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Are You Retired Military? Select Yes No
Receive Military Retirement Pay? Select Yes No
Do You Have an Active Appeal Pending? Select Yes No
Do You Have an Active Claim Pending? Select Yes No
Overall Disability Rating
Please select your current overall service-connected disability rating. This is a rating that the VA gave you for your condition(s). Overall Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40% 50%==The VA Rated You 50% 60%==The VA Rated You 60% 70%==The VA Rated You 70% 80%==The VA Rated You 80% 90%==The VA Rated You 90% 100%==The VA Rated You 100%
Service-Connected Disbilities
What is a Service-Connected Disability? - An injury or illness that the VA awarded a rating , which incurred or aggravated during active military service.
Skip any questions that do not apply to you.Ankle Disabilities
Do you have a service-connected disability for your ankle(s)? If so, please tell us your rating and which side of the body it relates to. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40%
Body Side Select Right Left Both
Back Disabilities
Do you have a service-connected disability for your back? If so, please tell us your rating and which side of the body it relates to. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40% 50%==The VA Rated You 50% 60%==The VA Rated You 60% 70%==The VA Rated You 70%
Lower Body Numbness and Tingling Select Yes - I have numbness and tingling. No- I do not have numbness and tingling.
Chronic Fatigue Syndrome
Do you have a service-connected disability for Chronic Fatigue Syndrome? If so, please tell us your rating. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40% 50%==The VA Rated You 50% 60%==The VA Rated You 60%
Diabetes Disability
Do you have a service-connected disability for diabetes? If so, please tell us your rating. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40% 50%==The VA Rated You 50% 60%==The VA Rated You 60%
Epilepsy Disability
Do you have a service-connected disability for Epilepsy? If so, please tell us your rating. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40% 50%==The VA Rated You 50% 60%==The VA Rated You 60%
Elbow Disabilities
Do you have a service-connected disability for your elbow(s)? If so, please tell us your rating and which side of the body it relates to. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40% 50%==The VA Rated You 50% 60%==The VA Rated You 60%
Body Side Select Right Left Both
Fibromyalgia Disability
Do you have a service-connected disability for Fibromyalgia? If so, please tell us your rating. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40% 50%==The VA Rated You 50% 60%==The VA Rated You 60%
Foot Disabilities
Do you have a service-connected disability for your feet? If so, please tell us your rating and which side of the body it relates to. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40% 50%==The VA Rated You 50% 60%==The VA Rated You 60% 70%==The VA Rated You 70%
Body Side Select Right Left Both
GERD Disability
Do you have a service-connected disability for GERD? If so, please tell us your rating. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40% 50%==The VA Rated You 50% 60%==The VA Rated You 60%
Headache Disabilities
Do you have a service-connected disability for your headaches? If so, please tell us your rating and which side of the body it relates to. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40% 50%==The VA Rated You 50% 60%==The VA Rated You 60%
Heart Disabilities
Do you have a service-connected disability for your heart? If so, please tell us your rating and which side of the body it relates to. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40% 50%==The VA Rated You 50% 60%==The VA Rated You 60%
Hip Disabilities
Do you have a service-connected disability for your hip(s)? If so, please tell us your rating and which side of the body it relates to. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40% 50%==The VA Rated You 50% 60%==The VA Rated You 60%
Body Side Select Right Left Both
Irratatable Bowel Disease
Do you have a service-connected disability for IBS? If so, please tell us your rating. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40% 50%==The VA Rated You 50% 60%==The VA Rated You 60%
Hip Disabilities
Do you have a service-connected disability for your knee(s)? If so, please tell us your rating and which side of the body it relates to. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40% 50%==The VA Rated You 50% 60%==The VA Rated You 60%
Body Side Select Right Left Both
Kidney Disability
Do you have a service-connected disability for Kidney? If so, please tell us your rating. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40% 50%==The VA Rated You 50% 60%==The VA Rated You 60%
Neck Disabilities
Do you have a service-connected disability for your neck? If so, please tell us your rating and if your upper or lower extremities are affected by your disability. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40%
Upper Body Numbness and Tingling Select Yes - I have numbness and tingling. No- I do not have numbness and tingling.
Mental Disabilities
Do you have a service-connected disability for any mental conditions? This includes anxiety, PTSD, and depression. If so, please tell us your rating. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40% 50%==The VA Rated You 50% 60%==The VA Rated You 60% 70%==The VA Rated You 70% 80%==The VA Rated You 80% 90%==The VA Rated You 90% 100%==The VA Rated You 100%
Neuropathy Disability
Do you have service-connected Neuropathy disabilities? If so, please tell us your rating. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40% 50%==The VA Rated You 50% 60%==The VA Rated You 60% 70%==The VA Rated You 70% 80%==The VA Rated You 80% 90%==The VA Rated You 90% 100%==The VA Rated You 100%
Prostate Disability
Do you have service-connected prostate disabilities? If so, please tell us your rating. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40% 50%==The VA Rated You 50% 60%==The VA Rated You 60% 70%==The VA Rated You 70% 80%==The VA Rated You 80% 90%==The VA Rated You 90% 100%==The VA Rated You 100%
Respiratory Disabilities
Do you have service-connected respiratory disabilities? If so, please tell us your rating. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40% 50%==The VA Rated You 50% 60%==The VA Rated You 60%
Scar Disabilities
Do you have service-connected scar disabilities? If so, please tell us your rating. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30%
Sinusitis Disabilities
Do you have service-connected sinusitis disabilities? If so, please tell us your rating. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40% 50%==The VA Rated You 50% 60%==The VA Rated You 60% 70%==The VA Rated You 70% 80%==The VA Rated You 80% 90%==The VA Rated You 90% 100%==The VA Rated You 100%
Shoulder Disabilities
Do you have a service-connected disability for your shoulder(s)? If so, please tell us your rating and which side of the body it relates to. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40% 50%==The VA Rated You 50%
Body Side Select Right Left Both
Sleep Apnea Disabilities
Do you have a service-connected disability for sleep apnea? If so, please tell us your rating. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40% 50%==The VA Rated You 50% 60%==The VA Rated You 60% 70%==The VA Rated You 70% 80%==The VA Rated You 80% 90%==The VA Rated You 90% 100%==The VA Rated You 100%
Wrist Disabilities
Do you have a service-connected disability for your wrist(s)? If so, please tell us your rating and which side of the body it relates to. Disability Rating Select Not Service Connected==Not Service Related 0%==The VA Rated You 0% 10%==The VA Rated You 10% 20%==The VA Rated You 20% 30%==The VA Rated You 30% 40%==The VA Rated You 40%
Body Side Select Right Left Both
Non-Listed Disabilities
Please list any additional disabilities that are not listed above. Only list disabilities that you are service-connected for and your current rating. Release of Information By checking this box, you agree to Veteran Comp's Terms of Use and Privacy Policy.
