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* Branch of Service Please select... Air Force Army Marine Corps Navy	* Rank
* Are you still on active duty? Yes No	* Date of Injury
* Are you a Reservist? Yes No	* Are you a Guardsman? Yes No

* Date of discharge	* Which conflict did you participate in: Please select... OEF OIF Other
Disability Rating %	Or, Estimated Disability Rating %
Do you need a wheelchair? Yes No	If yes, how often is it used? % of the time
* Do you have Traumatic Brain Injury? Yes No	* Do you have hearing loss? Yes No
* Do you have vision loss? Yes No	* Do you have Post Traumatic Stress Disorder? Yes No
* Have you had any experience that was so frightening, horrible, or upsetting that, IN THE PAST MONTH, you... Have had any nightmares about it or thought about it when you did not want to? Yes No Tried hard not to think about it or went out of your way to avoid situations that remind you of it? Yes No Were constantly on guard, watchful, or easily startled? Yes No Felt numb or detached from others, activities, or your surroundings? Yes No If you have answered yes to any one of the above questions please contact The NATIONAL VETERANS FOUNDATION - toll free @ 888-777-4443 - Mon. - Fri. 0900 - 2100 hours. Also contact the VA's PTSD information hotline at 802-296-6300.

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