Veteran Medical Claim Intake Questionnaire

Form Instructions and Disclaimers:

This form collects medical history and supporting information so our clinic can determine whether we are able to complete Disability Benefits Questionnaires and or prepare a medical opinion related to your claimed conditions.
We provide medical services only. We do not provide legal advice, and we do not guarantee any outcome with the Department of Veterans Affairs. All opinions are based solely on medical evidence, record review, and clinical evaluation.
Please answer all questions honestly and completely. If you need assistance filing or managing your claim, you should consider working with an accredited Veterans Service Organization or representative.
Completion and submission of this form does not obligate you to proceed with our services, and there is no fee for submitting the intake form alone. After review, we will notify you whether we are able to assist and provide a written estimate of the cost for the requested services.
Typical fee ranges for our medical services are as follows (this is an estimate based on a moderate level of complexity, your case-specific estimate will be sent after we receive this completed form):
- Medical Opinion or Nexus Letter: Includes record review for that condition only
  - 1 condition: $300
  - 2 conditions: $275 each
  - 3 to 4 conditions: $250 each
  - 5 or more conditions: $225 each
- DBQ Completion: Requires In-Person Visit (Overland Park, KS)
  - 1 condition: $150
  - 2 conditions: $135 each
  - 3 to 4 conditions: $125 each
  - 5 or more conditions: $110 each
- Bundled Discount: Nexus Plus DBQ= 15% Discount for the Same Condition

Full legal name*

First NameLast Name

Preferred name

Date of birth*

Date

Phone number*

Please enter a valid phone number.Format: (000) 000-0000.

Email address*

example@example.com

Mailing address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

PhoneTextEmailPortal message

MaleFemale

Height (inches)

Weight (lbs)

RightLeftAmbidextrous

Preferred language

Branch of service*

Dates of service*

Character of discharge*

Highest rank achieved*

MOS/AFSC/Rate (Military Job)*

Description of military duties

Specialized training (ie. Airborne, Special Forces, etc.)

Combat-related awards or combat indicators

Deployment history

YesNo

Medical OpinionMedical Exam / DBQ Completion (In-Person)Records ReviewOther

Claimed conditions (that you need help with)

YesNo

Current combined rating (%)

Effective date of current rating

Date

Current service connected conditions

YesNo

Describe any pending appeals

Primary care provider and location

Specialists (names and specialties)

Major diagnoses with year of diagnosis (ie. Asthma, degenerative disc disease, etc.)

Hospitalizations (dates and reasons)

Ongoing treatment plans (ie. Physical therapy, chiropractic care, pain management, etc.)

Don't include medications in this field, medications will be entered later

Surgical procedures

YesNoOther

Current medications

Medication allergies and reactions

Current occupation*

Post-service occupational exposures

Tobacco use

Alcohol use

Other substances

Work limitationsAssistive devicesAssistance with activities of daily living (ADLs)Other

Days missed from work in last 12 months due to claimed condition(s)

YesNo

Diagnostic tests

Exposure details (location, duration, protective equipment, symptoms)

Instructions for Uploading VA Medical Records / Service Treatment Records:

Download a full Blue Button report on My HealtheVet: VA Portal.
Sign in to My HealtheVet using Login.gov or ID.me.
Select Health Records.
Choose VA Blue Button Report.
Pick a date range.
Select what information to include (ideally "ALL").
Click Submit.
Choose PDF, then save the report.

Upload Service Treatment Records

Upload DD214 or NGB22

Upload personnel records or orders (if applicable)

Upload Line of Duty (LOD) documentation (if applicable)

Upload previous VA rating decision (if applicable)

Upload prior C&P exams (if applicable)

Upload VA problem list and medication list (if applicable)

Upload private medical records (if applicable)

Upload imaging and test reports (if applicable)

Upload buddy statements (if applicable)

Upload personal statements (if applicable)

Electronic signature*

Date of attestation*

Date

Veteran Medical Claim Intake Questionnaire – DBQ and Medical Opinion

Section 1: Veteran Identification and Contact

Section 2: Demographics

Section 3: Military Service History

Section 4: Claim Intent and Conditions

Section 5: Prior VA Claims and Ratings

Section 6: Medical History

Section 7: Surgical History

Section 8: Current Medications and Allergies

Section 9: Social and Occupational History

Section 10: Functional Impact

Section 11: Diagnostic Testing (x-ray, MRI, pulmonary function testing, lab studies, etc.) *Related to claimed condition only

Section 12: Exposure and Event Screening

Section 13: Document Upload (If available and relevant)

Final Section: Veteran Attestation