VA Sha Form - VA Claims

Part A · Section I · Identifier

Identifier

Please provide your basic identification information as it appears on official military records.

Q1 Name (Last, First, Middle)*

Q2 SSN (Social Security Number)*

Q3 DoD ID Number*

Q4Today's Date (self-assessment date)*

Section I · 1. Contact Information

1. Contact Information

Q1 Current Address*

Q2 Work Telephone Number

Q3 Personal Telephone Number*

Q4 Government Email

Q5 Personal Email*

Section I · 2. Personal Information

2. Personal Information

Q1Date of Birth (DoB)*

Q2 Age

Q3 Race and Ethnicity (mark all that apply)

Q4 Birth Sex (biological sex)*

Female Male

Section I · 3. Occupational Information

3. Occupational Information

Please specify other service branch

Q2 Component

Active Duty Reserve National Guard

Q3 Duty Status

Active Component Active Duty - Active Guard Reserve Active Duty - Non-Active Guard Reserve Not on active duty

Q4 Usual Occupation (most recent day-to-day job)

Q5 What is your military occupational code? For example: MOS, AOC, AFSC, NEC, or Designator Code.

Section I · 4. Examination Information

4. Examination Information

Q1Exam Date (if known)

Q2 Purpose of Exam

Please specify

Q3Date or anticipated date of release from Active Duty

Q4 Do you intend to file a claim, or have you already filed a claim, for disability compensation with the Veterans Benefits Administration?

Yes No (if no, skip to question 6)

Q5 Select the type of claim program/process

FDC (Fully Developed Claim) Program IDES (Integrated Disability Evaluation System) BDD (Benefits Delivery at Discharge) Standard Claim Process Not sure

Q6 Have you ever filed a disability claim with the VA?

Yes No

Q7 Have you had a physical exam within 12 months before your separation date?

Yes No Unsure (if no or unsure, skip to Section II)

If yes, provide exam details

Date of exam

Type of exam For example: School, Flight, Special Duty

Would you like that exam reviewed to determine if it is sufficient to meet the separation health assessment requirements?

Yes No

Section II · 1. General Medical Review

General Medical Review - Health Status

Please complete this section thoroughly. Your responses help us understand your current health status and wellness. For each response, briefly describe the history, including dates, as indicated and applicable.

Note: "Qualifying military service" includes active duty; orders 30 days or more in support of contingency operations; continuous active duty orders for 180 days or more; active duty, any period of active duty for training, and any period of inactive duty.

Q1 List your current medications, including supplements.

Q2 - Recent medical assessment

Date of your most recent military service medical assessment / physical exam

Compared to your last military service medical assessment/physical exam, your overall health is:

The Same Better Worse

If better or worse, explain:

Q3 Overall, how would you rate your health during the PAST MONTH?

The Same Better Worse

If better or worse, explain:

Q4 During the PAST MONTH, did you have physical health problems (illness or injury) that made it difficult for you to do your work or other regular daily activities?

Yes No

If yes, explain:

Q5 Do you currently require hearing aids, special medical supplies, Continuous Positive Airway Pressure (CPAP), adaptive equipment, assistive technology devices, and/or other special accommodations?

Yes No

If yes, explain:

Q6 Have you had any surgery since your last health assessment/exam? (Include privately paid elective surgeries.)

Yes No

If yes, explain:

Q7 Since your last health assessment/exam, has a health care provider recommended surgery(s) that you have not had (whether you are planning to have it or not)?

Yes No

If yes, explain:

Q8 Since your last health assessment/exam, have you received care or treatment for any medical and/or mental health condition(s) from a CIVILIAN or NON-MILITARY facility? This includes privately paid treatments and/or procedures (for example: photorefractive keratectomy (PRK), wisdom teeth removal, vasectomy, botox).

Yes No

If yes, explain

Q9 Have you suffered from any injury or illness while on active duty for which you did not seek medical care (to include mental health)?

Yes No

If yes, explain:

Section II · General Medical Review

Medical Conditions (Part 1 of 3)

During qualifying military service, have you ever experienced any of the following?

Q10 Allergies, including environmental and occupational allergies, and adverse reaction to serum, food, insect stings, or medicine.

Yes No

If yes, explain:

Q11 High or bad cholesterol

Yes No

If yes, explain:

Q12 Tuberculosis

Yes No

If yes, explain:

Q13 Coughing up blood

Yes No

If yes, explain:

Q14 Asthma

Yes No

If yes, explain:

Q15 Bronchitis

Yes No

If yes, explain:

Q16 Chronic cough or cough at night

Yes No

If yes, explain:

Q17 Wheezing, shortness of breath, or difficulty breathing (other than asthma)

Yes No

If yes, explain:

Q18 Other lung problems (for example: Chronic Obstructive Pulmonary Disease (COPD), chronic bronchitis, pneumonia, emphysema)

Yes No

If yes, explain:

Q19 Sinusitis

Yes No

If yes, explain:

Q20 Thyroid trouble or goiter

Yes No

If yes, explain:

Q21 Ear, nose, or throat trouble

Yes No

If yes, explain:

Q22 Frequent indigestion or heartburn (reflux)

Yes No

If yes, explain:

Q23 Stomach or intestinal problems (for example: ulcer)

Yes No

If yes, explain:

Q24 Kidney problems (for example: stones, infection)

Yes No

If yes, explain:

Q25 Liver problems (for example: hepatitis, cirrhosis)

Yes No

If yes, explain:

Q26 Constipation, loose bowels, or diarrhea

Yes No

If yes, explain:

Q27 Gallbladder trouble or gallstones

Yes No

If yes, explain:

Section II · General Medical Review

Medical Conditions (Part 2 of 3)

During qualifying military service, have you ever experienced any of the following?

Q28 Hernia

Yes No

If yes, explain:

Q29 Rectal disease, hemorrhoids, or blood from rectum

Yes No

If yes, explain:

Q30 Frequent or painful urination or blood in urine

Yes No

If yes, explain:

Q31 High or low blood sugar

Yes No

If yes, explain:

Q32 Sugar or protein in urine

Yes No

If yes, explain:

Q33 Diabetes

Yes No

If yes, explain:

Q34 Recent unexplained gain or loss of weight

Yes No

If yes, explain:

Q35 A head injury, memory loss, or amnesia

Yes No

If yes, explain:

Q36 Recurring headaches / migraines; frequent or severe headaches

Yes No

If yes, explain:

Q37 Periods of dizziness, fainting, or loss of consciousness

Yes No

If yes, explain:

Q38 Mental health problems (for example: depression, anxiety, Post-Traumatic Stress Disorder (PTSD), worry, or other mental health diagnosis)

Yes No

If yes, explain:

Q39 Neurological problems (for example: stroke, seizures, convulsions, epilepsy, fits, tremor)

Yes No

If yes, explain:

Q40 Paralysis

Yes No

If yes, explain:

Q41 Meningitis, encephalitis, or other neurological infection or disorder

Yes No

If yes, explain:

Q42 Rheumatic fever

Yes No

If yes, explain:

Q43 Prolonged bleeding

Yes No

If yes, explain:

Q44 Blood problems (for example: hemophilia, sickle cell disease)

Yes No

If yes, explain:

Q45 Immune system problems (for example: HIV, chemotherapy, radiation)

Yes No

If yes, explain:

Q46 Angina, also called angina pectoris

Yes No

If yes, explain:

Q47 Congestive Heart Failure

Yes No

If yes, explain:

Section II · General Medical Review

Medical Conditions (Part 3 of 3)

During qualifying military service, have you ever experienced any of the following?

Q48 Pain, pressure, or discomfort in your chest

Yes No

If yes, explain:

Q49 Palpitations, pounding heart, or abnormal heartbeat

Yes No

If yes, explain:

Q50 Heart murmur or valve problem (for example: mitral valve prolapse)

Yes No

If yes, explain:

Q51 Coronary heart disease

Yes No

If yes, explain:

Q52 Heart attack (also called myocardial infarction)

Yes No

If yes, explain:

Q53 High blood pressure

Yes No

If yes, explain:

Q54 Low blood pressure

Yes No

If yes, explain:

Q55 Skin diseases (other than cancer)

Yes No

If yes, explain:

Q56 Cancer (other than skin)

Yes No

If yes, explain:

Q57 Skin cancer

Yes No

If yes, explain:

Section II · 2. Joint, Spine, & Musculo-Skeletal System

2. Joint, Spine, & Musculo-Skeletal System

During qualifying military service, have you ever experienced pain and/or injury in the following?

Q1 Head and Neck

Yes No

If yes, explain:

Q2 Back and Chest

Yes No

If yes, explain:

Q3 Shoulder / Arm

Yes No

If yes, explain:

Q4 Elbow / Forearm

Yes No

If yes, explain:

Q5 Wrist / Hand / Fingers

Yes No

If yes, explain:

Q6 Hip / Thigh

Yes No

If yes, explain:

Q7 Leg / Knee

Yes No

If yes, explain:

Q8 Ankle / Foot / Toes

Yes No

If yes, explain:

Section II · 3. Health & Wellness

3. Health & Wellness

Q1 Do you currently use tobacco products (cigarettes, cigars, pipes, etc.), electronic nicotine products (e-cigarette/JUUL, e-hookah, vape-pen, vaporizer, tank system, other similar nicotine products), smokeless tobacco products (chewing tobacco, snuff, dip, snus (pronounced as "snoose"), or dissolvable tobacco)?

Yes No

If yes, explain:

Q2 Have you smoked at least 100 cigarettes in your entire life? (Note: A pack typically contains 20 cigarettes.)

Yes No (if no, skip to question 5)

Q3 During the past 12 months, have you ever tried to stop smoking?

Yes No Not Applicable

If yes, explain:

Q4 Have you ever had a serious health problem that was caused or made worse by smoking?

Yes No

If yes, explain:

Q5 During the past 12 months, how often were you exposed to secondhand smoke indoors (home, work, vehicle, etc.), a mixture of smoke that comes from the burning end of a tobacco product (cigarettes, cigars, pipes, etc.), or vapor indoors from a person using an e-cigarette/JUUL, ehookah, vape-pen, vaporizer, tank system, or other similar nicotine product?

Daily Less than daily Not at all

Q6 Do you have any ongoing health concerns with past use of recreational drugs or misuse of prescription drugs?

Yes No

If yes, explain:

Section II · 4. Hearing

4. Hearing

Q1 During qualifying military service have you ever had, or do you now have, persistent or recurring noises in your head or ears? (for example: ringing, buzzing, humming)

Yes No

If yes, explain:

Q2 During qualifying military service have you ever had, or do you now have, a change in your hearing that impacts duty performance?

Yes No

If yes, explain:

Q3 Do you currently, or have you ever worn, a hearing aid?

Yes No

If yes, explain:

Q4 During your deployment or during military training, were you exposed to loud noises, to include blasts, that resulted in a temporary or permanent decrease in hearing and/or ringing, humming, buzzing sounds in your ears or head?

Yes No

If yes, how many times? For how long? Describe exposure and any symptoms you are still experiencing.

Section II · 5. Vision

5. Vision

Q1 Do you wear corrective lenses (glasses or contacts)?

Yes No

If yes, explain:

During qualifying military service, have you ever experienced:

Q2 Eye disorder or trouble

Yes No

If yes, explain:

Q3 Surgery to correct vision

Yes No

If yes, explain:

Q4 Loss of vision in either eye

Yes No

If yes, explain:

Q5 Double vision (diplopia)

Yes No

If yes, explain:

Q6 Change in your vision that impacts your duty performance

Yes No

If yes, explain:

Section II · 6. Head Injury

6. Head Injury

During qualifying military service:

Q1 As a result of any injury or event, did you receive a jolt or blow to your head that IMMEDIATELY resulted in losing consciousness; losing memory of events before or after the injury; or seeing stars, becoming disoriented, functioning differently, or nearly blacking out?

Yes No Not Applicable

If yes, check all that apply:

Losing consciousness ("knocked out") Losing memory of events before or after the injury Seeing stars, becoming disoriented, functioning differently, or nearly blacking out

Q2 How many total times did you receive a jolt or blow to your head?

Q3 Have you ever experienced a head injury, concussion, or Traumatic Brain Injury (TBI)?

Yes No

If yes, explain:

Q4 - Follow-up: after the head injury, concussion, or TBI

Have you had prolonged symptoms that have not resolved?

Yes No

If yes, explain:

Are you currently experiencing any prolonged symptoms that have not resolved?

Yes No

If yes, explain:

Section II · 7. Environmental / Occupational

7. Environmental / Occupational (Part 1)

This section covers various potentially hazardous occupational and environmental exposures during qualifying military service. Exposures may have occurred while deployed, in training, or during other assignments. Consider your potential exposure to: burn pits, oil well fires, burning trash, dust storms, air pollution, explosions, fuels/fumes, pesticides/insecticides, cleaning agents, solvents, heavy metals/depleted uranium, nerve agents/gases, protective medication and vaccines (for example: Pyridostigmine Bromide (PB), Lariam (Mefloquine) pills), persistent chemicals such as PCBs, asbestos, radiation, unusual food/drinking water exposures, contaminated water, and personal hygiene exposures (for example: swimming, showering, etc.).

Q1 Were you potentially exposed to any occupational/environmental hazards (described above) while in a qualifying military duty service?

Yes No Unsure

If yes or unsure, provide details here:

Q2 Have you been based or stationed at a location where an open burn pit was used?

Yes No Unsure

If yes or unsure, provide details here:

Q3 Have you been potentially exposed to toxic airborne chemicals or other airborne contaminants?

Yes No Unsure

If yes or unsure, provide details here:

Q4 If Q2 or Q3 is "Yes" or "Unsure," have you enrolled in the Airborne Hazards and Open Burn Pit Registry?

Yes No Not Applicable

The Airborne Hazards and Open Burn Pit Registry (AHOBPR):

Are you eligible to participate? AHOBPR is open to Service members and Veterans who deployed to contingency operations in the Southwest Asia theater of operations at any time on or after August 2, 1990, or Afghanistan or Djibouti on or after September 11, 2001. The Southwest Asia theater includes the following countries, bodies of water, and the airspace above these locations: Iraq, Kuwait, Saudi Arabia, Bahrain, Gulf of Aden, Gulf of Oman, Oman, Qatar, and the United Arab Emirates; and waters of the Persian Gulf, Arabian Sea, Red Sea, Uzbekistan, and Syria. The VA will use deployment data provided by DoD to determine your eligibility. You can join the AHOBPR even if:

You do not think you were exposed to specific airborne hazards.
You are not experiencing symptoms or illnesses you think are related to exposures.
You have not filed a VA claim for compensation and benefits or applied for VA health care.
You are still an active duty Service member, reservist, or have returned to active service.

Visit www.publichealth.va.gov/airbornehazards to learn more about airborne hazards and the AHOBPR.

Q5 Federal law requires eligible members to enroll in the Airborne Hazards and Open Burn Pit Registry or to opt-out. If eligible, choose one:

I wish to enroll I wish to opt out Not Applicable

Q6 While deployed, were you potentially exposed to other deployment-related hazards?

Yes No Unsure

If yes or unsure, provide details here:

Section II · 7. Environmental / Occupational

7. Environmental / Occupational (Part 2)

Q8 If you checked any exposures, including "unsure," listed in question 7, please explain your exposure concerns in the right column, being as specific as possible.

Q9 Are you currently participating in any specialty occupational exposure examinations?

Yes No

If yes, explain:

During qualifying military service, have you ever experienced:

Q10 A blast or explosion?

Yes No

If yes, explain:

Q11 A vehicular accident/crash (any vehicle including aircraft)?

Yes No

If yes, explain:

Q12 A fragment wound or bullet wound?

Yes No

If yes, explain:

Section II · 8. Dental

8. Dental

Q1 Do you currently have any dental problems that need to be evaluated?

Yes No

If yes, explain:

Q2 Have you ever been diagnosed or treated for oral cancer?

Yes No

If yes, explain:

During qualifying military service, have you ever experienced:

Q3 A dental examination where you were told you had a Temporomandibular Disorder (TMD) or Temporomandibular Joint (TMJ) problem?

Yes No

If yes, explain:

Q4 Your jaw locked open and you could not close the jaw?

Yes No

If yes, explain:

Q5 Loss of a portion of the bone in your upper or lower jaw due to trauma or disease such as osteomyelitis or necrosis?

Yes No

If yes, explain:

Q6 Loss of any teeth because of service-related trauma?

Yes No

If yes, explain:

Q7 Physical (anatomical) loss or injury to your mouth, lips, or tongue?

Yes No

If yes, explain:

Section II · 9. Women's Health / Female Reproductive Organs

9. Women's Health / Female Reproductive Organs

During qualifying military service, have you ever:

Date of diagnosis (if applicable)

Diagnosed by laparoscopy?

Yes No Unsure

Q2 Please provide additional details for all marked disorders in question 1 (for example: date diagnosed, treatment, medications, and treatment center).

If Oophorectomy: how many ovaries?

One ovary Both ovaries

Q4 Please provide additional detail for all marked surgeries in question 3 (for example: date diagnosed, treatment center).

Q5 Pregnancy. List all pregnancies and associated outcomes and conditions. List dates, outcomes, treatment location, and complications, if any. *Complications include, but are not limited to: depression, anxiety, high blood pressure in pregnancy, preeclampsia, etc.
**Provide additional information, as necessary (for example: gestational diabetes).

Have you ever had:

Q6 A breast cancer screening (mammogram)?

Yes No Unsure (if no or unsure, skip to question 8)

If yes, when was your last screening? (YYYY/MM)

Q7 An abnormal mammogram result?

Yes No Unsure (if no or unsure, skip to question 8)

If yes, when did the abnormal result occur? What was the abnormal result? If applicable, when did you receive treatment or follow-up care? What was the treatment or follow-up care?

Q8 A cervical cancer screening (Pap and/or HPV test)?

Yes No Unsure (if no or unsure, skip to question 10)

If yes, when was your last screening? (YYYY/MM)

Q9 An abnormal result showing cancer or pre-cancer or a positive HPV test?

Yes No Unsure (if no or unsure, skip to question 10)

If yes, when did the abnormal result occur? What was the abnormal result? If applicable, when did you receive treatment or follow-up care?

Q11 Experiencing any of the following? (check all that apply)

Pelvic pain Current or recent genital lesions (sores on or near your vaginal area) Pelvic inflammatory disease, uterus prolapse, or displacement Pain during intercourse Leakage of urine affecting work / social activities Leakage of stool Low libido (reduced interest in sex) Bleeding after menopause None of the above

If yes to any symptom above, please explain:

Section II · 10. Mental Health Screening Questionnaires

10.1 Post-Traumatic Stress Disorder (PTSD) Screen

Note to the service member: Please respond to the following screening questionnaires. Your responses will be reviewed by the Examining Clinician, and additional questions may be asked.

Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. In the past month, have you...

Q1 Had nightmares about the event(s) or thought about the event(s) when you did not want to?

Yes No

Q2 Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)?

Yes No

Q3 Been constantly on guard, watchful, or easily startled?

Yes No

Q4 Felt numb or detached from people, activities, or your surroundings?

Yes No

Q5 Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?

Yes No

Section II · 10.2 Depression Screen

10.2 Depression Screen

Over the last 2 weeks, how often have you been bothered by any of the following problems?

Q1 Little interest or pleasure in doing things?

Not At All Several Days More Than Half the Days Nearly Every Day

Q2 Feeling down, depressed, or hopeless?

Not At All Several Days More Than Half the Days Nearly Every Day

Section II · 10.3 Alcohol Use Screen

10.3 Alcohol Use Screen

Q1 How often did you have a drink containing alcohol in the past year?

Q2 How many drinks containing alcohol did you have on a typical day when you were drinking in the past year?

Q3 For men: How often did you have six or more drinks on one occasion in the past year?

Q4 For women: How often did you have four or more drinks on one occasion in the past year?

Additional Space

Additional Response Space

Before submitting, please review your responses to ensure they are accurate and complete.

Space for additional response(s). Note the question number before each response (for example, 3.1).

Final Step · Signature

Signature

⚠ Certification: By typing your name below and clicking Submit, you certify that the information you have provided is accurate and complete to the best of your knowledge.

Signature of Service Member (type your full legal name)*

Date of Signature*

Identifier

1. Contact Information

2. Personal Information

3. Occupational Information

4. Examination Information

General Medical Review - Health Status

Medical Conditions (Part 1 of 3)

Medical Conditions (Part 2 of 3)

Medical Conditions (Part 3 of 3)

2. Joint, Spine, & Musculo-Skeletal System

3. Health & Wellness

4. Hearing

5. Vision

6. Head Injury

7. Environmental / Occupational (Part 1)

7. Environmental / Occupational (Part 2)

8. Dental

9. Women's Health / Female Reproductive Organs

10.1 Post-Traumatic Stress Disorder (PTSD) Screen

10.2 Depression Screen

10.3 Alcohol Use Screen

Additional Response Space

Signature

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