"Veteran's Interview Form - Plachta, Murphy & Associates"

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VETERAN’S INTERVIEW FORM
CLIENT INFORMATION
Name:
_________________________________________ Date: ________________________
Address:
______________________________________________________________________
______________________________________________________________________
Telephone:
Home: ___________________ Work: _________________ Other: ________________
Email: ___________________________________ SS#: _____________________________________
Date of Birth: ________________________ Place of Birth: __________________________________
Case #: _____________________________ Branch of Service: _______________________________
Service # (if known): __________________ Dates of Service: From: ___________ To: ___________
What was the veterans job while in the service? ___________________________________________
Were any combat medals/awards issued? Yes: ____ No: ____
Examples:
combat action ribbon, combat infantry/medal award, Navy Cross, Silver Star,
Bronze Star (with V device), Air Medal (with V device)
If yes, which ones: ____________________________________________________________
____________________________________________________________________________
Was the Veteran ever a POW? Yes: ____ No: ____
If yes, when and where: ________________________________________________________
____________________________________________________________________________
Did the Veteran seek medical treatment while in the service for any condition/injury?
Yes: ____ No: ____
If yes, please describe what type of treatment: _______________________________________
If yes, what the treatment: Impatient: ____ Outpatient: ____
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VETERAN’S INTERVIEW FORM
CLIENT INFORMATION
Name:
_________________________________________ Date: ________________________
Address:
______________________________________________________________________
______________________________________________________________________
Telephone:
Home: ___________________ Work: _________________ Other: ________________
Email: ___________________________________ SS#: _____________________________________
Date of Birth: ________________________ Place of Birth: __________________________________
Case #: _____________________________ Branch of Service: _______________________________
Service # (if known): __________________ Dates of Service: From: ___________ To: ___________
What was the veterans job while in the service? ___________________________________________
Were any combat medals/awards issued? Yes: ____ No: ____
Examples:
combat action ribbon, combat infantry/medal award, Navy Cross, Silver Star,
Bronze Star (with V device), Air Medal (with V device)
If yes, which ones: ____________________________________________________________
____________________________________________________________________________
Was the Veteran ever a POW? Yes: ____ No: ____
If yes, when and where: ________________________________________________________
____________________________________________________________________________
Did the Veteran seek medical treatment while in the service for any condition/injury?
Yes: ____ No: ____
If yes, please describe what type of treatment: _______________________________________
If yes, what the treatment: Impatient: ____ Outpatient: ____
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Please provide the following information for the Veteran’s primary care provider:
Name: ____________________________________________
Address: __________________________________________
__________________________________________
Phone #: __________________________________________
Name: ____________________________________________
Address: __________________________________________
__________________________________________
Phone #: __________________________________________
Is the Veteran currently being treated for a service related condition? Yes: ____ No: ____
If yes, please describe: _________________________________________________________
____________________________________________________________________________
Does the Veteran require in-home healthcare or nursing home care? Yes: ____ No: ____
If yes, please describe: _________________________________________________________
____________________________________________________________________________
Has the Veteran previously filed a claim with the Department of Veteran’s Affairs?
Yes: ____ No: ____
If yes, what is the claim #: ___________________________
If the above claim was regarding a Service Connected Disability, have you received a decision?
Yes: ____ No: ____
If yes, what was the date of the last decision: _____________________
If you were awarded a disability rating, what is your current rating percentage (%): _________
Did you serve “in Country” while in Vietnam? Yes: ____ No: ____
If yes, were you exposed to:
____ Agent Orange
____ Ionizing Radiation
____ Hiroshima/Nagasaki
____ Nuclear testing
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Are you age 65 or older? Yes: ____ No: ____
Are you currently employed? Yes: ____ No: ____
If yes, where: _________________________________________________________________
If not, what is the reason for your unemployment: ___________________________________
____________________________________________________________________________
____________________________________________________________________________
Do you have any income other than employment? Yes: ____ No: ____
If yes, please provide the amount and source of your income: __________________________
____________________________________________________________________________
____________________________________________________________________________
Thank you for your time and service to our country. We look forward to assisting you during
this process!
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