Military Medical Discharge Pension Eligibility Questionnaire
Please complete this form to help determine your eligibility for a military medical discharge pension. Accurate and complete information will assist in the assessment process.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Branch of Military Service
*
Please Select
Army
Navy
Air Force
Marines
Coast Guard
Other
Rank at Time of Discharge (if applicable)
*
Length of Military Service (in years)
*
Have you been officially discharged from military service due to medical reasons?
*
Yes
No
Please provide a brief description of your medical condition(s) leading to discharge or current claim.
*
How would you rate the impact of your medical condition(s) on your ability to perform daily activities?
*
1
2
3
4
5
Assessment of Medical Condition Impact
*
Rows
No Impact
Mild Impact
Moderate Impact
Severe Impact
Mobility
1
2
3
4
Self-care
5
6
7
8
Ability to Work
9
10
11
12
Social Interaction
13
14
15
16
Are you currently employed?
*
Yes
No
Please list any supporting medical documents you wish to upload (optional)
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Signature
*
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