Veteran Disability Evaluation Interview Questionnaire

Veteran Disability Evaluation Interview Questionnaire
Use this questionnaire to collect information about your service background, disability-related conditions, treatment history, and how your symptoms affect daily life.
Veteran Identification and Contact
Full Name
First NameMiddle NameLast Name
Preferred Name
Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Current Mailing Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Military Service Background
Branch of Service
Service Start Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Service End Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Discharge Status/Type
Unit or Service Notes
Deployment or Operation History
Condition and Symptom Summary
Primary condition(s) being evaluated
Other
Date symptoms began or were first noticed
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is this condition currently understood to be service-connected?
Current symptom severity

1
2
3
4
5
6
7
8
9
10
1 is Mild, 10 is Severe
Describe your symptoms, flare-ups, and how they have changed over time
Medical Treatment and Care History
Healthcare providers seen for this condition
Current medications related to this condition
Prior surgeries or procedures related to the condition
Therapy or rehabilitation history
Recent imaging, tests, or diagnostic studies
Hospitalizations or urgent care visits related to this condition
Other treatment, care, or follow-up related to this condition
Functional Impact and Daily Limitations

How much does your condition limit the following daily activities?

Rows	Not at all	Mildly	Moderately	Severely	Unable to do
Walking
Standing
Lifting
Sitting
Sleeping
Self-care
Work capacity
Concentration
Social activities

Assistive devices used
Other
How limited are you in walking long distances?

1
2
3
4
5
6
7
8
9
10
1 is Not limited, 10 is Completely limited
How limited are you in standing for extended periods?

1
2
3
4
5
6
7
8
9
10
1 is Not limited, 10 is Completely limited
How limited are you in lifting or carrying objects?

1
2
3
4
5
6
7
8
9
10
1 is Not limited, 10 is Completely limited
How limited are you in concentrating on tasks?

1
2
3
4
5
6
7
8
9
10
1 is Not limited, 10 is Completely limited
How limited are you in participating in social activities?

1
2
3
4
5
6
7
8
9
10
1 is Not limited, 10 is Completely limited
Examples of real-world limitations
Should be Empty:

Select theme:

Veteran Disability Evaluation Interview Questionnaire

Veteran Identification and Contact

Military Service Background

Condition and Symptom Summary

Medical Treatment and Care History

Functional Impact and Daily Limitations