DATE:           TIME (24hr): 

Name: SSN: Age: Date of birth Sex Date Completed ______________________ ___________________ _______ ___/___/_____ M F ___/___/____

Instructions:
• In order to make your health evaluation more complete, please take the time to complete this questionnaire carefully and accurately.
• We realize some questions may seem repetitive, but they help us to give a thorough evaluation. • Please use ink.
• Please use a “check mark” or “X” in the box provided, unless asked otherwise.

Section A: Demographics

A.1. What is your race?
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Unknown
Other

A.2. What is your ethnicity?
Hispanic or Latino
Non Hispanic or Non Latino
Unknown

A.3. What is the highest level of education that you have completed?
Less than high school diploma/equivalency
High school graduate or GED
Some college
College degree
Graduate school
Graduate degree
Technical/trade school
Unknown/other

A.4. Are you receiving disability benefits?
No       Yes
Have you applied for disability benefits?
No       Yes

A.5. Are you right or left hand dominant?
Don’t know
Right
Left
Both / Ambidextrous

A.6. Are you currently (please select best answer):
a.Not employed and not looking for work
b.Self-employed
c.Homemaker
d.Not employed and looking for work
e.Student
f.Retired
g.Unable to work due to health reasons
h.Employed part-time
i.Employed full-time
i.unknown

A.7. a) Prior to deployment, what was your marital status?
Married
Divorced
Never married
Widowed
Separated
Living as married
unknown

b). Currently, what is your marital status?
Married
Divorced
Never married
Widowed
Separated
Living as married
unknown

A.8. a) Do you have any children that you parent?
No       Yes

A.8. b) If yes, what are their ages and sex? age______male/female age______ male/female age______ male/female age______ male/female age______ male/female age______ male/female age______ male/female

A.9. Do you have elderly parents or other adults for whom you have caretaking responsibility?
No       Yes

A.10. What is your household’s current monthly income? $________________per month

A.11. In which conflict did you serve the most time?
a.WWII
b.Korea
c.Vietnam
d.Lebanon
e.Panama
f.Grenada
g.Persian Gulf War
h.Kosovo
i.Bosnia
j.Croatia
k.Somalia
l.Operation Enduring Freedom (OEF)
m.Operation Iraqi Freedom (OIF)
n.Other (please specify)____________
o.None
z. unknown

A.12. Date and rank upon most recent separation? a) Date ____/____/______ b) Rank____________________________

A.13. What is your current Military Occupational Specialty (MOS)? _______________________________________