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Are you a U.S. veteran?
- Yes, I proudly served
- No
Are you VA rated for any VA disabilities?*
- Yes
- No
Do you feel you are under rated for your current VA disabilities?*
- Yes
- No
Do you have a ringing, buzzing, or other sound in your ears?*
- Yes
- No
Were you exposed to loud noises during your active duty military service?*
- Yes
- No
Are you a combat veteran?*
- Yes
- No
What is the best email for you?*

Were you exposed to any event, injury, or personal trauma that would lead to PTSD during active duty military service?
- Yes
- No
Have you ever filed for a PTSD or mental health claim with the VA?
- Yes
- No
Were you denied the PTSD or mental health claim by the VA?
- Yes
- No
Have you received any treatment through the VA or a private mental health provider?
- Yes
- No

Are any of your joints (knees, wrist, back, neck, etc) VA rated at 0%?*
- Yes
- No
Which of the following are rated at 0%?*
- Back
- Neck
- Knee(s)
- Ankle(s)
- Hip(s)
- Shoulder(s)
- Elbow(s)
- Wrist(s)

Plantar Fasciitis / Pes Planus / Hallux Valgus at 0%*
- Yes
- No
Do you have any pain on the sole of you VA rated foot?*
- Yes
- No

Do you have a current diagnosis of ED?*
- Yes
- No
Are you VA rated for your ED?*
- Yes
- No
Are you VA rated for any of the following?*
- PTSD with or without medications
- Mental Health Condition with or without medications
- Hypertension (High Blood Pressure with or without medications
- Diabetes
- None of the above

Are you currently VA rated at 0% for GERD?*
- Yes
- No
If not rated, do you have a current diagnosis of GERD?*
- Yes
- No
Please check all of the following symptoms you are currently experiencing due to you GERD?*
- Heartburn
- Regurgitation
- Food coming back up into your throat or mouth
- Difficulty Swallowing
- Epigastric Pain
- Shoulder Pain
- Arm Pain
- Chest Pain
Are you VA rated for any joint or back condition?*
- Yes
- No
Have you taken NSAIDS (Motrin, Advil, Ibuprofen, Aspirin, etc) for this condition for an extend period?*
- Yes
- No

Are you currently VA rated at 0% for any Scars?*
- Yes
- No
Are any of your scars painful or tender to touching?*
- Yes
- No

Are you currently VA rated for tinnitus at 10%?*
- Yes
- No
Do you have a ringing, buzzing, or other sound in your ears?*
- Yes
- No
Were you exposed to loud noises during your active duty military service?*
- Yes
- No

Are you currently VA rated for Migraines or headaches at 0%?*
- Yes
- No
If not rated for headaches or migraines, do you have a current diagnosis of Migraines from a doctor?*
- Yes
- No
How often do you get migraines?*
- More than once a month
- More than once a week
- Less than once a month
- Never – Controlled by Medications
Do your migraines or headaches ever render you unable to function?*
- Yes
- No
Are you currently VA rated for any of the following?*
- Neck Condition
- Mental Health Condition (PTSD, Anxiety, Depression, etc)
- Obstructive Sleep Apnea
- None of the above

Do you have a current knee condition that is not VA rated?*
- Yes
- No
Do you have a current diagnosis from a doctor on this knee?*
- Yes
- No
Are you currently VA rated for any of the following?*
- Knee on the Opposite side
- Ankle Condition
- Foot Condition
- None of the above

Do you have a current back condition that is not VA rated?*
- Yes
- No
Do you have a current diagnosis from a doctor on this back condition?*
- Yes
- No
Are you currently VA rated for any of the following?*
- Knee Condition
- Ankle Condition
- Foot Condition
- None of the above

Do you have a current diagnosis of radiculopathy (pain, numbness, tingling) or sciatica in your legs?*
- Yes
- No
Are you currently VA rated for this condition?*
- Yes
- No
Are you currently VA rated for a lower back condition?*
- Yes
- No
Are you currently rated at 0% for your radiculopathy or sciatica?*
- Yes
- No

Do you have a current diagnosis of radiculopathy (pain, numbness, tingling) in your arms?*
- Yes
- No
Are you currently VA rated for this condition?*
- Yes
- No
Are you currently VA rated for a neck condition?*
- Yes
- No
Are you currently rated at 0% for your radiculopathy?*
- Yes
- No

Thank you so much for your time and service. Unfortunately, we cannot assist you at this time. Please feel free to reach out to us if you have any other questions.

Thank you so much for your time and service. Unfortunately, we cannot assist you at this time. Please feel free to reach out to us if you have any other questions.

Thank you so much for your service. Unfortunately, we cannot assist you at this time.

Unfortunately, we can only assist U.S. veterans. Thank you for your time.

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Last Name*
Mobile Phone*

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