General Medicine Questionnaire

PLEASE LIST ALL DISABILITIES YOU WOULD LIKE TO CLAIM ALONG WITH SYMPTOMS, MEDICATIONS YOU TAKE FOR THAT DISABILITY, AND HOW IT IMPACTS YOU SOCIALLY AND OCCUPATIONALLY

( Note: describe your symptoms on your worse day )

TINNITUS

Yes

If yes, please answer the following questions:

What was your MOS in service?

What were your exposures to cause the tinnitus?

How often does the ringing in the ears occur?

Is it most noticeable when noisy or quiet?

HEADACHES

Yes

If yes, please answer the following questions:

How many times a month do you get your most severe headaches (to where you have to isolate yourself)?

Where is the pain located on your head?

What kind of pain do you have (example: throbbing, pulsating, sharp)?

Medication you take (prescription or over the counter)?

Do you miss events with family and friends?

Do you miss work and how often?

GERD (Acid Reflux)

Yes

If yes, please answer the following questions:

What kind of symptoms do you experience (reflux, regurgitation, heartburn, etc.)?

How often do you get these symptoms?

Medication (prescription or over the counter)?

How does this affect your diet and overall health?

Do you miss work?

ERECTILE DYSFUNCTION

Yes

If yes, please answer the following questions:

Trouble getting an erection, staying erect or both?

Low desire?

Medication?

Can you ejaculate?

How does this make you feel?

FEMALE SEXUAL AROUSAL DISORDER

Yes

If yes, please answer the following questions:

Low desire?

Medication?

How does this make you feel?

SHOULDER

Yes

If yes, please answer the following questions:

Trouble lifting or gripping objects?

Medications (prescription or over the counter)?

Any activities you cannot do anymore?

Does the pain impact you at work and how?

NECK AND BACK

Yes

If yes, please answer the following questions:

What kind of symptoms do you experience (example: sharp, tightness, aching, etc.)?

Do you get any shooting pain or numbness and tingling down the legs or arms?

Medication (prescription or over the counter)?

Any activities you cannot do anymore?

Does the pain impact you at work and how?

HIPS, KNEES, ANKLES

Yes

If yes, please answer the following questions:

What kind of symptoms do you experience (sharp, aching, stiffness)?

Medication (prescription or over the counter)?

Do you use braces or a cane?

Any activities you cannot do anymore?

Does the pain impact you at work and how?

FEET

Yes

If yes, please answer the following questions:

Where is the pain located in your feet?

What kind of pain are you experiencing?

Do you wear inserts or special shoes?

Any activities you cannot do anymore?

Does the pain impact you at work and how?