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SHOULDER AND ARM CONDITIONS QUESTIONNAIRE (INCREASE)
Identifying Information
*
1.
What is your name (Last, First, MI)?
(Required.)
2.
At what email address would you like to be contacted?
*
3.
WHICH SHOULDER/CLAVICLE IS SERVICE-CONNECTED?
(Required.)
Right
Left
Both Right and Left
4.
RIGHT SHOULDER - Diagnosis EXACTLY as listed in your Rating Decision (or eBenefits, if known)
5.
LEFT SHOULDER - Diagnosis EXACTLY as listed in your Rating Decision (or eBenefits, if known)
*
6.
Which ARM do you consider your DOMINANT ARM
(Required.)
Right Arm
Left Arm
