Spine Nerve & Joint Group: Veteran Nexus Intake Form
Referring Party
Referring Office Name
Contact Name
Email
*
example@example.com
Veteran Information
Enter the veteran’s details for intake review.
Veteran Name
Date of Birth
-
Month
-
Day
Year
Date
Email
*
example@example.com
Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Claimed Conditions
Select all conditions that apply.
Which claimed conditions apply?
Lumbar spine condition
Cervical spine condition
Knee condition
Shoulder condition
PTSD
Anxiety/Depression
Tinnitus
Headaches/Migraines
Traumatic Brain Injury
Other claimed condition
Mechanism / Service Exposure
Select every exposure that may be relevant.
Which service exposures apply?
Repetitive physical training
Combat-related injury
Occupational strain
Fall or acute injury
Noise exposure
Psychological trauma
Environmental exposure
Other
Other
Other service exposure
Symptom Timeline
Choose the option that best matches the onset timeline.
When did symptoms begin?
Symptoms began during service
Symptoms began shortly after service
Symptoms developed years after service
Unsure
Supporting Evidence
Upload or select the records you have available.
What supporting evidence is available?
Service treatment records
VA medical records
Private medical records
Imaging (MRI, X-ray, etc.)
Lay statements
Other
Other supporting evidence
Document Upload
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