• Increased Rating Statement Form

    Please complete a statement form for EACH claim you intend to pursue that you are already service-connected for. If you have any questions, please contact your case manager for more information.
  • Format: (000) 000-0000.

  • THIS STATEMENT IS ABOUT ...

  • What body system is this condition related to? (CHOOSE ONE)*
    • Secondary Mental Health Symptoms 

    • If you experience mental health symptoms of depression or anxiety because of your symptoms or limitations, consider making an appointment with a mental health specialist. 

       

      Once you have a diagnosis, we may be able to help you file a separate claim for depression/anxiety secondary to your service-connected condition, if necessary.

  • Cancer

    Any Type
    Cancer

  • A rating of 100 percent shall continue beyond the cessation of any surgical, X-ray, antineoplastic chemotherapy, or other therapeutic procedure.

    Six months after discontinuance of such treatment, the appropriate disability rating shall be determined by mandatory VA examination.

    Once your cancer has been in remission for 6 months, the VA will propose to reduce your cancer rating and it will assign a rating based on the residuals of the cancer.

  • What kind of cancer treatment did you undergo?*
  • Did you have surgery to remove any of the following? Select ALL that apply.*
  • Do you have any of the following residual symptoms from the cancer or treatment? Select ALL that apply.*
    • Residual Scarring 
    • Please select ALL symptoms that you experience:*

  • Auditory

    Hearing Loss & Tinnitus
    Auditory
  • Which auditory or balance condition are you completing this statement about? Select ALL that apply.*
    • Hearing Loss and Tinnitus 
    • Do you experience any of the following symptoms related to your hearing loss and/or tinnitus? Select ALL that apply.*
    • Of the following sounds, which sounds do you have difficulty hearing WITHOUT the use of a hearing aid? Select ALL that apply.*
    • Ear Infections 
    • Do you experience any of the following symptoms? Select ALL that apply.*
    • Balance Disorders 
    • Do you have a formal diagnosis of a peripheral vestibular disorder or Meniere's syndrome from a physician?*
    • Select ALL symptoms you experience because of your balance disorder*
    • How often do you experience dizziness?*

  • Cardiovascular

    Heart Conditions and Hypertension
    Cardiovascular
  • Is continuous medication required to control your heart condition?*
  • Do you have a cardiac arrythmia or atrial fibrillation (irregular heartbeat)?*
  • Do you have a diagnosis of hypertension or high blood pressure?*
  • Have you had any non-surgical or surgical procedures for the treatment of your heart condition?*
  • Have you had METs or exercise-based testing?*
  • Have you had any diagnostic tests such as an ECG, Chest X-Ray, Echocardiogram, MUGA, or MRI?*
  • Do you experience the any of the following symptoms? Select ALL that apply:*
    • Arrythmias 
    • Has your arrythmia required treatment?*
    • Hypertension or High Blood Pressure 
    • Do you experience any of the following symptoms related to your blood pressure?*
    • Heart Surgeries 
    • METs Testing 
    • Do you experience any of the following symptoms with any level of physical activity? Select ALL that apply.*
    • Which of the following activities cause you to experience the symptoms you listed above?*

  • Dental and Oral

    Dental and Oral
  • Do you have any of the following symptoms?*
    • Teeth 
    • Were any of your teeth removed due to trauma or a disease such as osteomyelitis?*
    • Were you able to have veneers or a prosthetic tooth installed?
    • Which teeth did you lose?
    • Mandible 
    • Did you have all or part of your mandible (lower jaw bone) removed?*
    • Do you have any symptoms of difficulty chewing, talking, or yawning because of the removal of your mandible or lower jaw (complete or partial)?*
    • Has the lower jaw bone or mandible healed improperly, causing displacement or misalignment of your lower jaw bone?*
    • Does displacement or misalignment of your lower jaw bone or mandible cause any of the following symptoms? Select ALL that apply.*
    • How much does the displacement or malalignment of your lower jaw or mandible affect your ability to chew, speak, and perform other functions?*
    • Temporomandibular Disorder (TMJ) 
    • Has a physician restricted your diet to mechanically altered foods that are easier to chew and swallow because of your TMJ condition?*
    • Which types of things do you have difficulty doing because of your TMJ disorder?*

  • Digestive

    IBS, Stomach, GERD
    Digestive
  • What digestive condition is this statement about?*
    • Esophageal Condition (including GERD) 
    • Does your esophageal stricture cause any of the following symptoms? Select ALL that apply.*
    • Does your esophageal stricture require any of the following? Select ALL that apply.*
    • Gall Bladder Condition 
    • Which of the following applies to you?*
    • Do you experience any of the following symptoms? Select ALL that apply.*
    • Hemorrhoids 
    • Do you experience any of the following symptoms? Select ALL that apply.*
    • Hernia 
    • In the past 12 months, which activities have caused pain? Select ALL that apply.*
    • Intestinal Condition and Irritable Bowel or Colon Syndrome (IBS) 
    • How often have you experienced abdominal pain with defecation in the past 3 months?*
    • Do you experience any of the following symptoms? Select ALL that apply.*
    • Liver Condition 
    • Do you experience any of the following symptoms of a liver condition? Select ALL that apply.*
    • Do you experience any of the following symptoms? Select ALL that apply.*
    • Ulcer 
    • Do you have any of the following symptoms? Select ALL that apply.*
    • Have you been hospitalized for your ulcer symptoms in the past 12 months?*
    • Are your symptoms managed by daily prescription medication?*
    • Have you had surgery on an ulcer?*

  • Endocrine

    Diabetes, Thyroid, Cushing's, etc
    Endocrine
  • What endocrine condition do you have?*
    • Diabetes Mellitus 
    • Please select ALL symptoms you have related to your diabetes mellitus:*
    • Thyroid Condition 
    • Were you diagnosed with this thyroid condition more than 6 months ago?*
    • Which of the following symptoms do you experience because of your thyroid condition? Select ALL that apply.*
    • Addison's Disease 
    • Which of the following symptoms have you experienced in the past year?*
    • How many times have you experienced these symptoms? (crisis)*
    • How many times have you experienced these symptoms? (episodes)*
    • Cushing's Syndrome 
    • Were you diagnosed with Cushing's Syndrome more than 6 months ago?*
    • Is this condition getting progressively worse?*
    • Which of the following symptoms do you experience? Select ALL that apply.*

  • Gynecological

    Breast, Cervix, Uterus, Female Sexual Arousal Disorder
    Gynecological
  • Do you have a disease, injury, or adhesion to any of the following? Select ALL that apply.*
  • Do your symptoms require treatment?*
  • What treatment do your symptoms require?*
    • Breast 
    • Have you had a surgery to remove one or more breast?*
    • Endometriosis 
    • Do you have any of the following symptoms?*
    • Ovaries 
    • Have you had a surgery to remove one or more ovaries?*
    • Uterus 
    • Have you had a surgery to remove your uterus?*

  • Infectious Diseases, Immune Disorders, and Nutritional Deficiencies

    Chronic Fatigue Syndrome, Malaria, Rheumatic Fever, Lyme Disease, West Nile Virus, Lupus, HIV-Related Illnesses
    Infectious Diseases, Immune Disorders, and Nutritional Deficiencies
  • Which Infectious Disease, Immune Disorder, or Nutritional Deficiency are you completing this statement about?*
    • Chronic Fatigue Syndrome 
    • How have your symptoms worsened SIGNIFICANTLY since your last Comp & Pen Exam? Select ALL that apply.*
    • HIV-Related Illnesses 
    • Have you been diagnosed with any of the following conditions? Select ALL that apply.*
    • Lupus 
    • In the past 12 months, have you experienced at least one "flare-up" or a period where your lupus symptoms are worse and more disruptive than normal?*
    • Lyme Disease 
    • Have you had any of the following symptoms within the past year? Select ALL that apply.*
    • Since you were diagnosed with Lyme disease, has a doctor diagnosed you with Chronic Fatigue Syndrome?*
    • Malaria 
    • Rheumatic Fever 
    • Do you experience any of the following symptoms of your rheumatic fever condition? Select ALL that apply.*

  • Mental Health

    PTSD, Depression, Anxiety
    Mental Health
  • Please select ALL symptoms you currently experience:*
  • Do you have any of the following symptoms? Select ALL that apply:*
  • Which of the following best describes the current status of your SOCIAL relationships? Select ALL that apply.*
  • Which of the following best describes your use of medications to control your mental health symptoms?*

  • Psychotropic medications include anti-depressants, antipsychotics, mood stabilizers, anxiety medications, stimulants for ADHD, etc.

  • Neurological

    Epilepsies, Neuralgia, Nerve Injuries, Neuritis, Neuropathies, Migraines, Multiple Sclerosis, Traumatic Brain Injuries
    Neurological
  • What neurological condition is this statement about? Select ALL that apply.*
    • Epilepsies or Seizures 
    • Do you require continuous medication to control the epilepsy or seizure condition?*
    • When you have a seizure, do you experience any of the following? Select ALL that apply.*
    • How many MAJOR seizures have you had in the past 12 months?*

    • What is a major seizure?

      A major seizure is a seizure that affects the entire brain. Usually, major seizures involve loss of consciousness and uncontrollable shaking.

       

      What is a minor seizure?

      Minor seizures affect a portion of the brain, and usually involve brief interruptions of consciousness with symptoms such as mumbling, rocking, slight twitching of the muscles, and/or falling down.

    • How many MINOR seizures have you had in the past 12 months?*

    • Not sure about your symptoms? Click here or scan the QR code below to download the Track It! app to help keep track of your symptoms!
       Seizure Track It! App

      Or you can click the link below to download and fill out the My Seizure Event Diary

    • Does your seizure condition prevent you from driving?*
    • Does your seizure condition prevent you from working full time?*
    • Migraines or Headaches 
    • Do you experience any of the following symptoms? Select ALL that apply:*

    • Not sure about your symptoms? Click here or scan the QR code below to download the Migraine Buddy app to help keep track of your symptoms!

      Migraine Buddy App

       

    • Incapacitating or prostrating means that the migraine is so severe you feel exhausted and weak, to the point where you need to lie down or rest for a long time until the attack is over. You CANNOT complete ANY type of task during an incapacitating or prostrating attack.

    • In the past few months, how often have you experienced an incapacitating or prostrating migraine attack?*
    • Nerve Injuries or Neuropathies 
    • Do you have any of the following symptoms? Select ALL that apply.*
    • Traumatic Brain Injuries (TBI) 
    • Do you have a formal diagnosis of a TBI from a doctor or physician?*
    • Do you have any of the following symptoms?*
    • Do you experience any of the following symptoms? Select ALL that apply.*
    • How do your TBI symptoms impair your daily functioning?*
    • Have your TBI symptoms caused or contributed to any of the following? Select ALL that apply.*

  • Orthopedic

    shoulders, elbows, wrists, hands, neck, back, knees, ankles, feet, other
    Orthopedic
    • Spine (Neck and Back) 
    • Is this statement about your neck or your back?*
    • What types of things do you have a hard time doing because of your neck or back condition?*

    • Neck

    • Can you bend your neck AT ALL, or is your neck frozen in place?*
    • Can you touch your chin to your chest?*
    • Can you look up at the sky?*

    • Back

    • Can you bend AT ALL, or is your back frozen in place?*
    • Can you bend forward to touch your toes?*
    • Can you bend backward to stand up straight?*
    • Do you have any of the following symptoms of guarding when walking? Select ALL that apply.*

    • Muscle guarding is when your muscles tighten up on purpose to protect an area of your body that hurts or is injured. It’s like when you hug yourself really tight if you bump your elbow—it’s your body’s way of trying to keep the hurt part safe. The muscles stay tight and don’t want to move, kind of like you're putting up a shield to keep the injury from getting worse. This can make the area feel stiff or sore, and it might be hard to move around like normal. Muscle guarding can often result in abnormal gait or abnormal spinal contour. 

      • An abnormal gait is when someone walks in a way that doesn’t look or feel quite right. It might be because something is hurting, one leg feels weak, or your body isn’t moving the way it should. So, instead of walking smoothly, you might limp, wobble, drag their feet, or take very short steps.
      • Spinal contour is the shape or curve of your spine (the bones in your back) when you look at it from the side. Normally, your spine has gentle curves that help you stand up straight and move around easily. It’s kind of like the way a slinky is curved but not too much. If the curves are too big or too small, it can make your back feel uncomfortable or hurt. So, spinal contour is just a fancy way of talking about how your spine is shaped.

    • Surgeries

      Surgeries
    • Have you had surgery on your neck or back? Select ALL that apply.*
    • Shoulders 
    • Right Shoulder - Can you move your arm up and down AT ALL, or is your shoulder frozen in place?*
    • Left Shoulder - Can you move your arm up and down AT ALL, or is your shoulder frozen in place?*

    • Surgeries

      Surgeries
    • Have you had surgery on either shoulder? Select ALL that apply.*

    • Other Side

      Surgeries
    • Elbows 
    • Right Elbow - Can you bend your elbow AT ALL, or is your elbow frozen in place?*
    • Left Elbow - Can you bend your elbow AT ALL, or is your elbow frozen in place?*

    • Surgeries

      Surgeries
    • Have you had surgery on either elbow? Select ALL that apply.*
    • Wrists and Hands 
    • Does pain make it difficult to perform any of the following activities? Select ALL that apply.*
    • Have you had any of the following medical procedures?*

    • Surgeries

      Surgeries
    • Have you had surgery on either wrist? Select ALL that apply.*
    • Hips 
    • What kinds of activities do you have difficulty with because of your hip pain? Select ALL that apply:*

    • Surgeries

      Surgeries
    • Have you had surgery on either hip? Select ALL that apply.*

    • Other Side

      Surgeries
    • Knees 
    • What kinds of activities do you have difficulty with because of your knee pain? Select ALL that apply:*
    • Have you used any of the following conservative treatments to relieve your symptoms? Select ALL that apply.*

    • What is a flare-up? Flare-ups are temporary but intense episodes of increased symptoms. For veterans with chronic conditions, such as knee problems, flare-ups can involve severe pain, swelling, stiffness, and reduced mobility. These episodes can significantly impact daily life and the ability to work, making it essential for the VA to understand their severity and frequency.

    • Do you have any of the following symptoms because of your knee injury?*

    • Surgeries

      Surgeries
    • Have you had surgery on either knee? Select ALL that apply.*

    • Other Side

      Surgeries
    • Ankles 
    • What kinds of activities do you have difficulty with because of your ankle pain? Select ALL that apply:*

    • Surgeries

      Surgeries
    • Have you had surgery on either ankle? Select ALL that apply.*

    • Other Side

      Surgeries
    • Feet 
    • What kinds of activities do you have difficulty with because of your foot pain? Select ALL that apply:*

    • Surgeries

      Surgeries
    • Have you had surgery on either foot? Select ALL that apply.*

    • Other Side

      Surgeries
    • Other Orthopedic Condition 
    • What kinds of activities do you have difficulty with because of your orthopedic pain? Select ALL that apply:*

    • Surgeries

      Surgeries
    • Have you had surgery on either side? Select ALL that apply.*

  • Respiratory

    Allergic Rhinitis, Asbestosis, Asthma, Bronchitis, COPD, Deviated Septum, Emphysema, Interstitial Lung Disease, Laryngitis, Pulmonary Vascular Disease, Restrictive Lung Diseases, Sinusitis, Tuberculosis, Sleep Apnea
    Respiratory
  • What respiratory condition have you been diagnosed with? Select ALL that apply.*
    • COPD, Emphysema, Interstitial Lung Disease, Laryngitis, Pulmonary Vascular Disease, Restrictive Lung Disease 
    • Have you been prescribed any of the following for your breathing issues?*

    • There are many treatments for respiratory conditions, including:

      • Antibiotics: These are used to treat bacterial infections that can cause respiratory conditions such as pneumonia and bronchitis.
        Antivirals: These medications are used to treat viral infections such as influenza.
      • Bronchodilators: These medications help to open up the airways by relaxing the muscles around the airways. They are commonly used to treat asthma and chronic obstructive pulmonary disease (COPD).
      • Immunotherapy: This involves injecting allergens or other substances to desensitize the immune system and reduce the severity of allergic reactions.
      • Nebulizers: A nebulizer is a medical device that is used to deliver medication in the form of a mist or aerosol directly into the lungs. It is commonly used to treat respiratory conditions such as asthma, COPD, and cystic fibrosis. Nebulizers are particularly useful for people who have difficulty using inhalers or for those who require a higher dose of medication. They are also commonly used for children who are unable to use inhalers properly.
      • Oxygen Therapy: This involves breathing in oxygen through a mask or nasal cannula to help alleviate shortness of breath and improve oxygen levels in the blood. It is commonly used to treat conditions such as pneumonia, chronic bronchitis, and emphysema.
      • Steroids: Steroids are anti-inflammatory medications that are used to reduce swelling in the airways. They are commonly used to treat asthma, COPD, and other inflammatory lung conditions.
      • Surgery: In some cases, surgery may be necessary to remove lung tumors or repair structural abnormalities in the respiratory system.
    • How often do you see your doctor for difficulty breathing/asthma-related treatment?*
    • In the past 12 months, how many times have you been hospitalized for trouble breathing?*
    • Nose and Sinuses (deviated septum, asthma, allergic rhinitis, sinusitis) 
    • Does your deviated septum make it difficult to breathe out of your nose?
    • Did you LOSE part of your nose or do you have significant SCARRING because of your deviated septum?
    • Does your RHINITIS cause any of the following symptoms? Select ALL that apply.
    • Does your SINUSITIS cause any of the following symptoms? Select ALL that apply.
    • How often do you need to use your inhaler?*
    • How often do you see your doctor for difficulty breathing/asthma-related treatment?*
    • In the past 12 months, how many times have you been hospitalized for trouble breathing?*
    • Sleep Apnea 

  • Skin or Scarring

    Skin or Scarring
  • Please select any skin condition/illness that you are currently diagnosed with:*
  • Please select any medical / prescription treatment you receive for your skin condition.*
  • Where are your scars located?*
  • Please select ALL symptoms that you experience:*

  • Urinary

    Bladder, Kidneys, Prostate, Urinary Tract Infection, Kidney Infection, Erectile Dysfunction
    Urinary
  • What urinary condition is this statement about?*
    • Bladder or Prostate Condition 
    • Which of the following symptoms do you experience?*
    • How often do you feel the need to urinate during the DAY?*
    • How often do you wake up to urinate at NIGHT?*
    • How often do you need to change the catheter or absorbent materials (pads or depends)?
    • Kidneys 
    • Urinary Tract or Kidney Infection 
    • Does your urinary tract infection or kidney infection cause any of the following? Select ALL that apply.*
    • Erectile Dysfunction 
    • Do you have any of the following symptoms?*
    • Are you service-connected for any of the following conditions?*
    • Do you have any of the following symptoms? Select ALL that apply.*

  • Vision

    Vision
  • Do you have a formal diagnosis from a medical provider of any of the following eye conditions? Select ALL that apply.*
  • Do you have any of the following symptoms of an eye condition? Select ALL that apply.*
  • Do you have an anatomical loss of one or both eyes (meaning: one or both of your eyeball structures have been lost resulting in blindness, with only light perception)?*
  • Are you able to wear a prosthetic eye?*
  • Have you had any of the following medical treatments for your eye condition?*

  • Systemic immunosuppressants and biologic agents include Prednisone, Methylprednisolone, Methotrexate, Azathioprine, Mycophenolate Mofetil

     

  • Which medications/eye drops/etc. have you taken for your eye condition?*
    • Dry Eyes 
    • Which eye is affected?*
    • Which types of treatments have you used in the past year?*
    • Double Vision 
    • Which eye is affected?*
    • Eye Pain 
    • Which eye is affected?*

  • Other

    Other

  • Interference with Employment

    Interference with Employment
  • Date Last Worked*
     / /
    • Employed Full Time 
      • Did you lose your job or has it been harder to work because of your symptoms?
      • Have you missed time from work recently? 
      • Did you need a doctor's note?
      • Are you unable to work as much as you used to? 
      • Are you less productive at work because of your symptoms?
    • Does your employer provide special accommodations for your service-connected conditions? Select ALL that apply.*
    • Unemployed, Retired, Part Time, Student, Self Employed 
      • What types of things do you have a hard time doing because of your condition?
      • Describe which tasks you struggle with or can no longer complete on your own. 
      • Do your symptoms affect your ability to perform activities of daily living such as bathing or grooming?
      • Have your symptoms led to strained relationships with family or friends? 
      • How have your symptoms affected your mental health? 

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