Case Evaluation Form

Name

Email Address

Phone

What is your current VA disability rating percentage? What is your current VA disability rating percentage?0%10%20%30%40%50%60%70%80%90%100%

Do you have any pending appeals or do you have a decision within the last 12 months that you would like to appeal? Do you have any pending appeals or do you have a decision within the last 12 months that you would like to appeal? YESNO

Are you currently employed? Are you currently employed?YESNO

Do you Have any of the following Disabilities Do you Have any of the following Disabilities Foot Pain (flat feet, plantar fasciitis, etc) Ankle Pain Knee Pain Hip Pain Back Pain Nerve Pain/numbness/tingling in legs Neck Pain Nerve Pain/numbness/tingling in arms Shoulder Pain Headaches Skin Conditions Reflux disease (GERD) Asthma/COPD Sleep Apnea Sinusitis/Rhinitis Bowel/bladder Dysfunction Mental Health Condition (PTSD, Depression, Anxiety, ETC) Diabetes Hypertension Erectile Dysfuction Cancer (If so please sate which type in then textbox below) Heart Conditions Stroke Hearing loss/Tinnitus Other(Please Specify in the Section Below)

Is the VA compensating you for any of the following disabilities currently? Is the VA compensating you for any of the following disabilities currently? Foot Pain (flat feet, plantar fasciitis, etc) Ankle Pain Knee Pain Hip Pain Back Pain Nerve Pain/numbness/tingling in legs Neck Pain Nerve Pain/numbness/tingling in arms Shoulder Pain Headaches Skin Conditions Reflux disease (GERD) Asthma/COPD Sleep Apnea Sinusitis/Rhinitis Bowel/bladder Dysfunction Mental Health Condition (PTSD, Depression, Anxiety, ETC) Diabetes Hypertension Erectile Dysfuction Cancer (If so please sate which type in then textbox below) Heart Conditions Stroke Hearing loss/Tinnitus Other(Please Specify in the Section Below)

If there are any details of your case that you wish to provide us, please do so in the space provide: