Veteran Intake Form Veteran Intake Form: Nexus/DBQ Screening LinkedInThis field is for validation purposes and should be left unchanged.1. Basic Info:Name First Last PhoneEmail 2. The “Big Three” Eligibility Questions:Current Diagnosis: Do you have a formal medical diagnosis for this condition (e.g., Migraines, DDD, Sciatica)?YesNoService Event: Did a specific event or injury happen during your active duty service that caused this?YesNoVA Status: Are you currently service-connected (rated) for anything?YesNoIf yes, what is the primary rating?3. Case Specifics:What are we claiming? * [ ] Primary (Back, Neck, Joints)[ ] Secondary (Migraines, Radiculopathy, Hip/Knee Compensation)The "Decision" Status: Have you been denied for this recently?YesNoIf yes, date of the Denial Letter:The “Kinetic Chain” Check (For Secondary Claims):You mentioned [Joint X] hurts; are you already rated for [Joint Y]?Note to staff: Look for connections like Foot → Back or Back → Migraines.5. Document Readiness:Do you have your C-File or Blue Button Report ready to upload today?YesNoCAPTCHA
