SingleMarriedDivorcedWidowedIn a Relationship
Names and Ages of Family Members - Please List
Branch of Service
AirforceArmyCoast GuardMarinesNavyNational Guard
Military Occupational Specialty or Rate
Are You Still on Active Duty?
What is your planned ETS date?
Did You Receive an Honorable Discharge?
Discharge Date (if applicable)
Was/Were Your Injury(ies) a Result of
Date of Injury
Did You Receive a Purple Heart?
Is Your Injury
What is Your VA Disability Rating?
What is Your Military Disability Rating?
Can You Provide Proof of Your Injury if Needed?
Military Medals Awarded
Circumstances Surrounding Your Injury(ies)
Types of Injury(ies) - Please be Specific
Medications Currently Taking: Prescribed and Non-Prescribed
Any Addictions or Allergies?
Legal Convictions (felonies or misdemeanors) or Issues? Please be Specific
Tell Us About Yourself
Interests or Hobbies - Please List
Interests Before Combat - Please List
Other Information You Feel May Be Important
In What Areas Are You Looking for Help?
How Did You Hear About OHD?