Veterans PTSD Disability Benefits Questionnaire
Please complete this form to help assess your eligibility for PTSD-related disability benefits. Your responses are confidential and will be used for evaluation purposes only.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email
*
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
Marine Corps
Coast Guard
Other
Service Period (Years Served)
*
Have you been diagnosed with PTSD by a healthcare professional?
*
Yes
No
Please indicate the severity and frequency of the following PTSD symptoms over the past month.
*
Rows
Not at all
Several days
More than half the days
Nearly every day
Re-experiencing traumatic events (flashbacks, nightmares)
1
2
3
4
Avoidance of reminders or activities
5
6
7
8
Negative changes in mood or thoughts
9
10
11
12
Hyperarousal (irritability, difficulty sleeping, hypervigilance)
13
14
15
16
How much do your PTSD symptoms interfere with your daily life (work, relationships, self-care)?
*
No interference
1
2
3
4
5
6
7
8
9
Extreme interference
10
1 is No interference, 10 is Extreme interference
Are you currently receiving treatment or counseling for PTSD?
*
Yes
No
If yes, please describe your current treatment (e.g., therapy, medication).
Additional Comments (optional)
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