returned properly.
Status Update
N/A
ClientID
N/A
ClientOwner
N/A
Medical Evidence/Records
Please identify which type(s) of evidence/medical records you provided:
(e.g. service treatment records, VA treatment records, private treatment records)
*
N/A
Please explain why evidence/records were not provided, examples provided below. Please note, having records but not being able to access them will not be acceptable for a DBQ: *
N/A

I use private care, can’t take time off, I used other means of coping, I am afraid of the VA, I do not like the VA, I do not trust the VA, I cannot afford it, I am unaware of VA services, I self medicate, I just deal with it, etc.
Please provide the approximate date range for the evidence/records you provided. These dates are required for your documents:
If you indicated that you did NOT provide any records, please select any dates in these fields to continue.
Start Date *
N/A

Select a date
End Date: *
N/A

Select a date
Important Questionnaire Details
Please complete this questionnaire to the best of your ability, with as much DETAIL as possible. If additional information is needed, it may delay the completion of your documents.

Please review the following:
The information shared on this questionnaire has a MAJOR impact on the outcome of my disability questionnaires (DBQs). If I DO NOT fully complete each section/text box/answer in detail, I understand/am aware that there is a high chance that it may lower my overall projected increase for each DBQ that GVC4Vets / Global Vets Consulting LLC provides.
N/A

I fully understand the statement above regarding my questionnaire(s) and the details provided concerning my worsening condition(s).
*
I fully understand the statement above regarding my questionnaire(s) and the details provided concerning my worsening condition(s).
Required
Medical Disabilities:
Please select ONLY the disabilities that we are helping to increase: *
N/A
Ankle Questionnaire
Which ankle is service connected? *
N/A

Right Ankle
Left Ankle
Both Ankles

***IF WE ARE ONLY INCREASING ONE ANKLE BUT YOU ARE SERVICE CONNECTED FOR BOTH YOU MUST STILL COMPLETE THE QUESTIONNAIRE FOR BOTH ANKLES***
Briefly describe the history of your ankle condition, including how and when your symptoms began: *
N/A
Ankle Flare-Ups & Daily Life

A flare-up occurs when symptoms of your condition suddenly worsen and may be debilitating. Think about when your symptoms (pain, swelling, difficulty moving) are the most severe (this may only be 1-2 times per year).
How would you describe the severity of your flares? *
N/A
How often do you experience ankle flare-ups? *
N/A
How long do your flares typically last? *
N/A
Briefly list the symptoms of your flare-ups: *
N/A
What causes your flares? What helps alleviate your flares? *
N/A
Medication Tracking — Ankle

Do you take medication for this condition?
Yes No

How many medications do you currently take for this condition?

Medication 1

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:

Medication 2

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:

Medication 3

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:

Medication 4

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:
What activities are specifically challenging during flares? *
N/A
How does your ankle condition affect your daily life? *
N/A
Do you have a history of ankle instability? *
N/A

Yes
No
Briefly describe your instability: *
N/A
Ankle Range of Motion

Please use the images as a reference when answering the questions below regarding your range of motion.
Plantar Flexion Full Range of Motion: 45 Degrees
PLANTAR FLEXION - POINTING THE FOOT DOWN
Right Ankle - While seated, point your foot down, as shown in the image. On an average day, to what degree can you point your foot down? *
N/A
Right Ankle - At what degree do you begin to experience pain? *
N/A
Right Ankle - To what degree can you point your foot down during a flare? *
N/A
Left Ankle - While seated, point your foot down, as shown in the image. On an average day, to what degree can you point your foot down? *
N/A
Left Ankle - At what degree do you begin to experience pain? *
N/A
Left Ankle - To what degree can you point your foot down during a flare? *
N/A
Dorsiflexion Full Range of Motion: 20 Degrees.
DORSIFLEXION - FLEXING THE FOOT UPWARD
Right Ankle - While seated, flex your foot upward. On an average day, to what degree can you flex your foot? *
N/A
Right Ankle - At what degree do you begin to experience pain? *
N/A
Right Ankle - To what degree can you flex your foot upward during a flare? *
N/A
Left Ankle - While seated, flex your foot upward. On an average day, to what degree can you flex your foot? *
N/A
Left Ankle - At what degree do you begin to experience pain? *
N/A
Left Ankle - To what degree can you flex your foot upward during a flare? *
N/A
Additional Symptoms
Do you ever experience any of the following in your ankle(s)? *
N/A
Does your ankle condition interfere with your ability to stand? *
N/A

Yes
No
Please describe: *
N/A
Does your ankle condition interfere with your ability to walk? *
N/A

Yes
No
Please describe: *
N/A
Does your ankle condition cause you to be unstable when standing (instability of station)? *
N/A

Yes
No
Please describe: *
N/A
Does your ankle condition interfere with your ability to sit? *
N/A

Yes
No
Please describe: *
N/A
Do you ever experience swelling in your ankle(s)? *
N/A

Yes
No
Please describe: *
N/A
Ankle Surgery
Have you ever had surgery on your right ankle? *
N/A

Yes
No
How many surgeries have you had on your right ankle? *
N/A

IF YOU HAVE HAD MORE THAN 4 SURGERIES PLEASE SELECT 4 AND COMPLETE THE ADDITIONAL QUESTION IN REGARDS TO YOUR OTHER SURGERIES

Right Ankle Surgery #1 Details:

	Month	Year
Surgery Date: *

Both month & year MUST be completed. Please do not leave blank.

Type of Ankle Surgery: *
N/A

Right Ankle Surgery #2 Details:

	Month	Year
Surgery Date: *

Both month & year MUST be completed. Please do not leave blank.

Type of Surgery: *
N/A

Right Ankle Surgery #3 Details:

	Month	Year
Surgery Date: *

Both month & year MUST be completed. Please do not leave blank.

Type of Surgery: *
N/A

Right Ankle Surgery #4 Details:

	Month	Year
Surgery Date: *

Both month & year MUST be completed. Please do not leave blank.

Type of Surgery: *
N/A
If you have had more than 4 surgeries on your right ankle, please put month/year and type of surgery below for each additional surgery:
N/A
Have you ever had surgery on your left ankle? *
N/A

Yes
No
How many surgeries have you had on your left ankle? *
N/A

IF YOU HAVE HAD MORE THAN 4 SURGERIES PLEASE SELECT 4 AND COMPLETE THE ADDITIONAL QUESTION IN REGARDS TO YOUR OTHER SURGERIES

Left Ankle Surgery #1 Details:

	Month	Year
Surgery Date: *

Both month & year MUST be completed. Please do not leave blank.

Type of Ankle Surgery: *
N/A

Left Ankle Surgery #2 Details:

	Month	Year
Surgery Date: *

Both month & year MUST be completed. Please do not leave blank.

Type of Surgery: *
N/A

Left Ankle Surgery #3 Details:

	Month	Year
Surgery Date: *

Type of Surgery: *
N/A

Left Ankle Surgery #4 Details:

	Month	Year
Surgery Date: *

Type of Surgery: *
N/A
If you have had more than 4 surgeries on your left ankle, please put month/year and type of surgery below for each additional surgery:
N/A
Right leg: Are you SERVICE CONNECTED for right leg shin splints? *
N/A

Yes
No

***If you are SERVICE CONNECTED, you will see SHIN SPLINTS listed as a diability on your disability breakdown.
Please select all that apply for your shin splints in your right leg: *
N/A
Left leg: Are you SERVICE CONNECTED for left leg shin splints? *
N/A

Yes
No

***If you are SERVICE CONNECTED, you will see SHIN SPLINTS listed as a diability on your disability breakdown.
Please select all that apply for your shin splints in your left leg: *
N/A
Do you use any assistive devices to help you walk?

Occasionally Regularly Constantly

Wheelchair

Brace

Crutches

Cane

Walker
Describe how your ankle condition affects your ability to perform job tasks such as standing, walking, lifting, sitting, driving etc.? *
N/A
Asthma Questionnaire
Briefly describe the history of your respiratory condition, including how and when your symptoms began: *
N/A
Briefly describe an asthma attack: *
N/A
Current Medication Regimen
Do you take oral (pill or liquid form) steroids or immunosuppressive medications to treat this condition?
Examples: Prednisone, Prednisolone, Decadron, Deltasone, Dexamethasone, Medrol, Orasone, Pediapred and Prelone
*
N/A

Yes
No
How many oral steroids or immunosuppresants do you take? *
N/A
Name of Medication #1: *
N/A
Dosage of Medication #1: *
N/A
Frequency of Medication #1: *
N/A
Name of Medication #2: *
N/A
Dosage of Medication #2: *
N/A
Frequency of Medication #2: *
N/A
Name of Medication #3: *
N/A
Dosage of Medication #3: *
N/A
Frequency of Medication #3: *
N/A
Please list each additional oral steroid or immunosuppressant that you take to treat your respiratory condition AND their dosages/frequency: *
N/A
Do you currently use an INHALED bronchodilator to treat this condition?
Examples: AccuNeb, Albuterol, Bambuterol, Formoterol, Levalbuteral, Maxair, Proventil, Salbutamol, Sereveut, Salmeterol, Terbutaline, Ventolin, Xopenex
*
N/A

Yes
No
How often? *
N/A
Do you currently use an INHALED anti-inflammatory medication to treat this condition?
Examples: Flovent (Flutocasone HFA), Advair, Symbicort, Atrovent, Aerobid (Flunisolide), Azmacort (triamcinolone), Ipratropium Bromide (Atrovent), Pulmicort
*
N/A

Yes
No
How often? *
N/A
Do you currently use oral bronchodilators (pills/tablets) to treat this condition?
Examples: pill/tablet albuterol, salbutamol
*
N/A

Yes
No
How often? *
N/A
Do you use any other medications to treat your respiratory condition? *
N/A

Yes
No
How many additional medications do you take? *
N/A
Name of Medication #1: *
N/A
Dosage of Medication #1: *
N/A
Frequency of Medication #1: *
N/A
Name of Medication #2: *
N/A
Dosage of Medication #2: *
N/A
Frequency of Medication #2: *
N/A
Name of Medication #3: *
N/A
Dosage of Medication #3: *
N/A
Frequency of Medication #3: *
N/A
Please list each additional medication you take to treat your respiratory condition AND their dosages/frequency: *
N/A
If you use outpatient oxygen therapy for your respiratory condition, how many hours per day?
N/A
Treatment & Daily Life
During the past year, have you had any asthma attacks that resulted in respiratory failure? *
N/A

Yes
No
Average number of attacks every week that resulted in respiratory failure: *
N/A
During the past year, have you sought a physician’s care for asthma attacks? *
N/A

Yes
No
Indicate frequency of physician visits for required care of asthma attacks during the past 12 months: *
N/A
Describe how your respiratory condition affects your ability to perform job tasks such as standing, walking, lifting, sitting etc.? *
N/A
Diagnostic Test Results
Pulmonary Function Test (PFT)

Please upload PFT results from within the last year that show the severity of your service-connected disability. We are unable to complete a Respiratory DBQ without a copy of your PFT results:
*
N/A
Upload file
Back Questionnaire
Briefly describe the history of your back condition, including how and when your symptoms began: *
N/A
Back Flare-Ups & Daily Life

A flare-up occurs when symptoms of your condition suddenly worsen and may be debilitating. Think about when your symptoms (pain, swelling, difficulty moving) are the most severe (this may only be 1-2 times per year).
How would you describe the severity of your flares? *
N/A
How often do you experience flare-ups? *
N/A
How long do your back flares typically last? *
N/A
Briefly list the symptoms of your flare-ups: *
N/A
What causes your flares? What helps alleviate your flares? *
N/A
Medication Tracking — Back

Do you take medication for this condition?
Yes No

How many medications do you currently take for this condition?

Medication 1

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:

Medication 2

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:

Medication 3

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:

Medication 4

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:
What activities are specifically challenging during flares? *
N/A
How does your back condition affect your daily life? *
N/A
Back Range of Motion

Please use the images as a reference when answering the questions below regarding your range of motion.
Forward Flexion Full Range of Motion: 90 Degrees
FORWARD FLEXION
On an average day, to what degree can you bend forward? *
N/A
At what degree do you begin to experience pain? *
N/A
To what degree can you bend forward during a flare? *
N/A
EXTENSION
On an average day, to what degree can you lean back? *
N/A
At what degree do you begin to experience pain? *
N/A
To what degree can you lean back during a flare? *
N/A
Lateral Flexion Full Range of Motion: 30 Degrees
RIGHT LATERAL FLEXION
On an average day, to what degree can you bend to the right? *
N/A
At what degree do you begin to experience pain when bending to the right? *
N/A
To what degree can you bend to the right during a flare? *
N/A
Lateral Flexion Full Range of Motion: 30 Degrees
LEFT LATERAL FLEXION
On an average day, to what degree can you bend to the left? *
N/A
At what degree do you begin to experience pain when bending to the left? *
N/A
To what degree can you bend to the left during a flare? *
N/A
Lateral Rotation Full Range of Motion: 30 Degrees
RIGHT LATERAL ROTATION
On an average day, to what degree can you twist to the right? *
N/A
At what degree do you begin to experience pain when twisting to your right? *
N/A
To what degree can you twist to the right during a flare? *
N/A
Lateral Rotation Full Range of Motion: 30 Degrees
LEFT LATERAL ROTATION
On an average day, to what degree can you twist to the left? *
N/A
At what degree do you begin to experience pain when twisting to your left? *
N/A
To what degree can you twist to the left during a flare? *
N/A
Additional Symptoms
Which of the following do you experience in your back? *
N/A
Do you experience muscle spasms in your back? *
N/A

Yes
No
Do your muscle spasms affect your ability to walk? *
N/A

Yes
No
Do you experience guarding (an involuntary reaction to protect an area of pain)? *
N/A

Yes
No
Does your guarding affect your ability to walk? *
N/A

Yes
No
Does your back condition interfere with your ability to sit? *
N/A

Yes
No
Please describe: *
N/A
Does your back condition interfere with your ability to stand? *
N/A

Yes
No
Please describe: *
N/A
Do you experience swelling in your back? *
N/A

Yes
No
Please describe: *
N/A
Does your back condition interfere with your ability to walk? *
N/A

Yes
No
Please describe: *
N/A
Does your back condition cause you to be unsteady when standing (instability of station)? *
N/A

Yes
No
Please describe: *
N/A
Radiculopathy
**Please note, the VA will only grant a rating for severe radiculopathy if you are already service-connected for this condition.
Do you EVER experience shooting pain, numbness, tingling or loss of feeling in one or both of your legs?

None Mild Moderate Severe**

Right Leg *

Left Leg *

Mild: Occasional symptoms. Moderate: Symptoms affect daily life; more constant and painful and/or weakened movement. Severe: Consistent, severe pain that interferes with activities daily.
Back Surgery
Have you ever had surgery on your back? *
N/A

Yes
No
How many surgeries have you had on your back? *
N/A

IF YOU HAVE HAD MORE THAN 4 SURGERIES PLEASE SELECT 4 AND COMPLETE THE ADDITIONAL QUESTION IN REGARDS TO YOUR OTHER SURGERIES

Back Surgery #1 Details:

	Month	Year
Surgery Date: *

Type of Back Surgery: *
N/A

Back Surgery #2 Details:

	Month	Year
Surgery Date: *

Type of Back Surgery: *
N/A

Back Surgery #3 Details:

	Month	Year
Surgery Date: *

Type of Back Surgery: *
N/A

Back Surgery #4 Details:

	Month	Year
Surgery Date: *

Type of Back Surgery: *
N/A
If you have had more than 4 surgeries on your back, please put month/year and type of surgery below for each additional surgery:
N/A
Do you use any assistive devices?

Occasionally Regularly Constantly

Wheelchair

Brace

Crutches

Cane

Walker
If you use any additional assistive devices, please list them here and identify if you use them occasionally, regularly, or constantly:
N/A
Describe how your back condition affects your ability to perform job tasks such as standing, walking, lifting, sitting, driving etc.? *
N/A
Diabetes Questionnaire
Current diabetes treatment: *
N/A

Select all that apply
Please provide examples of activities you must avoid to prevent hypoglycemic episodes:
Examples: mowing the lawn, running, ascending/descending stairs
*
N/A
Please describe "other" checked above: *
N/A
How often do you visit a doctor for episodes of ketoacidosis? *
N/A
How often do you visit a doctor for episodes of hypoglycemia? *
N/A
Within the past year, how many times have you been hospitalized to treat episodes of ketoacidosis? *
N/A
Within the past year, how many times have you been hospitalized to treat hypoglycemic reactions? *
N/A
Has diabetes caused unintentional, progressive weight loss? *
N/A

Yes
No
What was your initial weight? *
N/A
What is your current weight? *
N/A
Complications of Diabetes
Dominant hand: *
N/A

Right
Left
Ambidextrous
Do you experience symptoms of diabetic neuropathy in any of your limbs? Symptoms include: numbness, shooting pain and/or tingling sensation anywhere in your legs or arms, loss of feeling in fingers/toes.

None Mild Moderate Severe

Right Arm *

Left Arm *

Right Leg *

Left Leg *
Do you have erectile dysfunction as a result of diabetes? *
N/A

Yes
I do not have erectile dysfunction
I have erectile dysfunction but it is unrelated to diabetes
Are you prescribed medication for erectile dysfunction? *
N/A

Yes
No
How many medications are you prescribed for ED? *
N/A

If you are prescribed more than 3 medications, please select MORE THAN 3 and complete the dropdowns below.
Name of Medication #1: *
N/A
Dosage of Medication #1: *
N/A
Frequency of Medication #1: *
N/A
Name of Medication #2: *
N/A
Dosage of Medication #2: *
N/A
Frequency of Medication #2: *
N/A
Name of Medication #3: *
N/A
Dosage of Medication #3: *
N/A
Frequency of Medication #3: *
N/A
Please list each additional medication(s) you're prescribed to treat ED AND their dosages/frequency: *
N/A
Have you had a testicle removed? *
N/A

Yes
No
Which testicle was removed? *
N/A
Reason for removal: *
N/A
Other reason for removal: *
N/A
Are you able to achieve an erection sufficient for ejaculation without medication? *
N/A

Yes
No
Are you able to achieve an erection sufficient for ejaculation WITH medication? *
N/A

Yes
No
Most recent A1C and test date (if available):
N/A
Most recent fasting plasma glucose and test date (if available):
N/A
How does your diabetes affect your ability to perform job tasks (i.e. standing, walking, lifting/carrying, typing, driving, talking on the phone)? *
N/A
Elbow Questionnaire
Dominant hand: *
N/A

Right
Left
Ambidextrous
Which elbow is service connected? *
N/A

Right Elbow
Left Elbow
Both Elbows

***IF WE ARE ONLY INCREASING ONE ELBOW BUT YOU ARE SERVICE CONNECTED FOR BOTH YOU MUST STILL COMPLETE THE QUESTIONNAIRE FOR BOTH ELBOWS***
Briefly describe the history of your elbow condition, including how and when your symptoms began: *
N/A
Elbow Flare-Ups & Daily Life

A flare-up occurs when symptoms of your condition suddenly worsen and may be debilitating. Think about when your symptoms (pain, swelling, difficulty moving) are the most severe (this may only be 1-2 times per year).
How would you describe the severity of your flares? *
N/A
How often do you experience flare-ups? *
N/A
How long do your elbow flares typically last? *
N/A
Briefly list the symptoms of your flare-ups: *
N/A
What causes your flares? What helps alleviate your flares? *
N/A
Medication Tracking — Elbow

Do you take medication for this condition?
Yes No

How many medications do you currently take for this condition?

Medication 1

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:

Medication 2

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:

Medication 3

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:

Medication 4

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:
What activities are specifically challenging during flares? *
N/A
How does your elbow condition affect your daily life? *
N/A
Elbow Range of Motion

Please use the images as a reference when answering the questions below regarding your range of motion.
Flexion Full Range of Motion: 145 Degrees
FLEXION - BENDING ARM UPWARDS
Right Elbow - Begin with your hand by your side. Bending your elbow, bring your hand up towards your shoulder. On an average day, to what degree can you bend your elbow? *
N/A
Right Elbow - At what degree do you experience pain? *
N/A
Right Elbow - To what degree can you bend your elbow during a flare? *
N/A
Left Elbow - Begin with your hand by your side. Bending your elbow, bring your hand up towards your shoulder. On an average day, to what degree can you bend your elbow? *
N/A
Left Elbow - At what degree do you experience pain? *
N/A
Left Elbow - To what degree can you bend your elbow during a flare? *
N/A
Extension Full Range of Motion: 0 Degrees
EXTENSION - STRAIGHTENING THE ARM
Right Elbow - Place your hand at your side and try to straighten your arm completely. On an average day, to what degree can you straighten your arm? *
N/A
Right Elbow - At what degree do you experience pain? *
N/A
Right Elbow - To what degree can you straighten your arm during a flare? *
N/A
Right Elbow - To what degree can you straighten your arm during a flare? *
N/A
Right Elbow - To what degree can you straighten your arm during a flare? *
N/A
Right Elbow - To what degree can you straighten your arm during a flare? *
N/A
Right Elbow - To what degree can you straighten your arm during a flare? *
N/A
Right Elbow - To what degree can you straighten your arm during a flare? *
N/A
Right Elbow - To what degree can you straighten your arm during a flare? *
N/A
Right Elbow - To what degree can you straighten your arm during a flare? *
N/A
Right Elbow - To what degree can you straighten your arm during a flare? *
N/A
Right Elbow - To what degree can you straighten your arm during a flare? *
N/A
Right Elbow - To what degree can you straighten your arm during a flare? *
N/A
Right Elbow - To what degree can you straighten your arm during a flare? *
N/A
Right Elbow - To what degree can you straighten your arm during a flare? *
N/A
Left Elbow - Place your hand at your side and try to straighten your arm completely. On an average day, to what degree can you straighten your arm? *
N/A
Left Elbow - At what degree do you experience pain? *
N/A
Left Elbow - To what degree can you straighten your arm during a flare? *
N/A
Left Elbow - To what degree can you straighten your arm during a flare? *
N/A
Left Elbow - To what degree can you straighten your arm during a flare? *
N/A
Left Elbow - To what degree can you straighten your arm during a flare? *
N/A
Left Elbow - To what degree can you straighten your arm during a flare? *
N/A
Left Elbow - To what degree can you straighten your arm during a flare? *
N/A
Left Elbow - To what degree can you straighten your arm during a flare? *
N/A
Left Elbow - To what degree can you straighten your arm during a flare? *
N/A
Left Elbow - To what degree can you straighten your arm during a flare? *
N/A
Left Elbow - To what degree can you straighten your arm during a flare? *
N/A
Left Elbow - To what degree can you straighten your arm during a flare? *
N/A
Left Elbow - To what degree can you straighten your arm during a flare? *
N/A
Left Elbow - To what degree can you straighten your arm during a flare? *
N/A
SUPINATION - ROTATING THE PALM UP
Right Elbow - Raise your arm in front of you, with your thumb pointed up. Rotate your forearm so your palm is up, as if you were holding a bowl of soup in the palm of your hand. On an average day, to what degree can you rotate your palm up? *
N/A
Right Elbow - At what degree do you experience pain? *
N/A
Right Elbow - To what degree can you rotate your palm up during a flare? *
N/A
Left Elbow - Raise your arm in front of you, with your thumb pointed up. Rotate your forearm so your palm is up, as if you were holding a bowl of soup in the palm of your hand. On an average day, to what degree can you rotate your palm up? *
N/A
Left Elbow - At what degree do you experience pain? *
N/A
Left Elbow - To what degree can you rotate your palm up during a flare? *
N/A
PRONATION - ROTATING THE PALM DOWN
Right Elbow - Raise your arm in front of you with your thumb pointed up. Rotate your forearm so the palm of your hand is down. On an average day, to what degree can you rotate your palm down? *
N/A
Right Elbow - At what degree do you experience pain? *
N/A
Right Elbow - To what degree can you rotate your palm down during a flare? *
N/A
Left Elbow - Raise your arm in front of you with your thumb pointed up. Rotate your forearm so the palm of your hand is down. On an average day, to what degree can you rotate your palm down? *
N/A
Left Elbow - At what degree do you experience pain? *
N/A
Left Elbow - To what degree can you rotate your palm down during a flare? *
N/A
Elbow Surgery & Additional Information
Do you ever experience any of the following in your elbow(s)? *
N/A
Do you ever experience swelling in your elbow(s)? *
N/A

Yes
No
Please describe: *
N/A
Have you ever had surgery on your right elbow? *
N/A

Yes
No
How many surgeries have you had on your right elbow?
N/A

IF YOU HAVE HAD MORE THAN 4 SURGERIES PLEASE SELECT 4 AND COMPLETE THE ADDITIONAL QUESTION IN REGARDS TO YOUR OTHER SURGERIES

Right Elbow Surgery #1 Details:

	Month	Year
Surgery Date: *

Type of Elbow Surgery: *
N/A

Right Elbow Surgery #2 Details:

	Month	Year
Surgery Date: *

Type of Elbow Surgery: *
N/A

Right Elbow Surgery #3 Details:

	Month	Year
Surgery Date: *

Type of Elbow Surgery: *
N/A

Right Elbow Surgery #4 Details:

	Month	Year
Surgery Date: *

Type of Elbow Surgery: *
N/A
If you have had more than 4 surgeries on your elbow, please put month/year and type of surgery below for each additional surgery:
N/A
Have you ever had surgery on your left elbow? *
N/A

Yes
No
How many surgeries have you had on your left elbow?
N/A

IF YOU HAVE HAD MORE THAN 4 SURGERIES PLEASE SELECT 4 AND COMPLETE THE ADDITIONAL QUESTION IN REGARDS TO YOUR OTHER SURGERIES

Left Elbow Surgery #1 Details:

	Month	Year
Surgery Date: *

Type of Elbow Surgery: *
N/A

Left Elbow Surgery #2 Details:

	Month	Year
Surgery Date: *

Type of Elbow Surgery: *
N/A

Left Elbow Surgery #3 Details:

	Month	Year
Surgery Date: *

Type of Elbow Surgery: *
N/A

Left Elbow Surgery #4 Details:

	Month	Year
Surgery Date: *

Type of Elbow Surgery: *
N/A
If you have had more than 4 surgeries on your elbow, please put month/year and type of surgery below for each additional surgery:
N/A
Do you use any assistive devices for your elbow(s)?
N/A
Please describe the other assistive device(s) you use for your elbow(s): *
N/A
How often do you use your brace? *
N/A
How often do you use your other assistive device(s)? *
N/A
Describe how your elbow condition affects your ability to perform job tasks such as typing/using a computer, lifting objects, reaching, driving etc.? *
N/A
Foot Questionnaire
Which foot is service connected? *
N/A

Right
Left
Both
Briefly describe the history of your foot condition, including how and when your symptoms began: *
N/A
Describe your foot pain: *
N/A
How do flare-ups impact you?
A flare-up occurs when symptoms of your condition suddenly worsen and may be debilitating. Think about when your symptoms (pain, swelling, difficulty moving) are the most severe (this may only be 1-2 times per year).
*
N/A
Medication Tracking — Foot/Feet

Do you take medication for this condition?
Yes No

How many medications do you currently take for this condition?

Medication 1

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:

Medication 2

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:

Medication 3

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:

Medication 4

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:
How does your foot condition affect your daily life? *
N/A
Are you service connected for pes planus (flat foot/feet)?
Please ensure to check your disability breakdown to see if you are service connected for pes planus or flat foot/feet.

N/A

Yes
No
Do you experience any of the following?
N/A

*Noticable deformity: Characterized by clearly evident pronation (natural side-to-side movement of the foot) and/or abduction (motions away from the centerline foot, off balance).
Have you ever used any of the following? *
N/A
Are you service connected for plantar fasciitis?
Please ensure to check your disability breakdown to see if you are service connected for plantar fasciitis.

*
N/A

Yes
No
Have you tried any non-surgical treatments (brace, splint, physical therapy, massage, stretching, anti-inflammatory medications)? *
N/A

No
Yes, they relieved my plantar fasciitis symptoms
Yes, but they did NOT relieve my symptoms
Have you undergone surgical treatment for plantar fasciitis? *
N/A

No
Yes, surgery relieved my symptoms
Yes, surgery did NOT relieve my symptoms
Surgery was recommended, but I was not a surgical candidate due to age or a chronic health condition
Foot Surgery Information
Have you ever had surgery on your right foot? *
N/A

Yes
No
How many surgeries have you had on your right foot? *
N/A

IF YOU HAVE HAD MORE THAN 4 SURGERIES PLEASE SELECT 4 AND COMPLETE THE ADDITIONAL QUESTION IN REGARDS TO YOUR OTHER SURGERIES

Right Foot Surgery #1 Details:

	Month	Year
Surgery Date: *

Type of Foot Surgery: *
N/A

Right Foot Surgery #2 Details:

	Month	Year
Surgery Date: *

Type of Foot Surgery: *
N/A

Right Foot Surgery #3 Details:

	Month	Year
Surgery Date: *

Type of Foot Surgery: *
N/A

Right Foot Surgery #4 Details:

	Month	Year
Surgery Date: *

Type of Foot Surgery: *
N/A
If you have had more than 4 surgeries on your foot, please put month/year and type of surgery below for each additional surgery:
N/A
Have you ever had surgery on your left foot? *
N/A

Yes
No
How many surgeries have you had on your left foot?
N/A

IF YOU HAVE HAD MORE THAN 4 SURGERIES PLEASE SELECT 4 AND COMPLETE THE ADDITIONAL QUESTION IN REGARDS TO YOUR OTHER SURGERIES

Left Foot Surgery #1 Details:

	Month	Year
Surgery Date: *

Type of Foot Surgery: *
N/A

Left Foot Surgery #2 Details:

	Month	Year
Surgery Date: *

Type of Foot Surgery: *
N/A

Left Foot Surgery #3 Details:

	Month	Year
Surgery Date: *

Type of Foot Surgery: *
N/A

Left Foot Surgery #4 Details:

	Month	Year
Surgery Date: *

Type of Foot Surgery: *
N/A
If you have had more than 4 surgeries on your foot, please put month/year and type of surgery below for each additional surgery:
N/A
Which of the following do you experience? *
N/A
Do you use any assistive devices?

Occasionally Regularly Constantly

Wheelchair

Brace

Crutches

Cane

Walker

Orthotics
If you use any additional assistive devices, please list them here and identify if you use them occasionally, regularly, or constantly:
N/A
Describe how your foot condition affects your ability to perform job tasks such as standing, walking, driving etc.? *
N/A
GERD Questionnaire
Briefly describe the history of your GERD condition, including how and when your symptoms began: *
N/A
Do you take medication(s) for GERD? *
N/A

Yes
No
How many medications do you take? *
N/A

If you take more than 3 medications, please select MORE THAN 3 and complete the dropdowns below.
Name of Medication #1: *
N/A
Dosage of Medication #1: *
N/A
Frequency of Medication #1: *
N/A
Name of Medication #2: *
N/A
Dosage of Medication #2: *
N/A
Frequency of Medication #2: *
N/A
Name of Medication #3: *
N/A
Dosage of Medication #3: *
N/A
Frequency of Medication #3: *
N/A
Please list each additional medication(s) you take to treat GERD AND their dosages/frequency: *
N/A
Which of the following best describes the severity of your condition? *
N/A

My symptoms are fairly frequent and definitely impair my overall health and wellness.
My symptoms are very frequent, debilitating at times, and severely impair my health.
Signs and Symptoms
Which symptoms do you experience?
Select all that apply
*
N/A

Select all that apply
Do you experience sleep disturbances due to GERD? *
N/A

Yes
No
Sleep disturbance frequency: *
N/A
Average duration of each episode: *
N/A
Has GERD caused you to lose weight? *
N/A

Yes
No
Average initial weight: *
N/A
Current weight: *
N/A
Do you experience nausea due to GERD? *
N/A

Yes
No
Frequency of nausea: *
N/A
Average duration of each episode: *
N/A
Do you experience vomiting due to GERD? *
N/A

Yes
No
Frequency of vomiting: *
N/A
Average duration of each episode: *
N/A
Do you ever vomit blood due to GERD? (hematemesis) *
N/A

Yes
No
Annual frequency: *
N/A
Average duration of each episode: *
N/A
Do you experience both of the following due to GERD: anemia AND melena (dark feces containing digested blood)?
If yes, you will be prompted to upload test results to confirm anemia
*
N/A

Yes
No
Annual frequency of melena: *
N/A
Average duration of each melena episode: *
N/A
Please upload blood test results from within the past 6 months with hemoglobin and hemocrit readings confirming anemia: *
N/A
Upload file
How does GERD affect your ability to perform job tasks (i.e. office work, physical tasks, sitting, standing, walking, driving)? *
N/A
1. Briefly describe the history of this condition:
N/A
2. List any continuous medications used to treat this condition INCLUDING the dosage and frequency:
N/A
3. Have you lost any weight due to this condition?
N/A

Yes
No
Average weight prior to this condition:
N/A
Current weight:
N/A
4. Has this condition caused anemia?
N/A

Yes
No
Please upload a copy of your latest CBC test (hemoglobin, hemocrit, white blood count, and platelets numbers):
N/A
Upload file
Joints & Affected Systems
5. Does this condition cause joint pain or limit your range of motion in any of the following joints?

Right Left

Shoulder

Elbow

Hands

Hip

Knee

Ankle

Toe(s)
5. Does this condition cause joint pain or limit your range of motion in your Neck, Back, or Sacroiliac Joints?
N/A
6. Describe your pain (constant, intermittent, sharp, aching, etc.) and limited motion:
N/A
7. Has this condition caused any joint deformities? If yes, please describe:
N/A
8. Are there any other systems affected by this condition?
N/A
Briefly describe the affects this condition has on each system selected:
N/A
Non-Incapacitating Episodes
10. Have you had any non-incapacitating episodes due to this condition?
N/A

Yes
No
Briefly describe a non-incapacitating episode:
N/A
Date of most recent non-incapacitating episode:
N/A

dd-MMM-yyyy
Duration of most recent non-incapacitating episode:
N/A
Incapacitating Episode
11. Have you had any incapacitating episodes due to this condition?
N/A

Yes
No
How many incapacitating episodes have you had within the last year?
N/A
Date of most recent incapacitating episode:
N/A

dd-MMM-yyyy
Duration of most recent incapacitating episode:
N/A
Total amount of time you were incapacitated within the last 12 months:
N/A
Briefly describe an incapacitating episode:
N/A
Additional Information
18. Have had any surgeries to treat this condition?
N/A

Yes
No
Please provide the type of surgery and surgery month/year:
N/A
19. Do you use any assistive devices?
N/A

Wheelchair
Brace
Crutches
Cane
Walker
Other
20. Does this condition affect your ability to work or perform occupational tasks (sitting, standing, walking, lifting objects, driving, etc.)? Provide specific examples:
N/A
Headache Questionnaire
Briefly describe the history of your headache condition, including how and when your symptoms began: *
N/A
Do you take medication(s) to treat headaches/migraines? *
N/A

Yes
No
How many medications do you take for your headaches/migraines? *
N/A
Name of Medication #1: *
N/A
Dosage of Medication #1: *
N/A
Frequency of Medication #1: *
N/A
Name of Medication #2: *
N/A
Dosage of Medication #2: *
N/A
Frequency of Medication #2: *
N/A
Name of Medication #3: *
N/A
Dosage of Medication #3: *
N/A
Frequency of Medication #3: *
N/A
Please list each additional medication you are currently taking for headaches/migraines, including the dosage & frequency: *
N/A
Where is your head pain typically located? *
N/A

Pain localized to one side of the head
Pain on both sides of the head
What symptoms do you experience during a headache/migraine?
N/A
How long does a headache/migraine typically last? *
N/A

Less than 1 day
1-2 days
2 + days
Where do you usually feel pain? *
N/A

Right side of the head
Left side of the head
Both sides of the head
Other
During the last 3 MONTHS, on average, how many debilitating headaches/migraines have you had? *
N/A

Less than one every two months
About one every two months
About 1-2 every month
More than two every month
Do your headaches/migraines interfere with or prevent you from making a living? *
N/A

Yes
No
Describe how headaches/migraines impact your ability to work and function on a day-to-day basis: *
N/A
Heart Questionnaire
Briefly describe the history of your heart condition, including how and when your symptoms began: *
N/A
Do you currently take any heart medication(s)?
N/A

Yes
No
How many heart medications do you take? *
N/A
Name of Medication #1: *
N/A
Dosage of Medication #1: *
N/A
Frequency of Medication #1: *
N/A
Name of Medication #2: *
N/A
Dosage of Medication #2: *
N/A
Frequency of Medication #2: *
N/A
Name of Medication #3: *
N/A
Dosage of Medication #3: *
N/A
Frequency of Medication #3: *
N/A
Please list each additional heart medication AND the dosage/frequency: *
N/A
Have you ever had a heart attack? *
N/A

Yes
No
How many heart attacks have you had? *
N/A

Heart Attack #1 Details:

	Month	Year
Heart Attack Date: *

Please specify the treatment facility: *
N/A

Heart Attack #2 Details:

	Month	Year
Heart Attack Date: *

Please specify the treatment facility: *
N/A

Heart Attack #3 Details:

	Month	Year
Heart Attack Date: *

Please specify the treatment facility: *
N/A
If you have had more than 3 heart attacks, please provide the following for each additional heart attack: Date (month/year) and treatment facility: *
N/A
Have you had any of the following surgical procedures? *
N/A

*Please select all that apply

Percutaneous Coronary Intervention (Angioplasty) Details:

	Month	Year
Surgery Date: *

Please specify the treatment facility: *
N/A

Coronary Artery Bypass Surgery Details:

	Month	Year
Surgery Date: *

Please specify the treatment facility: *
N/A

Valve Replacement Details:

	Month	Year
Surgery Date: *

Which valve was replaced? *
N/A
Please specify the treatment facility: *
N/A

Heart Transplant Details:

	Month	Year
Surgery Date: *

Please specify the treatment facility: *
N/A

Implanted Pacemaker Details:

	Month	Year
Surgery Date: *

Please specify the treatment facility: *
N/A

Implanted Defibrillator Details:

	Month	Year
Surgery Date: *

Please specify the treatment facility: *
N/A

Ventricular Aneurysmectomy Details:

	Month	Year
Surgery Date: *

Please specify the treatment facility: *
N/A
Other Surgical Procedure - Surgery Type: *
N/A

Other Surgical Procedure Details:

	Month	Year
Surgery Date: *

Please specify the treatment facility: *
N/A
Have you ever been hospitalized for non-surgical treatment of your heart condition? *
N/A

Yes
No
Reason for Non-Surgical Hospitalization:
N/A

Non-Surgical Hospitalization Details:

	Month	Year
Date of Admission: *

Please specify the treatment facility: *
N/A
Please list additional hospitalizations for non-surgical treatment of your heart condition here, including the reason, date of admission and treatment facility:
N/A
Please list your most recent blood pressure reading: *
N/A
Symptoms
Current heart symptoms (select all that apply): *
N/A
Other heart symptoms: *
N/A
At what activity level do you begin to experience the symptoms above? *
N/A

Eating, dressing, taking a shower, slow walking for 1-2 blocks
Light yard work (weeding), mowing lawn (power mower), brisk walking
Walking 1 flight of stairs, push mowing the lawn, heavy yard work (digging)
Climbing stairs quickly, moderate bicycling, sawing wood, jogging
How does your heart condition affect your ability to perform job tasks (i.e. sitting, standing, walking, typing, driving, lifting)? *
N/A
Please upload your most recent* ECHO or EKG/ECG (including the explanation of results) and any other supporting documents:
*EKG/ECG or ECHO results must be from a test conducted within the last 12 months
*
N/A
Upload file
Hip Questionnaire
Which hip is service connected? *
N/A

Right Hip
Left Hip
Both Hips

***IF WE ARE ONLY INCREASING ONE HIP BUT YOU ARE SERVICE CONNECTED FOR BOTH YOU MUST STILL COMPLETE THE QUESTIONNAIRE FOR BOTH HIPS***
Briefly describe the history of your hip condition, including how and when your symptoms began: *
N/A
Hip Flare-Ups & Daily Life

A flare-up occurs when symptoms of your condition suddenly worsen and may be debilitating. Think about when your symptoms (pain, swelling, difficulty moving) are the most severe (this may only be 1-2 times per year).
How would you describe the severity of your flares? *
N/A
How often do you experience flare-ups? *
N/A
How long do your hip flares typically last? *
N/A
Briefly list the symptoms of your flare-ups: *
N/A
What causes your flares? What helps alleviate your flares? *
N/A
Medication Tracking — Hip

Do you take medication for this condition?
Yes No

How many medications do you currently take for this condition?

Medication 1

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:

Medication 2

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:

Medication 3

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:

Medication 4

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:
What activities are specifically challenging during flares? *
N/A
How does your hip condition affect your daily life? *
N/A
Hip Range of Motion

Please use the images as a reference when answering the questions below regarding your range of motion.
Hip Flexion Full Range of Motion: 120 Degrees
HIP FLEXION - RAISING THIGH UP TOWARDS CHEST
Right Hip - Begin by standing or laying down, now raise your thigh up towards your chest. On an average day, to what degree can you raise your thigh? *
N/A
Right Hip - At what degree do you begin to experience pain? *
N/A
Right Hip - To what degree can you raise your thigh during a flare? *
N/A
Left Hip - Begin by standing or laying down, now raise your thigh up towards your chest. On an average day, to what degree can you raise your thigh? *
N/A
Left Hip - At what degree do you begin to experience pain? *
N/A
Left Hip - To what degree can you raise your thigh during a flare? *
N/A
Hip Extension Full Range of Motion: 30 Degrees
HIP EXTENSION - LIFTING THE LEG BACK
Right Hip - Stand with your feet together and slowly lift one leg back (as seen in the image). On an average day, to what degree can you lift your leg back? *
N/A
Right Hip - At what degree do you begin to experience pain? *
N/A
Right Hip - To what degree can you lift your leg back during a flare? *
N/A
Left Hip - Stand with your feet together and slowly lift one leg back (as seen in the image). On an average day, to what degree can you lift your leg back? *
N/A
Left Hip - At what degree do you begin to experience pain? *
N/A
Left Hip - To what degree can you lift your leg back during a flare? *
N/A
Hip Abduction Full Range of Motion: 45 Degree
HIP ABDUCTION - LIFTING THE LEG OUT TO THE SIDE
Right Hip - Stand with your feet together and slowly lift one leg out to the side. On an average day, to what degree can you lift your leg out? *
N/A
Right Hip - At what degree do you begin to experience pain? *
N/A
Right Hip - To what degree can you lift your leg out during a flare? *
N/A
Left Hip - Stand with your feet together and slowly lift one leg out to the side. On an average day, to what degree can you lift your leg out? *
N/A
Left Hip - At what degree do you begin to experience pain? *
N/A
Left Hip - To what degree can you lift your leg out during a flare? *
N/A
Hip Adduction Full Range of Motion: 25 Degrees
HIP ADDUCTION - CROSSING THE LEGS
Right Hip: On an average day, are you able to cross your right leg over your left? *
N/A

Yes
No
Right Hip - Stand with your feet together and slowly cross your right leg over the left. On an average day, to what degree can you cross your leg? *
N/A
Right Hip - Stand with your feet together and slowly cross your right leg over the left. On an average day, to what degree can you cross your leg? *
N/A
Right Hip - At what degree do you begin to experience pain? *
N/A
Right Hip - During a flare, are you able to cross your right leg over your left? *
N/A

Yes
No
Right Hip - To what degree can you cross your right leg over your left during a flare? *
N/A
Right Hip - To what degree can you cross your right leg over your left during a flare? *
N/A
Left Hip - On an average day, are you able to cross your left leg over your right? *
N/A

Yes
No
Left Hip - Stand with your feet together and slowly cross your left leg over the right. On an average day, to what degree can you cross your leg? *
N/A
Left Hip - Stand with your feet together and slowly cross your left leg over the right. On an average day, to what degree can you cross your leg? *
N/A
Left Hip - At what degree do you begin to experience pain? *
N/A
Left Hip - During a flare, are you able to cross your left leg over your right? *
N/A

Yes
No
Left Hip - To what degree can you cross your left leg over your right during a flare? *
N/A
Left Hip - To what degree can you cross your left leg over your right during a flare? *
N/A
Hip External Rotation Full Range of Motion: 60 Degrees
EXTERNAL ROTATION - ROTATING THE LEG OUT
RIght Hip - Stand with your feet together and pointed straight ahead. Slowly rotate your foot out (away from your body). On an average day, to what degree can you rotate your leg out? *
N/A
Right Hip - At what degree do you begin to experience pain? *
N/A
RIght Hip - To what degree can you rotate your leg out during a flare? *
N/A
Left Hip - Stand with your feet together and pointed straight ahead. Slowly rotate your foot out (away from your body). On an average day, to what degree can you rotate your leg out? *
N/A
Left Hip - At what degree do you begin to experience pain? *
N/A
Left Hip - To what degree can you rotate your leg out during a flare? *
N/A
Hip Internal Rotation Full Range of Motion: 40 Degrees
INTERNAL ROTATION - ROTATING THE LEG IN (TOWARDS YOUR OTHER LEG)
Right Hip - Stand with your feet together and pointed straight ahead. Slowly rotate your foot in (towards your other foot). On an average day, to what degree can you rotate your foot in? *
N/A
Right Hip - At what degree do you begin to experience pain? *
N/A
Right Hip - To what degree can you rotate your foot in during a flare? *
N/A
Left Hip - Stand with your feet together and pointed straight ahead. Slowly rotate your foot in (towards your other foot). On an average day, to what degree can you rotate your foot in? *
N/A
Left Hip - At what degree do you begin to experience pain? *
N/A
Left Hip - To what degree can you rotate your foot in during a flare? *
N/A
Additional Information
Which of the following do you experience in your service connected hip(s)? *
N/A
Does your hip condition interfere with your ability to stand? *
N/A

Yes
No
Please describe: *
N/A
Does your hip condition interfere with your ability to walk?
N/A

Yes
No
Please describe: *
N/A
Does your hip condition cause you to be unsteady when standing (instability of station)? *
N/A

Yes
No
Please describe: *
N/A
Does your hip condition interfere with your ability to sit? *
N/A

Yes
No
Please describe: *
N/A
Do you experience swelling in your hips? *
N/A

Yes
No
Please describe: *
N/A
Hip Surgery
Have you ever had a total hip joint replacement in your right hip?
N/A

Yes
No

Right Hip Replacement Details:

	Month	Year
Right Hip Replacement Date: *

Which of the following best describes your right hip now? *
N/A
Have you ever had a total hip joint replacement in your left hip?
N/A

Yes
No

Left Hip Replacement Details:

	Month	Year
Left Hip Replacement Date: *

Which of the following best describes your left hip now? *
N/A
Have you ever had arthroscopic ligament repair surgery on your right hip?
N/A

Yes
No

Right Hip Arthroscopic Repair Details:

	Month	Year
Right Hip Arthroscopic Repair Date: *

Have you ever had arthroscopic ligament repair surgery on your left hip?
N/A

Yes
No

Left Hip Arthroscopic Repair Details:

	Month	Year
Left Hip Arthroscopic Repair Date: *

Have you undergone any other hip surgeries on your right hip? *
N/A

Yes
No
How many additional surgeries have you had on your right hip? *
N/A

IF YOU HAVE HAD MORE THAN 4 SURGERIES, PLEASE SELECT 4 AND COMPLETE THE ADDITIONAL QUESTION IN REGARDS TO YOUR OTHER SURGERIES

Right Hip Surgery #1 Details:

	Month	Year
Surgery Date: *

Type of Hip Surgery: *
N/A

Right Hip Surgery #2 Details:

	Month	Year
Surgery Date: *

Type of Hip Surgery: *
N/A

Right Hip Surgery #3 Details:

	Month	Year
Surgery Date: *

Type of Hip Surgery: *
N/A

Right Hip Surgery #4 Details:

	Month	Year
Surgery Date: *

Type of Hip Surgery: *
N/A
If you have had more than four surgeries on your right hip, please put month/year and type of surgery below for each additional surgery:
N/A
Have you undergone any other hip surgeries on your left hip? *
N/A

Yes
No
How many additional surgeries have you had on your left hip? *
N/A

IF YOU HAVE HAD MORE THAN 4 SURGERIES, PLEASE SELECT 4 AND COMPLETE THE ADDITIONAL QUESTION IN REGARDS TO YOUR OTHER SURGERIES

Left Hip Surgery #1 Details:

	Month	Year
Surgery Date: *

Type of Hip Surgery: *
N/A

Left Hip Surgery #2 Details:

	Month	Year
Surgery Date: *

Type of Hip Surgery: *
N/A

Left Hip Surgery #3 Details:

	Month	Year
Surgery Date: *

Type of Hip Surgery: *
N/A

Left Hip Surgery #4 Details:

	Month	Year
Surgery Date: *

Type of Hip Surgery: *
N/A
If you have had more than four surgeries on your left hip, please put month/year and type of surgery below for each additional surgery:
N/A
Do you use any assistive devices to help you walk?

Occasionally Regularly Constantly

Wheelchair

Hip Brace

Crutches

Cane

Walker
If you use an assistive device to help you walk that is not listed above, please identify the device and if you use it occasionally, regularly or constantly:
N/A
Describe how your hip condition affects your ability to perform job tasks such as standing, walking, lifting, sitting, driving etc.? *
N/A
IBS Questionnaire
Briefly describe the history of your intestinal condition, including how and when your symptoms began: *
N/A
Do you take medication(s) for IBS? *
N/A

Yes
No
How many medications do you take for IBS?* *
N/A
Name of Medication #1: *
N/A
Dosage of Medication #1: *
N/A
Frequency of Medication #1: *
N/A
Name of Medication #2: *
N/A
Dosage of Medication #2: *
N/A
Frequency of Medication #2: *
N/A
Name of Medication #3: *
N/A
Dosage of Medication #3: *
N/A
Frequency of Medication #3: *
N/A
Please list each additional medication(s) you take to treat IBS AND their dosages/frequency: * *
N/A
Have you had surgery to treat any intestinal condition? *
N/A

Yes
No
How many surgeries have you had to treat your intestinal condition? *
N/A

IF YOU HAVE HAD MORE THAN 4 SURGERIES, PLEASE SELECT 4 AND COMPLETE THE ADDITIONAL QUESTION IN REGARDS TO YOUR OTHER SURGERIES

Intestinal Surgery #1 Details:

	Month	Year
Surgery Date: *

Type of Intestinal Surgery: *
N/A

Intestinal Surgery #2 Details:

	Month	Year
Surgery Date: *

Type of Intestinal Surgery: *
N/A

Intestinal Surgery #3 Details:

	Month	Year
Surgery Date: *

Type of Intestinal Surgery: *
N/A

Intestinal Surgery #4 Details:

	Month	Year
Surgery Date: *

Type of Intestinal Surgery: *
N/A
If you have had more than four surgeries to treat your intestinal condition, please put month/year and type of surgery below for each additional surgery: *
N/A
Do you experience diarrhea? *
N/A

Yes
No
How often? How does it interfere with your life? *
N/A
Do you experience alternating diarrhea and constipation? *
N/A

Yes
No
How often? How does it interfere with your life? *
N/A
Do you experience abdominal distention (bloating)? *
N/A

Yes
No
How often do you experience bloating? Describe the feeling: *
N/A
Do you experience nausea? *
N/A

Yes
No
How often? How does it interfere with your life? *
N/A
Do you experience vomiting? *
N/A

Yes
No
How often? How does it interfere with your life? *
N/A
How often do you have episodes of bowel disturbance/abdominal distress? Select one: *
N/A

Occasionally
Frequently
More or less constantly
Describe a typical IBS flare/attack: *
N/A
How many flare-ups/attacks of IBS have you had within the last 12 months? *
N/A
Has IBS caused you to lose weight? *
N/A

Yes
No
Average initial weight: *
N/A
Current weight: *
N/A
How does this condition affect your ability to perform job tasks (driving, walking, office work, traveling, etc.)? *
N/A
Knee(s) Questionnaire
Which knee is service connected? *
N/A

Right Knee
Left Knee
Both Knees

***IF WE ARE ONLY INCREASING ONE KNEE BUT YOU ARE SERVICE CONNECTED FOR BOTH YOU MUST STILL COMPLETE THIS QUESTIONNAIRE FOR BOTH KNEES.
Briefly describe the history of your knee condition, including how and when your symptoms began: *
N/A
Flare-Ups, Dislocation, & Other Knee Details

A flare-up occurs when symptoms of your condition suddenly worsen and may be debilitating. Think about when your symptoms (pain, swelling, difficulty moving) are the most severe (this may only be 1-2 times per year).
How would you describe the severity of your flares? *
N/A
How often do you experience flare-ups? *
N/A
How long do your flares typically last? *
N/A
Briefly list the symptoms of your flare-ups: *
N/A
What causes your flares? What helps alleviate your flares? *
N/A
Medication Tracking — Knee

Do you take medication for this condition?
Yes No

How many medications do you currently take for this condition?

Medication 1

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:

Medication 2

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:

Medication 3

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:

Medication 4

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:
What activities are specifically challenging during flares? *
N/A
How does your knee condition affect your daily life? *
N/A
Does your right knee joint ever dislocate? *
N/A

Yes
No
Right Knee Dislocation - How frequently does this happen? *
N/A
Right Knee Dislocation - Please describe the sensation/feeling: *
N/A
Does your left knee joint ever dislocate? *
N/A

Yes
No
Left Knee Dislocation - How frequently does this happen? *
N/A
Left Knee Dislocation - Please describe the sensation/feeling: *
N/A
Do you ever experience a build up of fluid around your RIGHT knee? *
N/A

Yes
No
Do you ever experience a build up of fluid around your LEFT knee? *
N/A

Yes
No
Knee Range of Motion

Please use the images as a reference when answering the questions below regarding your range of motion.
FLEXION - BENDING THE KNEE
Right Knee: Hold the back of a chair to help you balance. Now bend your right knee and lift your foot back, as if you were preparing to kick a ball. On an average day, to what degree can you bend your knee? *
N/A
Right Knee: At what degree do you begin to experience pain? *
N/A
Right Knee: To what degree can you bend your knee during a flare? *
N/A
Left Knee: Hold the back of a chair to help you balance. Now bend your left knee and lift your foot back, as if you were preparing to kick a ball. On an average day, to what degree can you bend your knee? *
N/A
Left Knee: At what degree do you begin to experience pain? *
N/A
Left Knee: To what degree can you bend your knee during a flare? *
N/A
EXTENSION - STRAIGHTENING THE LEG
Right Knee: Sit down in a chair with your feet on the floor. Straighten your leg, so there is no bend in your knee, if possible. On an average day, to what degree can you extend your knee? *
N/A
Right Knee: At what degree do you begin to experience pain? *
N/A
Right Knee: To what degree can you extend your knee during a flare? *
N/A
Right Knee: To what degree can you extend your knee during a flare? *
N/A
Right Knee: To what degree can you extend your knee during a flare? *
N/A
Right Knee: To what degree can you extend your knee during a flare? *
N/A
Right Knee: To what degree can you extend your knee during a flare? *
N/A
Left Knee: Sit down in a chair with your feet on the floor. Straighten your leg, so there is no bend in your knee, if possible. On an average day, to what degree can you extend your knee? *
N/A
Left Knee: At what degree do you begin to experience pain? *
N/A
Left Knee: To what degree can you extend your knee during a flare? *
N/A
Left Knee: To what degree can you extend your knee during a flare? *
N/A
Left Knee: To what degree can you extend your knee during a flare? *
N/A
Left Knee: To what degree can you extend your knee during a flare? *
N/A
Left Knee: To what degree can you extend your knee during a flare? *
N/A
Additional Symptoms
Do you ever experience any of the following in your service-connected knee(s)? *
N/A
Does your knee condition interfere with your ability to stand? *
N/A

Yes
No
Please describe: *
N/A
Does your knee condition interfere with your ability to walk? *
N/A

Yes
No
Please describe: *
N/A
Does your knee condition cause you to be unstable when standing (instability of station)? *
N/A

Yes
No
Please describe: *
N/A
Does your knee condition interfere with your ability to sit? *
N/A

Yes
No
Please describe: *
N/A
Do you ever experience swelling in your knee(s)? *
N/A

Yes
No
Please describe: *
N/A
Instability of the Knee(s)
Do you experience persistent instability (the sensation of the knee twisting or moving from side to side when doing basic activities) in your right knee? *
N/A

Yes
No
Have you ever sprained or torn ligaments in your right knee? *
N/A
Have you received a prescription from a medical provider for any of the following for the instability in your right knee? *
N/A
Do you experience persistent instability (the sensation of the knee twisting or moving from side to side when doing basic activities) in your left knee? *
N/A

Yes
No
Have you ever sprained or torn ligaments in your left knee? *
N/A
Have you received a prescription from a medical provider for any of the following for the instability in your left knee? *
N/A
Patellar Instability
Right Knee Patellar Instability: Do you experience recurrent patellar instability (partial or total dislocations of your kneecap)? *
N/A

Yes
No
Have you had surgery to treat your patellar instability in your right knee?
*
N/A

Yes
No

Right Knee Patellar Instability Surgery Details:

	Month	Year
Surgery Dates: *

Have you received a prescription from a medical provider for any of the following for your patellar instability in your right knee?
*
N/A
Left Knee Patellar Instability: Do you experience recurrent patellar instability (partial or total dislocations of your kneecap)? *
N/A

Yes
No
Have you had surgery to treat your patellar instability in your left knee?
*
N/A

Yes
No

Left Knee Patellar Instability Surgery Details:

	Month	Year
Surgery Dates: *

Have you received a prescription from a medical provider for any of the following for your patellar instability in your left knee?
*
N/A
Shin Splints
Are you SERVICE CONNECTED for shin splints in your right leg? *
N/A

Yes
No

***If you are SERVICE CONNECTED, you will see SHIN SPLINTS listed as a diability on your disability breakdown.
Please select all that apply for your shin splints in your right leg: *
N/A
Are you SERVICE CONNECTED for shin splints in your left leg? *
N/A

Yes
No

***If you are SERVICE CONNECTED, you will see SHIN SPLINTS listed as a diability on your disability breakdown.
Please select all that apply for your shin splints in your left leg: *
N/A
Meniscus Conditions & Total Knee Replacements
Have you ever been diagnosed with a meniscus condition for your right knee? *
N/A

Yes
No
Type of meniscus injury: *
N/A

Right Knee Meniscus Injury Details:

	Month	Year
Meniscus Injury Date: *

Do you experience any of the following on your right knee? *
N/A
Have you ever been diagnosed with a meniscus condition for your left knee? *
N/A

Yes
No
Type of meniscus injury: *
N/A

Left Knee Meniscus Injury Details:

	Month	Year
Meniscus Injury Date: *

Do you experience any of the following on your left knee? *
N/A
Have you ever had a total knee joint replacement in your right knee? *
N/A

Yes
No

Right Knee Replacement Details:

	Month	Year
Knee Replacement Date: *

Which of the following best describes your right knee following the knee replacement? *
N/A

Intermediate degrees of residual weakness, pain, or limitation of motion
Chronic residuals consisting of severe painful motion or weakness
Have you ever had a total knee joint replacement in your left knee? *
N/A

Yes
No

Left Knee Replacement Details:

	Month	Year
Knee Replacement Date: *

Which of the following best describes your left knee following the knee replacement? *
N/A

Intermediate degrees of residual weakness, pain, or limitation of motion
Chronic residuals consisting of severe painful motion or weakness
Additional Surgery & Information
Have you undergone any other right knee surgeries? *
N/A

Yes
No
How many surgeries have you had on your right knee? *
N/A

IF YOU HAVE HAD MORE THAN 4 SURGERIES, PLEASE SELECT 4 AND COMPLETE THE ADDITIONAL QUESTION IN REGARDS TO YOUR OTHER SURGERIES

Right Knee Surgery #1 Details:

	Month	Year
Surgery Date: *

Both month & year MUST be completed. Please do not leave blank.

Type of Knee Surgery: *
N/A

Right Knee Surgery #2 Details:

	Month	Year
Surgery Date: *

Both month & year MUST be completed. Please do not leave blank.

Type of Knee Surgery: *
N/A

Right Knee Surgery #3 Details:

	Month	Year
Surgery Date: *

Both month & year MUST be completed. Please do not leave blank.

Type of Knee Surgery: *
N/A

Right Knee Surgery #4 Details:

	Month	Year
Surgery Date: *

Both month & year MUST be completed. Please do not leave blank.

Type of Knee Surgery: *
N/A
If you have had more than four surgeries on your right knee, please put month/year and type of surgery below for each additional surgery:
N/A
Have you undergone any other left knee surgeries? *
N/A

Yes
No
How many surgeries have you had on your left knee? *
N/A

IF YOU HAVE HAD MORE THAN 4 SURGERIES, PLEASE SELECT 4 AND COMPLETE THE ADDITIONAL QUESTION IN REGARDS TO YOUR OTHER SURGERIES

Left Knee Surgery #1 Details:

	Month	Year
Surgery Date: *

Both month & year MUST be completed. Please do not leave blank.

Type of Knee Surgery: *
N/A

Left Knee Surgery #2 Details:

	Month	Year
Surgery Date: *

Both month & year MUST be completed. Please do not leave blank.

Type of Knee Surgery: *
N/A

Left Knee Surgery #3 Details:

	Month	Year
Surgery Date: *

Both month & year MUST be completed. Please do not leave blank.

Type of Knee Surgery: *
N/A

Left Knee Surgery #4 Details:

	Month	Year
Surgery Date: *

Both month & year MUST be completed. Please do not leave blank.

Type of Knee Surgery: *
N/A
If you have had more than four surgeries on your left knee, please put month/year and type of surgery below for each additional surgery:
N/A
Do you use any assistive devices to help you walk?

Occasionally Regularly Constantly

Wheelchair

Brace

Crutches

Cane

Walker
If you use an assistive device to help you walk that is not listed above, please identify the device and if you use it occasionally, regularly or constantly:
N/A
Describe how your knee condition affects your ability to perform job tasks such as standing, walking, lifting, sitting, driving etc.? *
N/A
Mental Questionnaire
Which of the following BEST describes your level of occupational and social impairment with regarding your diagnosed mental disorder? *
N/A

Symptoms only decrease my ability to perform tasks during periods of significant stress.
Occupational and social impairment with occasional decrease in work efficiency. Unable to perform occupational tasks at times, generally functional.
Occupational and social impairment with reduced reliability and productivity.
Occupational and social impairment with deficiencies in most areas (work, school, family relations, judgement, thinking and/or mood).
Total occupational and social impairment.
Please provide as many details as possible in ALL of the written sections of this questionnaire. Providing a minimum 5-8 sentence detailed description for each text answer allows us to generate the most accurate medical documents.
Background Information
Did any specific event(s) during your military service contribute to your mental disorder? *
N/A

Yes
No
Please describe: *
N/A
Social, Marital & Family History
Are you currently married or in a relationship? *
N/A

Yes
No
How has this condition affected your relationship with your spouse/partner/significant other? *
N/A
Do you feel that this condition has contributed to why you are not currently in a relationship? Please explain: *
N/A
How has this condition affected your relationships with your friends, children and extended family? *
N/A
Additional relevant information:
N/A
Occupational History
Describe how this condition has affected your ability to work:
What type of tasks do you struggle with? Were you recently hired or fired? Do you struggle to keep jobs?
*
N/A
Describe your relationships and interactions with your coworkers and supervisors:
*
N/A
Has this condition caused you to arrive late to work, leave work early, or miss work completely? Please elaborate: *
N/A
If your symptoms have contributed to disciplinary action (being counseled, written up or fired), please describe:
N/A
Treatment
Have you EVER received treatment for this condition? (i.e. counseling/therapy, psychiatry, inpatient, outpatient, 5150 hold, etc.) *
N/A

Yes
No
Please list the date(s), frequency, and type(s) of treatment: *
N/A
Please explain why you have not received treatment: *
N/A
Do you currently take any medication(s) specifically for mental health? *
N/A

Yes
No
How many medications do you take for your Mental Health? *
N/A
Name of Medication #1 *
N/A
Dosage of Medication #1 *
N/A
Frequency of Medication #1: *
N/A
Name of Medication #2: *
N/A
Dosage of Medication #2: *
N/A
Frequency of Medication #2: *
N/A
Name of Medication #3: *
N/A
Dosage of Medication #3: *
N/A
Frequency of Medication #3: *
N/A
Please list each additional medication you are currently taking for your mental condition, including the dosage & frequency: *
N/A
Substance Use & Abuse
Do you use alcohol? *
N/A

Yes
No
How much and how often do you drink? *
N/A
Do you use drugs? *
N/A

Yes
No
Describe your drug use, including the type of drugs you use and how often you use them: *
N/A
Are you service connected for PTSD? *
N/A

Yes
No
How were you exposed to actual or threatened death, serious injury and/or sexual violence?
Select all that apply
*
N/A
Which of the following do you experience?
Select all that apply
*
N/A
Avoidance factors:
Select all that apply
*
N/A
How has the trauma impacted your mood and thoughts?
Select at least 2:
*
N/A
How has the trauma affected your reactions to things?
Select at least 2:
*
N/A
Understanding Your Symptoms
Please carefully review each of the following symptoms.
Select YES for all of the symptoms that you have experienced during the past year and describe how they affect you. This information is very important when anticipating which rating the VA may assign to your mental disability.
Depressed mood

Persistent feelings of sadness and loss of interest.

Example: I'd describe my mood as "low," and feel sad and upset. It's affected my sleeping and eating habits and I've been skipping activities that I usually enjoy. I have a hard time experiencing joy.
Have you experienced episodes of a depressed mood within the last year? *
N/A

Yes
No
Anxiety

A feeling of worry, nervousness, or unease

Example: I feel tense and worried, but I'm not always sure why. My heart races, I get knots in my stomach and sometimes I feel light-headed. I feel uncomfortable and like I don't want to be where I am, but I also can't think of anywhere I could go or anything I could do that would make things better.
Have you experienced anxiety within the past year? *
N/A

Yes
No
Suspiciousness

A quality of distrust or disbelief

Example: I am suspicious of others; I feel like they often have an ulterior motive. There aren't many people I can trust.
Have you experienced suspiciousness within the past year? *
N/A

Yes
No
Panic attacks

A sudden episode of intense fear, doom, or dread; intense fear or anxiety that triggers severe physical reactions when there is no real danger or apparent cause

Example: I get super anxious then feel like my throat is closing and I'm suffocating. I feel like I have no control over my body or thoughts and like my world is falling apart. I feel an urgent need to leave the area or something terrible will happen.
Have you had any panic attacks within the past year? *
N/A

Yes
No
Panic attack frequency: *
N/A

Weekly or less often
More than once a week
Near-continuous panic OR depression affecting the ability to function independently, appropriately and effectively

Experiences one or more of the following symptoms on most days/nights:
a. panic
b. anxiety
c. depression

Example: I feel depressed more days than not; I just don’t want to get out of bed or face the day! Panic and anxiety feel like constant companions in my life and often prevent me from doing things that I used to enjoy. It’s so hard for me to be present with my family and at work because I feel that I am constantly wrestling with these feelings.
Within the past year, did you experience near-continuous panic OR depression that affected your ability to function independently?
*
N/A

Yes
No
Please describe how near continuous panic or anxiety affects you: *
N/A
Chronic sleep impairment

Difficulty falling asleep or difficulty sleeping through the night

Example: I can't seem to fall asleep no matter how tired I am and/or I am constantly waking up at night.
Have you experienced chronic sleep impairment within the past year? *
N/A

Yes
No
Mild memory loss

Slight, but noticeable forgetfulness

Example: I have a hard time remembering things like names, directions and recent events. I have to write down my grocery list, so I don't forget something while shopping.
Have you experienced mild memory loss within the past year? *
N/A

Yes
No
Impairment of short AND long-term memory

Difficulty remembering things for a short period of time AND difficulty recalling information intended to be stored over a long period of time.

Example: I also have a hard time remembering details that I learned previously (my spouse's birthdate, how to tie my shoes, or how to style my hair).
Have you experienced impairment of short and long-term memory within the past year? *
N/A

Yes
No
Memory loss for names of close relatives, own occupation or own name

Inability to recall intimate details about your life, including the names of close family members, what your job is/was, and/or what your own name is

Example: Sometimes I wake up next to my husband, and I just can’t remember his name. If someone asks me where I work, I go completely blank and forget.
Have you experienced memory loss for names of close relatives, own occupation or own name within the past year? *
N/A

Yes
No
Please list specific examples: *
N/A
Flattened affect

Absence emotional expression

Example: I'm unable to visually and/or verbally express any emotion.
Have you experienced flattened affect within the past year? *
N/A

Yes
No
Circumstantial, circumlocutory, or stereotyped speech

Including many nonessential details; intentionally evasive, overusing words when not necessary; when someone lacks the developmental or verbal ability to communicate appropriately and says the same things over and over, rhyme, etc.

Example: Sometimes in a conversation, I can tell that the other person is no longer engaged, but I just can’t seem to move from a topic. I often repeat the same phrase or word over and over because I'm not capable of of saying anything else.
Have you experienced circumstantial, circumlocutory, or stereotyped speech within the past year? *
N/A

Yes
No
Please elaborate and describe how it affects your daily life: *
N/A
Speech that is occasionally illogical, obscure or irrelevant

Saying things that are completely unrelated to the conversation, do not make sense at all and/or are totally out of context

Example: People literally don't understand what I'm saying when I'm speaking. My words are off track and unclear.
Has your speech been occasionally illogical, obscure or irrelevant within the past year? *
N/A

Yes
No
Please provide specific examples and describe how this has affected your daily life: *
N/A
Difficulty understanding complex commands

Struggling to understand a sequence of operations

Example: When my boss gives me orders, I often have to go back for clarification and ask him to explain it to me several times before I can complete the task. I have a hard time understanding the order of things. I feel overwhelmed if someone tells me too many details or directions at once.
Have you experienced difficulty understanding complex commands within the past year? *
N/A

Yes
No
Impaired judgement

The inability to make appropriate decisions; not being able to fully understand or consider relevant facts that are necessary to make an informed decision

Example: After a few drinks, I think it's probably ok to drive as long as I don't feel drunk. I have given money away to strangers on the internet because they said they needed it. Sometimes it's easier to skip taking a shower because I'm not sure what clothes to wear.
Has your judgement been impaired within the past year? *
N/A

Yes
No
Please elaborate and provide specific examples: *
N/A
Impaired abstract thinking

Difficulty thinking about objects, principles and ideas that are not physically present

Example: I find it hard to use my imagination, formulate theories, and understand relationships between verbal and non-verbal ideas. I don't always understand analogies and metaphors. I don't often understand humor unless it is explained thoroughly.
Have you experienced impaired abstract thinking within the past year? *
N/A

Yes
No
Gross impairment in thought process or communication

Extreme difficulty with communicating or thinking clearly due to the severity of psych symptoms

Example: I seriously struggle with communicating my thoughts or ideas with others; I also find it very difficult to think clearly. I try to explain my thoughts and they're so extremely disjointed, literally no one is able to understand what I'm saying.
Have you experienced gross impairment in your thought process or communication within the past year? *
N/A

Yes
No
Please elaborate and describe how it affects your daily life: *
N/A
Disturbances of motivation and mood

Psych symptoms cause a shift in mood and desire/ability to complete tasks

Example: My mood swings and negative emotions make me less productive. I when I get really sad/angry/upset, I end up missing work because I don't want to do anything other than stay in bed.
Have you experienced disturbances of motivation and mood within the past year? *
N/A

Yes
No
Please provide specific examples: *
N/A
Difficulty establishing and maintaining effective work and social relationships

Finds it challenging to establish and maintain successful relationships with people in work and social settings

Example: I have a hard time making new friends. I've tried reaching out to old friends, but I don't feel like I'm able to keep up with them. I've also tried to talk to my coworkers, but we don't really seem to connect.
Have you experienced difficulty establishing and maintaining effective work or social relationships within the past year? *
N/A

Yes
No
Describe the challenges you experience with establishing and maintaining social relationships: *
N/A
Difficulty adapting to stressful circumstances including work and work-like settings

Difficulty adjusting to stress (both in and out of the workplace)

Example: When things are stressful, I feel like I can barely handle it. It’s as if even the slightest amount of stress causes me to feel completely overwhelmed. Traveling is a nightmare. I have a very hard time adjusting if a deadline changes at work.
Have you felt like it was difficult to adapt to stressful circumstances within the past year? *
N/A

Yes
No
Please provide examples of stressful circumstances and describe why it was difficult to adapt: *
N/A
Inability to establish and maintain effective relationships

Being UNABLE to make and keep relationships with others, especially romantic interests, friends, family and coworkers

Example: I find it virtually impossible to make and keep friendships or romantic relationships. My relationship with my family is virtually nonexistent. I can’t seem to be a part of those relationships.
Have you been unable to establish and maintain effective relationships within the past year? *
N/A

Yes
No
Describe the relationship(s) you were UNABLE to establish/maintain. How did your mental health condition play a role in that? *
N/A
Suicidal ideation

Thoughts about suicide (with or without a plan)

Example: There are times when I feel that everyone would be better off without me and I think of ways to end my own life. I have been saving my pills for a long time and if things get bad enough, I will just take them all at once to escape. I’m not sure if I would follow through with it, but I often fantasize about what it would be like to fall asleep and never wake up.
Do you ever experience suicidal ideation (thoughts about suicide, with or without a plan)? *
N/A

Yes
No
With or without a plan? *
N/A

With a plan
Without a plan
Do you feel you could act on this? *
N/A

Yes
No
Please explain: *
N/A
Obsessional rituals that interfere with routine activities

Persistent behaviors that interfere with everyday activities

Example: I won't sit down in a room unless my back is against a wall and I am facing the door. I am often late for work because I feel the need to double and triple-check that all the lights in my house are off before I can leave. I am afraid that the house will be broken into, so I stay up, walking around the house, checking the locks and windows several times a night.
Have any obsessional rituals interfered with your daily activities within the past year? *
N/A

Yes
No
Please describe the rituals and how they interrupted your daily life: *
N/A
Impaired impulse control

Decreased emotional or behavioral self-control

Example: I sometimes go on spending sprees or gamble my money away and it has led to a huge amount of debt. When I start drinking, I feel like I can’t stop. I get so irritable, I don’t even know why, but sometimes I will just ‘snap’ and get so violent I put holes in the walls or scare those around me.
Have you experienced impaired impulse control within the past year? *
N/A

Yes
No
Please explain: *
N/A
Spatial disorientation

Being unable to determine your body position relative to your surroundings; getting lost in familiar and unfamiliar places

Example: I get completely lost in places that should be familiar to me. Sometimes I am driving home from work and I end up on the other side of town, totally unaware of where I was going or where I needed to be.
Have you experienced spatial disorientation within the past year? *
N/A

Yes
No
Please provide specific examples of where you were and how the situation was resolved: *
N/A
Persistent delusions or hallucinations

Delusions: A strongly held belief despite evidence that the belief is false

Example: I believe that there is an individual who is stalking me and trying to harm me. I made a police report, but they didn't take me seriously. I am convinced my spouse is having an affair, despite my friends, family and spouse assuring me otherwise.

Hallucinations: A sensory experience that seems real, but isn't; involves one or more of the senses (smell, sight, sound, taste, touch)

Example: I hear voices when no one is speaking. I see tiny black spots on my skin that no one else can see. I hear things like footsteps, doors slamming or music playing when no one else does. I feel insects crawling on me even though I can't see anything.
Have you experienced persistent delusions or hallucinations within the past year? *
N/A

Yes
No
Please describe you delusion(s) or hallucination(s) in detail: *
N/A
Grossly inappropriate behavior

Conduct that is unwarranted and is generally interpreted to be extremely demeaning or offensive

Example: At times, I do and say things that are extremely inappropriate. I couldn’t stop laughing at my friend’s funeral. I have gone into public naked.
Have you experienced grossly inappropriate behavior within the past year? *
N/A

Yes
No
Please describe the behaviors, including details as to why they were extremely inappropriate: *
N/A
Persistent danger of hurting self or others

Ongoing/continual behaviors that put yourself or others in danger

Example: I battle with ongoing thoughts of physically hurting myself (i.e. cutting or burning) or wanting to harm other people. I am always on the verge of acting on those thoughts. I often lose control of my temper and experience uncontrollable rage, resulting in fights or abuse to others.
Do you ever experience persistent danger of hurting self or others? *
N/A

Yes
No
Do you feel you could act on this? *
N/A

Yes
No
Please explain: *
N/A
Neglect of personal appearance and hygiene

Failure to care for your appearance or perform tasks to maintain health/prevent disease

Example: Sometimes I skip showering, brushing my teeth, or changing my clothes because I don't have any motivation.
Have you neglected your personal appearance and hygiene within the past year? *
N/A

Yes
No
Please provide specific examples of how you negelected your appearance or hygiene: *
N/A
Intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene

At times, being UNABLE to perform daily self-care activities

Example: Sometimes I feel so upset, I can't get out of bed for days and don't eat, shower or change my clothes. There are days when I can't handle dealing with my medications, so I just don't take them. My anxiety gets so bad, I end up paying my bills late (if I pay them at all).
In the last year, have there been times when you were UNABLE to perform activities of daily living? *
N/A

Yes
No
Please explain: *
N/A
Disorientation to time or place

A usually temporary state of confusion about the time or place, often as a result of disease or drugs

Example: There are times where I do not recognize where I am at all, even if I have been there before. Sometimes I don’t remember what year it is or who the president is. It’s like I completely lose track of time and space.
Have you experienced disorientation to time or place within the past year? *
N/A

Yes
No
Please explain and provide specific examples: *
N/A
Additional Information
Please provide any additional details about symptoms here:
N/A
Do you feel capable of managing your financial affairs? *
N/A

Yes
No (if selected, the VA will assign someone to manage your assets and make financial decisions for you)
Do you fully understand that by selecting No, you will no longer be able to make financial decisions for yourself or manage your own assets and the VA will assign someone to do so instead?
*
N/A

I understand
I do not understand
Neck Questionnaire
Dominant hand: *
N/A

Right
Left
Ambidextrous
Briefly describe the history of your neck condition, including how and when your symptoms began: *
N/A
Neck Flare-Ups & Daily Life

A flare-up occurs when symptoms of your condition suddenly worsen and may be debilitating. Think about when your symptoms (pain, swelling, difficulty moving) are the most severe (this may only be 1-2 times per year).
How would you describe the severity of your flares? *
N/A
How often do you experience flare-ups? *
N/A
How long do your neck flares typically last? *
N/A
Briefly list the symptoms of your flare-ups: *
N/A
What causes your flares? What helps alleviate your flares? *
N/A
Medication Tracking — Neck

Do you take medication for this condition?
Yes No

How many medications do you currently take for this condition?

Medication 1

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:

Medication 2

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:

Medication 3

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:

Medication 4

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:
What activities are specifically challenging during flares? *
N/A
How does your neck condition affect your daily life? *
N/A
Neck Range of Motion

Please use the images as a reference when answering the questions below regarding your range of motion.
Forward Flexion Full Range of Motion: 45 Degrees

<85 Flex w0ex w/ Pain 20%; <15 Flex
FORWARD FLEXION - BENDING YOUR HEAD DOWN
Begin by looking straight ahead, now tilt your head forward. On an average day, to what degree can you tilt your head forward? *
N/A
At what degree do you begin to experience pain? *
N/A
To what degree can you tilt your head forward during a flare? *
N/A
Extension Full Range of Motion: 45 Degrees
EXTENSION - LOOKING UP
Tilt your head back, so you are looking at the ceiling. On an average day, to what degree can you tilt your head back? *
N/A
At what degree do you begin to experience pain? *
N/A
To what degree can you tilt your head back during a flare? *
N/A
Lateral Flexion Full Range of Motion: 45 Degrees
RIGHT LATERAL FLEXION - TILTING YOUR HEAD TO THE RIGHT
Look straight ahead and tilt your head to the right, bringing your ear down towards your shoulder. On an average day, to what degree can you tilt your head to the right? *
N/A
At what degree do you begin to experience pain? *
N/A
To what degree can you tilt your head to the right during a flare? *
N/A
Lateral Flexion Full Range of Motion: 45 Degrees
LEFT LATERAL FLEXION - TILTING YOUR HEAD TO THE LEFT
Look straight ahead and tilt your head to the left, bringing your ear down towards your shoulder. On an average day, to what degree can you tilt your head to the left? *
N/A
At what degree do you begin to experience pain? *
N/A
To what degree can you tilt your head to the left during a flare? *
N/A
Lateral Rotation Full Range of Motion: 80 Degrees
RIGHT LATERAL ROTATION - LOOKING TO THE RIGHT
Begin by looking straight ahead, now turn your head to the right. On an average day, to what degree can you turn your head to the right? *
N/A
At what degree do you begin to experience pain? *
N/A
To what degree can you turn your head to the right during a flare? *
N/A
Lateral Rotation Full Range of Motion: 80 Degrees
LEFT LATERAL ROTATION - LOOKING TO THE LEFT
Begin by looking straight ahead, now turn your head to the left. On an average day, to what degree can you turn your head to the left? *
N/A
At what degree do you begin to experience pain? *
N/A
To what degree can you turn your head to the left during a flare? *
N/A
Which of the following do you experience in your neck? *
N/A
Do you experience muscle spasms in your neck? *
N/A

Yes
No
Do your muscle spasms affect your ability to walk? *
N/A

Yes
No
Do you experience guarding (an involuntary reaction to protect an area of pain)? *
N/A

Yes
No
Does guarding your neck interfere with your ability to walk? *
N/A

Yes
No
Does your neck condition interfere with your ability to sit? *
N/A

Yes
No
Please describe: *
N/A
Does your neck condition interfere with your ability to stand? *
N/A

Yes
No
Please describe: *
N/A
Do you experience swelling in your neck? *
N/A

Yes
No
Please describe: *
N/A
Does your neck condition interfere with your ability to walk? *
N/A

Yes
No
Please describe: *
N/A
Does your neck condition cause you to be unsteady when standing (instability of station)? *
N/A

Yes
No
Please describe: *
N/A
Radiculopathy
**Please note, the VA will only grant a rating for severe radiculopathy if you are already service-connected for this condition.
Do you experience shooting pain, numbness, tingling or loss of feeling in one or both of your arms?

None Mild Moderate Severe**

Right Arm *

Left Arm *

Mild: Occasional symptoms. Moderate: Symptoms affect daily life; more constant and painful and/or weakened movement. Severe: Consistent, severe pain that interferes with activities daily.
Have you ever had surgery on your neck? *
N/A

Yes
No
How many surgeries have you had on your neck? *
N/A

IF YOU HAVE HAD MORE THAN 4 SURGERIES, PLEASE SELECT 4 AND COMPLETE THE ADDITIONAL QUESTION IN REGARDS TO YOUR OTHER SURGERIES

Neck Surgery #1 Details:

	Month	Year
Surgery Date: *

Type of Neck Surgery: *
N/A

Neck Surgery #2 Details:

	Month	Year
Surgery Date: *

Type of Neck Surgery: *
N/A

Neck Surgery #3 Details:

	Month	Year
Surgery Date: *

Type of Neck Surgery: *
N/A

Neck Surgery #4 Details:

	Month	Year
Surgery Date: *

Type of Neck Surgery: *
N/A
If you have had more than four surgeries on your neck please put month/year and type of surgery below for each additional surgery:
N/A
Do you use any assistive devices?

Occasionally Regularly Constantly

Wheelchair

Neck Brace

Crutches

Cane

Walker
If you use any additional assistive devices, please list them here and identify if you use them occasionally, regularly, or constantly:
N/A
Describe how your neck condition affects your ability to perform job tasks such as standing, walking, lifting or carrying objects, typing, sitting, driving etc.? *
N/A
Nerve Questionnaire
Briefly describe the history of your nerve condition, including how and when your symptoms began: *
N/A
Dominant hand: *
N/A

Right
Left
Ambidextrous
Common Symptoms of Neuropathy include:
- Numbness or tingling anywhere in your arms or legs
- Loss of feeling in your hands, fingers, toes or feet
- Shooting pain in your arms or legs
- Partial paralysis of the affected extremity
Please select the severity of your symptoms:

None Mild Moderate Severe

Right Arm *

Left Arm *

Right Leg *

Left Leg *
Do you use any assistive devices?

Occasionally Regularly Constantly

Wheelchair

Brace

Crutches

Cane

Walker
If you use any additional assistive devices, please list them here and identify if you use them occasionally, regularly, or constantly:
N/A
Have you ever had surgery to treat your nerve condition?
N/A

Yes
No
Please list the type(s) of surgery and the date(s) (MONTH/YEAR): *
N/A
How does your nerve condition affect your ability to perform job tasks (sitting, walking, typing, lifting objects, driving etc.)? *
N/A
1. Please describe the pain: *
N/A
3. How many service connected scars do you have? *
N/A

1
2
3
4
5
6
Scar 1: HISTORY (how it happened): *
N/A

Happened during combat (please be as detailed as possible)
Scar 1: DIMENSIONS (in centimeters) *
N/A

EXAMPLE: Left knee scar approx. 8 cm long x .5 cm wide
Scar 1: LOCATION: *
N/A

EXAMPLE: Located on front right side of knee
Scar 1: Is this scar painful? *
N/A

Yes
No
Scar 2: HISTORY (how it happened): *
N/A

Happened during combat (please be as detailed as possible)
Scar 2: DIMENSION (in centimeters)
N/A

EXAMPLE: Left knee scar approx. 8 cm long x .5 cm wide
Scar 2: LOCATION: *
N/A

EXAMPLE: Located on front right side of knee
Scar 2: Is this scar painful? *
N/A

Yes
No
Scar 3: HISTORY (how it happened): *
N/A

Happened during combat (please be as detailed as possible)
Scar 3: DIMENSIONS (in centimeters) *
N/A

EXAMPLE: Left knee scar approx. 8 cm long x .5 cm wide
Scar 3: LOCATION: *
N/A

EXAMPLE: Located on front right side of knee
Scar 3: Is this scar painful? *
N/A

Yes
No
Scar 4: HISTORY (how it happened): *
N/A

Happened during combat (please be as detailed as possible)
Scar 4: DIMENSIONS (in centimeters): *
N/A

EXAMPLE: Left knee scar approx. 8 cm long x .5 cm wide
Scar 4: LOCATION: *
N/A

EXAMPLE: Located on front right side of knee
Scar 4: Is this scar painful? *
N/A

Yes
No
Scar 5: HISTORY (how it happened): *
N/A

Happened during combat (please be as detailed as possible)
Scar 5: DIMENSION (in centimeters): *
N/A

EXAMPLE: Left knee scar approx. 8 cm long x .5 cm wide
Scar 5: LOCATION: *
N/A

EXAMPLE: Located on front right side of knee
Scar 5: Is this scar painful? *
N/A

Yes
No
Scar 6: HISTORY (how it happened): *
N/A

Happened during combat (please be as detailed as possible)
Scar 6: DIMENSIONS (in centimeters): *
N/A

EXAMPLE: Left knee scar approx. 8 cm long x .5 cm wide
Scar 6: LOCATION: *
N/A

EXAMPLE: Located on front right side of knee
Scar 6: Is this scar painful? *
N/A

Yes
No
3. Do any of your service-connected scars frequently lose the top layer of skin? *
N/A

Yes
No
Please identify which scars: *
N/A
4. If any of your scars affect your ability to work, please provide examples:
N/A

5. IF ANY OF THE SCARS LISTED ARE ON YOUR HEAD, FACE OR NECK, PLEASE COMPLETE THE FOLLOWING:

	Scar 1	Scar 2	Scar 3	Scar 4	Scar 5	Scar 6
Elevated Surface?
Depressed Surface?
Adherent to Underlying Tissue (connected to the skin beneath the scar):
Underlying Soft Tissue Missing?
Hypopigmentation? (Scar is lighter that surrounding skin):
Hyperpigmentation? (Scar is darker than surrounding skin):
Hardened/Inflexible?
Shiny:
Scaly:

6. Please elaborate on the symptoms you checked off (For example: scar on my neck is darker than the surrounding skin, shiny and hard):
N/A
Shoulder Questionnaire
Which shoulder is service connected? *
N/A

Right Shoulder
Left Shoulder
Both Shoulders

***IF WE ARE ONLY INCREASING ONE SHOULDER BUT YOU ARE SERVICE CONNECTED FOR BOTH YOU MUST STILL COMPLETE THE QUESTIONNAIRE FOR BOTH SHOULDERS***
Dominant Hand: *
N/A
Briefly describe the history of your shoulder condition, including how and when your symptoms began: *
N/A
Shoulder Flare-Ups & Daily Life

A flare-up occurs when symptoms of your condition suddenly worsen and may be debilitating. Think about when your symptoms (pain, swelling, difficulty moving) are the most severe (this may only be 1-2 times per year).
How would you describe the severity of your flares? *
N/A
How often do you experience flare-ups? *
N/A
How long do your shoulder flares typically last? *
N/A
Briefly list the symptoms of your flare-ups: *
N/A
What causes your flares? What helps alleviate your flares? *
N/A
Medication Tracking — Shoulder

Do you take medication for this condition?
Yes No

How many medications do you currently take for this condition?

Medication 1

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:

Medication 2

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:

Medication 3

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:

Medication 4

Medication Type:

Medication Name:

Dosage Amount:

Dosage Unit:

Frequency:

Relief provided:
What activities are specifically challenging during flares? *
N/A
How does your shoulder condition affect your daily life? *
N/A
Shoulder Range of Motion

Please use the images as a reference when answering the questions below regarding your range of motion.
Shoulder Flexion Full Range of Motion: 180 Degrees
FLEXION - RAISING THE ARM DIRECTLY OUT IN FRONT OF YOU
Right Shoulder: On an average day, to what degree can you raise your arm directly in front of you? *
N/A
Right Shoulder: At what degree do you begin to experience pain? *
N/A
Right Shoulder: To what degree can you raise your arm in front of you during a flare? *
N/A
Left Shoulder: On an average day, to what degree can you raise your arm directly in front of you? *
N/A
Left Shoulder: At what degree do you begin to experience pain? *
N/A
Left Shoulder: To what degree can you raise your arms in front of you during a flare? *
N/A
Shoulder Abduction Full Range of Motion: 180 Degrees
ABDUCTION - LIFTING THE ARM TO THE SIDE
Right Shoulder: On an average day, to what degree can you lift your arm out to the side? *
N/A
Right Shoulder: At what degree do you begin to experience pain? *
N/A
Right Shoulder: How far can you lift your arm out to the side during a flare? *
N/A
Left Shoulder: On an average day, how far can you lift your arm out to the side? *
N/A
Left Shoulder: At what degree do you begin to experience pain? *
N/A
Left Shoulder: To what degree can you lift your arm out to the side during a flare? *
N/A
Internal Rotation Full Range of Motion: 90 Degrees
INTERNAL ROTATION - ROTATING YOUR ARM DOWN
Right Shoulder: Begin with your arm lifted to your side at shoulder level (if possible) and elbow locked at a 90-degree angle. On an average day, how far can you rotate your arm down towards the ground? *
N/A
Right Shoulder: At what degree do you begin to experience pain? *
N/A
Right Shoulder: How far can you rotate your arm downwards during a flare? *
N/A
Left Shoulder: Begin with your arm lifted to your side at shoulder level (if possible) and elbow locked at a 90-degree angle. On an average day, how far can you rotate your arm down towards the ground? *
N/A
Left Shoulder: At what degree do you begin to experience pain? *
N/A
Left Shoulder: How far can you rotate your arm downwards during a flare? *
N/A
External Rotation Full Range of Motion: 90 Degrees
EXTERNAL ROTATION - ROTATING YOUR ARM UP
Right Shoulder: Begin with your arm lifted to your side at shoulder level (if possible) and elbow locked at a 90-degree angle. On an average day, how far can you rotate your arm up (as if waving hello)? *
N/A
Right Shoulder: At what degree do you begin to experience pain? *
N/A
Right Shoulder: How far can you rotate your arm up during a flare? *
N/A
Left Shoulder: Begin with your arm lifted to your side at shoulder level (if possible) and elbow locked at a 90-degree angle. On an average day, how far can you rotate your arm up (as if waving hello)? *
N/A
Left Shoulder: At what degree do you begin to experience pain? *
N/A
Left Shoulder: How far can you rotate your arm up during a flare? *
N/A
Additional Symptoms
Do you ever experience any of the following in your shoulder(s): *
N/A
Do you ever experience swelling in your shoulder(s)? *
N/A

Yes
No
Please describe: *
N/A
Do you experience episodes of instability or dislocations in your service connected shoulder(s)?

No Occasionally Frequently

Right Shoulder *

Left Shoulder *
Shoulder Surgery
Have you ever had surgery on your right shoulder? *
N/A

Yes
No
How many surgeries have you had on your right shoulder? *
N/A

IF YOU HAVE HAD MORE THAN 4 SURGERIES, PLEASE SELECT 4 AND COMPLETE THE ADDITIONAL QUESTION IN REGARDS TO YOUR OTHER SURGERIES

Right Shoulder Surgery #1 Details:

	Month	Year
Surgery Date: *

Type of Shoulder Surgery: *
N/A

Right Shoulder Surgery #2 Details:

	Month	Year
Surgery Date: *

Type of Shoulder Surgery: *
N/A

Right Shoulder Surgery #3 Details:

	Month	Year
Surgery Date: *

Type of Shoulder Surgery: *
N/A

Right Shoulder Surgery #4 Details:

	Month	Year
Surgery Date: *

Type of Shoulder Surgery: *
N/A
If you have had more than four surgeries on your right shoulder please put month/year and type of surgery below for each additional surgery:
N/A
Have you ever had surgery on your left shoulder? *
N/A

Yes
No
How many surgeries have you had on your left shoulder? *
N/A

IF YOU HAVE HAD MORE THAN 4 SURGERIES, PLEASE SELECT 4 AND COMPLETE THE ADDITIONAL QUESTION IN REGARDS TO YOUR OTHER SURGERIES

Left Shoulder Surgery #1 Details:

	Month	Year
Surgery Date: *

Type of Shoulder Surgery: *
N/A

Left Shoulder Surgery #2 Details:

	Month	Year
Surgery Date: *

Type of Shoulder Surgery: *
N/A

Left Shoulder Surgery #3 Details:

	Month	Year
Surgery Date:

Type of Shoulder Surgery: *
N/A

Left Shoulder Surgery #4 Details:

	Month	Year
Surgery Date: *

Type of Shoulder Surgery: *
N/A
If you have had more than four surgeries on your left shoulder please put month/year and type of surgery below for each additional surgery:
N/A
Additional Information
Do you use any assistive devices for your shoulder?
N/A
Please identify the other assistive device(s) you use for your shoulder: *
N/A
How often do you use your brace? *
N/A
How often do you use your other assistive device(s)? *
N/A
Describe how your shoulder condition affects your ability to perform job tasks such as typing/using a computer, lifting objects, reaching, driving etc.? *
N/A
Sinusitis Questionnaire
Briefly describe the history of your sinus condition, including how and when your symptoms began: *
N/A
Do you currently take any medication(s) for sinusitis? *
N/A

Yes
No
How many medications do you take for sinusitis? *
N/A
Name of Medication #1: *
N/A
Dosage of Medication #1: *
N/A
Frequency of Medication #1: *
N/A
Name of Medication #2: *
N/A
Dosage of Medication #2: *
N/A
Frequency of Medication #2: *
N/A
Name of Medication #3: *
N/A
Dosage of Medication #3: *
N/A
Frequency of Medication #3: *
N/A
Please list each additional medication(s) you take to treat sinusitis AND their dosages/frequency:
N/A
Select all sinus symptoms that apply: *
N/A
Near constant sinusitis: how often do you experience symptoms?
N/A
Please describe the symptoms you selected in detail: *
N/A
Total number of non-incapacitating episodes during the last 12 months:
Non-incapacitating episodes are characterized by sinus headaches, sinus pain/tenderness, discharge and crusting.
*
N/A

1
2
3
4
5
6
7 or more
Total number of incapacitating episodes during the last 12 months:
The VA defines an incapacitating episode as one that requires bedrest prescribed by a physician AND 4-6 weeks of antibiotic treatment.
*
N/A

0
1
2
3 or more
Have you ever had sinus surgery? *
N/A

Yes
No
How many sinus surgeries have you had? *
N/A

IF YOU HAVE HAD MORE THAN 4 SURGERIES, PLEASE SELECT 4 AND COMPLETE THE ADDITIONAL QUESTION IN REGARDS TO YOUR OTHER SURGERIES

Sinus Surgery #1 Details:

	Month	Year
Surgery Date: *

Sinus Surgery #1 - Please identify the following:
1. Type of surgery (endoscopic or open)
2. Type of procedure
3. Sinuses operated on (maxillary, frontal, ethmoid, sphenoid)
4. Side operated on (left, right, both)
*
N/A

Sinus Surgery #2 Details:

	Month	Year
Surgery Date: *

Sinus Surgery #2 - Please identify the following:
1. Type of surgery (endoscopic or open)
2. Type of procedure
3. Sinuses operated on (maxillary, frontal, ethmoid, sphenoid)
4. Side operated on (left, right, both)
*
N/A

Sinus Surgery #3 Details:

	Month	Year
Surgery Date: *

Sinus Surgery #3 - Please identify the following:
1. Type of surgery (endoscopic or open)
2. Type of procedure
3. Sinuses operated on (maxillary, frontal, ethmoid, sphenoid)
4. Side operated on (left, right, both)
*
N/A

Sinus Surgery #4 Details:

	Month	Year
Surgery Date: *

Sinus Surgery #4 - Please identify the following:
1. Type of surgery (endoscopic or open)
2. Type of procedure
3. Sinuses operated on (maxillary, frontal, ethmoid, sphenoid, pansinusitis)
4. Side operated on (left, right, both)
*
N/A
If you have had more than four sinus surgeries please provide the following for each:
1. Date of surgery (month/year)
2. Type of surgery (endoscopic or open)
3. Type of procedure
4. Sinuses operated on (maxillary, frontal, ethmoid, sphenoid)
5. Side operated on (left, right, both)

N/A
Are you currently service connected for allergic rhinitis? *
N/A

Yes
No
Has rhinitis caused blockage in more than 50% of both of your nasal passages? *
N/A

Yes
No
Is one of your nasal passages completely blocked due to rhinitis?
N/A
Have you been diagnosed with permanent enlargement of the nasal turbinates? *
N/A

Yes
No
Have you been diagnosed with nasal polyps? *
N/A

Yes
No
Regardless of your current employment status, how does your sinus condition affect your ability to work or perform occupational tasks? *
N/A
Skin Questionnaire
Briefly describe the history of your service connected skin condition, including how and when your symptoms began: *
N/A
How many medications have you used in the past year to treat your skin condition? *
N/A
Type of medication #1 *
N/A
Name of medication #1: *
N/A
Dosage of medication #1 (please specify unit of measurement i.e. 20 mg): *
N/A

Unit of measurement MUST be specified in order to complete your DBQ
Route of administration - medication #1: *
N/A
Total amount of time you used medication #1 within the past 12 months: *
N/A
Type of medication #2 *
N/A
Name of medication #2: *
N/A
Dosage of medication #2 (please specify unit of measurement i.e. 20 mg): *
N/A

Unit of measurement MUST be specified in order to complete your DBQ
Route of administration - medication #2: *
N/A
Total amount of time you used medication #2 within the past 12 months: *
N/A
Type of medication #3 *
N/A
Name of medication #3: *
N/A
Dosage of medication #3 (please specify unit of measurement i.e. 20 mg): *
N/A

Unit of measurement MUST be specified in order to complete your DBQ
Route of administration - medication #3: *
N/A
Total amount of time you used medication #3 within the past 12 months: *
N/A
Type of medication #4 *
N/A
Name of medication #4: *
N/A
Dosage of medication #4 (please specify unit of measurement i.e. 20 mg): *
N/A

Unit of measurement MUST be specified in order to complete your DBQ
Route of administration - medication #4: *
N/A
Total amount of time you used medication #4 within the past 12 months: *
N/A
If you have had any other type of treatment within the last year, please list the type and dates: *
N/A
What percentage of your total body does your skin condition cover?
*
N/A

Less than 5%
5 to less than 20%
20 to less than 40%
More than 40%
What percentage of your face, hands and neck does your skin condition cover?
*
N/A

Less than 5%
5 to less than 20%
20 to less than 40%
More than 40%
Describe the location of your skin condition: *
N/A
Describe the appearance of your skin condition: *
N/A
Are you service connected for acne? *
N/A

Yes
No
Select all that apply: *
N/A
Does this condition affect your ability to work? If yes, please describe: *
N/A
Sleep Apnea Questionnaire
Briefly describe the history of your sleep apnea, including how and when your symptoms began: *
N/A
Do you currently use medication for sleep apnea? *
N/A

Yes
No
How many medications do you take for sleep apnea? *
N/A
Name of Medication #1: *
N/A
Dosage of Medication #1: *
N/A
Frequency of Medication #1: *
N/A
Name of Medication #2: *
N/A
Dosage of Medication #2: *
N/A
Frequency of Medication #2: *
N/A
Name of Medication #3: *
N/A
Dosage of Medication #3: *
N/A
Frequency of Medication #3: *
N/A
Please list each additional medication you take for your sleep apnea AND their dosages/frequency. * *
N/A
Select all that apply: *
N/A
Sleep Study
Have you ever had a sleep study? *
N/A

Yes
No
Approximate date of sleep study: *
N/A
Facility where sleep study was performed, if known: *
N/A
In your own words, how does sleep apnea affect your daily life and ability to work? *
N/A
Prostate Cancer Questionnaire
Briefly describe the history of your prostate cancer, including how and when your symptoms began: *
N/A
Select the option that best describes your condition's current status: *
N/A

Prostate cancer is currently active
Prostate cancer is currently in remission
Please list any types of treatment you’ve received and the approximate start/end date (month/year) it occurred: *
N/A

If you have not had treatement, please type NONE
Have you have had surgery to treat this condition? *
N/A

Yes
No
Please list the type of surgery and the month/year it was performed: *
N/A
Which best describes your urine leakage? *
N/A

I do not wear absorbent material
I require absorbent material (such as a diaper or padding) be changed less than 2 times daily
I require absorbent material (such as a diaper or padding) to be changed 2-4 times per day
I require absorbent material (such as a diaper or padding) to be changed 5+ times per day
Daytime urinary frequency: *
N/A

I urinate every 4+ hours
I urinate once every 2-3 hours
I urinate once every 1-2 hours
I urinate more than once per hour
Nighttime urinary frequency: *
N/A

I do not wake up at night to urinate
I wake up twice a night to urinate
I wake up 3-4 times a night to urinate
I wake up 5+ times a night to urinate
If you have a history of recurrent urinary tract or kidney infections, list all medications used to treat the infection INCLUDING dosage and frequency: *
N/A

If none, please type NONE
If you have erectile dysfunction, describe the origin/cause:
N/A
Select one of the following: *
N/A

I do not have erectile dysfunction
I have erectile dysfunction but am not prescribed medication for it
I have erectile dysfunction and CAN achieve an erection with medication
I have been prescribed erectile dysfunction medication, but it doesn’t work
In your own words, how does this condition affect your daily life and ability to work: *
N/A
Hemorrhoid Questionnaire
Briefly describe the history of this condition, including how and when your symptoms began: *
N/A
List any medications you use continuously to treat hemorrhoids (include dosage and frequency):
Please write "N/A" if you do not use medications.
*
N/A
Which best describes your hemorrhoids: *
N/A
Select all that apply: *
N/A
Do your hemorrhoids cause persistent bleeding? *
N/A

Yes
No
Do your hemorrhoids cause anal fissures (small tears)? *
N/A

Yes
No
Prostatitis Questionnaire
Briefly describe the history of your prostate condition, including how and when your symptoms began: *
N/A
Do you currently take any medication(s) for prostatitis?
N/A

Yes
No
How many medications do you take for prostatitis? *
N/A
Name of Medication #1: *
N/A
Dosage of Medication #1: *
N/A
Frequency of Medication #1: *
N/A
Name of Medication #2: *
N/A
Dosage of Medication #2: *
N/A
Frequency of Medication #2: *
N/A
Name of Medication #3: *
N/A
Dosage of Medication #3: *
N/A
Frequency of Medication #3: *
N/A
Please list each additional medication(s) you take to treat prostatitis AND the dosages/frequency: *
N/A
Have you had a testicle removed? *
N/A

Yes
No
Which testicle was removed? *
N/A

Right
Left
Both
Reason for removal: *
N/A
Please explain other: *
N/A
Do you wear absorbent material (such as a diaper or padding) for this condition? *
N/A

Yes
No
Which of the following best describes your urine leakage: *
N/A

Absorbent material must be changed less than 2 times per day
Absorbent material must be changed 2-4 times per day
Absorbent material must be changed 4+ times per day
Does your voiding dysfunction require the use of an appliance? *
N/A

Yes
No
What type of appliance? *
N/A
Which best describes your daytime urinary frequency: *
N/A

I urinate every 4+ hours
I urinate once every 2-3 hours
I urinate once every 1-2 hours
I urinate more than once per hour
Which best describes your nighttime urinary frequency: *
N/A

I do not wake up at night to urinate
I wake up twice a night to urinate
I wake up 3-4 times a night to urinate
I wake up 5+ times a night to urinate
Do you have erectile dysfunction as a result of your prostate condition? *
N/A

Yes
No
Have you taken medication for ED? *
N/A

Yes
No
Are you able to achieve an erection sufficient for ejaculation without medication? *
N/A

Yes
No
Are you able to achieve an erection sufficient for ejaculation with medication? *
N/A

Yes
No
Have you ever received treatment for your prostatitis? *
N/A

Yes
No
Have you undergone long-term prescription drug therapy? *
N/A

Yes
No
List medications used and indicate dates of use over the past 12 months: *
N/A
Have you experienced recurrent symptomatic infections requiring drainage/frequent hospitalization? *
N/A

Yes
No
How many times in the past year were you hospitalized for infections related to prostatitis? *
N/A
Have you undergone continuous intensive management? *
N/A

Yes
No
Indicate types of treatment and medications used over the past 12 months: *
N/A
Have you undergone intermittent intensive management? *
N/A

Yes
No
Indicate types of treatment and medications used over the past 12 months: *
N/A
How does this condition affect your ability to perform job tasks (office work, manual labor, driving, walking, sitting, standing etc.)? *
N/A
Signature *
N/A

E-Signature Field
Clear

Please use your mouse or finger (for touch screen devices) to sign.
Date *
N/A

Select a date
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OTHERWISE, ALL WORK COMPLETED THUS FAR WILL BE LOST.
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	Occasionally	Regularly	Constantly
Wheelchair
Brace
Crutches
Cane
Walker

	None	Mild	Moderate	Severe**
Right Leg *
Left Leg *

	Occasionally	Regularly	Constantly
Wheelchair
Brace
Crutches
Cane
Walker

	None	Mild	Moderate	Severe
Right Arm *
Left Arm *
Right Leg *
Left Leg *

Veteran Stress Management

Veteran Stress Management

Veteran Stress Management

DPA Assessment

Veteran Information

Medical Evidence/Records

Important Questionnaire Details

Medical Disabilities:

Ankle Questionnaire

Ankle Flare-Ups & Daily Life

Ankle Range of Motion

Additional Symptoms

Ankle Surgery

Asthma Questionnaire

Current Medication Regimen

Treatment & Daily Life

Diagnostic Test Results

Back Questionnaire

Back Flare-Ups & Daily Life

Back Range of Motion

Additional Symptoms

Radiculopathy

Back Surgery

Diabetes Questionnaire

Complications of Diabetes

Elbow Questionnaire

Elbow Flare-Ups & Daily Life

Elbow Range of Motion

Elbow Surgery & Additional Information

Foot Questionnaire

Foot Surgery Information

GERD Questionnaire

Signs and Symptoms

Joints & Affected Systems

Non-Incapacitating Episodes

Incapacitating Episode

Additional Information

Headache Questionnaire

Heart Questionnaire

Symptoms

Hip Questionnaire

Hip Flare-Ups & Daily Life

Hip Range of Motion

Additional Information

Hip Surgery

IBS Questionnaire

Knee(s) Questionnaire

Flare-Ups, Dislocation, & Other Knee Details

Knee Range of Motion

Additional Symptoms

Instability of the Knee(s)

Patellar Instability

Shin Splints

Meniscus Conditions & Total Knee Replacements

Additional Surgery & Information

Mental Questionnaire

Background Information

Social, Marital & Family History

Occupational History

Treatment

Substance Use & Abuse

Understanding Your Symptoms

Additional Information

Neck Questionnaire

Neck Flare-Ups & Daily Life

Neck Range of Motion

Radiculopathy

Nerve Questionnaire

Shoulder Questionnaire

Shoulder Flare-Ups & Daily Life

Shoulder Range of Motion

Additional Symptoms

Shoulder Surgery

Additional Information

Sinusitis Questionnaire

Skin Questionnaire

Sleep Apnea Questionnaire

Sleep Study

Prostate Cancer Questionnaire

Hemorrhoid Questionnaire