“Head to Toe” Intake Survey
Veterans Benefits Advocacy
Accredited Independent VA Claims Agents

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Name: ______________________ ___________________  ______________________
Examiner: Dennis W. Mills, Ph.D.; Accredited Independent VA Claims Agent #24454
Examiner: Mark Fleming,  Accredited Independent VA Claims Agent #16923
Date: _______________

 Yes - Service in or over lraq or Afghanistan
 Yes - Service - Service in Desert Storm
 Yes - Service in or over Vietnam

Diabetes Asthma Emphysema or COPD
Other lung disease Type of lung disease:
Heart disease Type of heart disease:
Arthritis or other rheumatic disease Specify type:
Cancer Type of cancer:
Other chronic condition Specify: ____________________________________________

Have you ever had any of the following?


 AIDS/HIV

 Allergies

 Epilepsy

 Anemia 

 Arthritis

 Artificial Joints

 Asthma

 Blood Disease

 Cancer

 Diabetes-Type 1 or 2

 Dizziness

 Excessive Bleeding

 Fainting

 Glaucoma

 Growths

 Kidney Disease

 Head Injuries

 Heart Disease

 Heart Murmur

 Hepatitis-A / B / C

 High Blood Pressure

 Jaundice

 Liver Disease

 Mental Disorders

 Nervous Disorders

 Pacemaker

 Radiation Treatment

 Respiratory Problems

 Rheumatic Fever

 Rheumatism

 Sinus Problems

 Stomach Problems

 Stroke

 Tumors

 Ulcers

 Venereal Disease

 Tuberculosis

 Tobacco use

 Cold sores

 Drug allergies

 Food allergies

 Enviro allergies

 Artificial joints

 Cholera [6300]

 Malaria [6304]
 Rheumatic fever
 Lyme disease


 surgery   
 injections   
 physical therapy   
 medications   
 acupuncture   
 chiropractic   
 none of the above   


Describe injuries _______________________________________________________

Blood Pressure: _____/______

Pneumonia?    [6828]
Emphysema?    [6603]

 

Deep venous thrombosis (blood clots in the legs)   [7121]
Peripheral neuropathy   [7913]
Decreased range of motion?  [5260, 5261]
Varicose veins   [7120]
Describe injuries _________________________________________________________________ 

TBI Questions

Some effects are most visible just after the injury, and for most people, these will generally fade as time goes by. Other behavioral and cognitive effects may be more complicated and include difficulty remembering, making decisions, solving problems, and performing day-to-day functions like driving a car, dressing, or bathing.

Have you ever been treated in an emergency room, or hospitalized following an injury?
Were you ever injured and should have received medical attention, but didn’t?
Were you dazed or confused (D/C), have a lapse in memory (Mem), or actually knocked out (KO)?
Were you treated in the ER, hospitalized (Hosp), or admitted to a rehabilitation facility (Rehab)?

3 Question DVBIC TBI Screening Tool
38 CFR § 4.124a  pp. 867-869 [8045 Residuals of TBI]
1. Did you have any injury(ies) during your deployment from any of the following?
(check all that apply):
A. _Fragment wound above the shoulder
B. _Bullet
C. _Vehicular accident/crash (any type of vehicle, including airplane)
D. _Fall
E. _Blast (Improvised Explosive Device, RPG, Land mine, Grenade, etc.)
F. _Other specify: __________________________________________

2. Did any injury received while you were deployed result in any of the following?
(check all that apply):
A. _Being dazed, confused or “seeing stars”  B. _Not remembering the injury C. _Losing consciousness (knocked out) for less than a minute D. _Losing consciousness for 1-20 minutes  E. _Losing consciousness for longer than 20 minutes
F. _Having any symptoms of concussion afterward (such as headache, dizziness, irritability, etc.) G. _Head Injury H. _None of the above

3. Are you currently experiencing any of the following problems that you think might be related to a possible head injury or concussion?
(check all that apply):
A. _Headaches  B. _Ringing in the ears  C. _Dizziness  D. _Irritability E. _ Memory problems  F. _Sleep problems  G. _Balance problems
H. _Other specify:___________________________________________________________________
Describe injury(ies)
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Mental Health
Receiving mental health care now? Yes            No

[Depression] “During the past month, have you often been bothered by feeling down, depressed, or hopeless?”  and (2) “During the past month, have you often been bothered by little interest or pleasure in doing things?”  

Major Depressive Disorder  [9434]

Generalized Anxiety Disorder  [9400]
Do you AVOID certain situations because of anxiety?  
When are you most anxious? _____________________________________

Panic disorder  [9412]

Chronic Adjustment Disorder]   [9440]

Bipolar Disorder  Yes [9432]

Mood Disorder  Yes  [9435]

Schizophrenia Disorder    Yes  [9201-9211]

Have you been diagnosed for PTSD?    Yes  When? ­______   No
Where? ____________________  [9411]
Prescriptions for PTSD: _________________________________________________________

Primary Care PTSD Screen (PC-PTSD) [9411]

In your life, have you ever had any experience that was so frightening, horrible, or upsetting that, in the past month, you:


PTSD Checklist – Military Version (PCL-M)
Below is a list of problems and complaints that veterans sometimes have in response to stressful military experiences. Please read each one carefully, put and “X” in the box to indicate how much you have been bothered by that problem in the last month.

 

Not at all (1)

A little bit (2)

Moderately (3)

Quite a bit (4)

Extremely (5)

1. Repeated, disturbing memories, thoughts, or images off a stressful military experience

 

 

 

 

 

2. Repeated, disturbing dreams of a stressful military experience?

 

 

 

 

 

3. Suddenly acting or feeling as if a stressful military experience were happening again (as if you were reliving it)?

 

 

 

 

 

4.Feeling very upset when something reminded you of a stressful military experience?

 

 

 

 

 

5. Having physical reactions (e.g., heart pounding, trouble breathing, or sweating) when something reminded you of a stressful military experience?

 

 

 

 

 

6. Avoid thinking about or talking about a stressful military experience or avoid having feelings related to it?

 

 

 

 

 

7. Avoid activities or situations because they remind you of a stressful military experience?

 

 

 

 

 

8. Trouble remembering important parts of a stressful military experience?

 

 

 

 

 

9. Loss of interest in things that you used to enjoy?

 

 

 

 

 

10. Feeling distant or cut off from other people?

 

 

 

 

 

11. Feeling emotionally numb or being unable to have loving feeling for those close to you?

 

 

 

 

 

12. Feeling as if your future will somehow be cut short?

 

 

 

 

 

13. Trouble falling or staying asleep?

 

 

 

 

 

14. Feeling irritable or having angry outbursts?

 

 

 

 

 

15. Having difficulty concentrating?

 

 

 

 

 

16. Being “super alert” or watchful on guard?

 

 

 

 

 

17. Feeling jumpy or easily startled?

 

 

 

 

 

TOTAL