Veteran Intake Questionnaire
Please complete this questionnaire to help determine whether a medical record review and independent medical opinion may be appropriate. Completion does not guarantee a medical review or nexus opinion will be provided.
SECTION 1: Veteran Identification
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
State of Residence
*
Branch of Service
*
Dates of Active Service
*
Deployment Locations (if applicable)
Military Occupational Specialty (MOS)
SECTION 2: Claim Information
What condition(s) are you seeking a nexus letter for?
*
Is this claim for:
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Direct service connection
Secondary condition
Aggravation of a pre-existing condition
Unsure
Have you previously filed a VA claim for this condition?
*
Yes
No
Was the claim:
Approved
Denied
Deferred
Have you had a VA Compensation & Pension (C&P) exam for this condition?
*
Yes
No
Unsure
SECTION 3: Condition History
What condition are you currently diagnosed with?
*
Who diagnosed the condition? (Provider type or specialty)
*
When were you first diagnosed?
*
When did symptoms first begin?
*
Describe the symptoms you currently experience.
*
How often do symptoms occur?
*
How do these symptoms affect your daily life or ability to work?
*
SECTION 4: Military Service Connection
Describe the event, injury, exposure, or circumstances during military service that you believe caused this condition.
*
Approximate date or timeframe of the event:
*
Location where the event occurred:
*
Was this documented in your service treatment records?
*
Yes
No
Unsure
Were you treated during service for this condition?
*
Yes
No
If yes, describe the treatment received.
SECTION 5: Secondary Conditions (if applicable)
What service-connected condition do you believe caused or worsened this condition?
When did symptoms of the secondary condition begin?
How do you believe the primary condition contributed to the development of this condition?
SECTION 6: Treatment History
Please list treatments you have received for this condition.
Medications:
Physical therapy:
Surgery or procedures:
Mental health treatment (if applicable):
Hospitalizations (if applicable):
Current treating providers (VA or private):
SECTION 7: Medical Records Available
Please indicate which records you can provide.
Service Treatment Records (STRs)
VA medical records
Private medical records
Imaging reports (MRI, CT, X-ray)
Specialist evaluations
VA C&P exam reports
VA rating decision letters
Lay statements or buddy statements
SECTION 8: Personal Statement
Please describe in your own words how this condition has affected your life since leaving military service. Include any impact on work, relationships, sleep, physical functioning, or mental health.
*
SECTION 9: Acknowledgment
I understand that Stephanie Hensley, DNP, APRN, FNP-C provides independent medical record review and medical opinion services only. Completion of this questionnaire does not guarantee that a nexus letter will be provided. Any medical opinion rendered will be based solely on available medical evidence and professional medical judgment.
Signature
*
Date
*
-
Month
-
Day
Year
Date
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