Veterans Benefits Questionnaire Definition: Medical Services is hands-on or standby assistance with 2 or more issues below. Check if it applies.Definition: Medical Services is hands-on or standby assistance with 2 or more issues below. Check if it applies. Bathing Dressing Toileting Feeding Ambulating Hygiene Blindness Transferring Incontinence Bedridden Extreme Weakness Prosthetic Adjustments 1. Person #1 – Name of Veteran, whether living or deceased Age 2. Person #2 – Name of Current/Surviving Spouse, if applicable Age 3. Person #1 is a veteran and needs Medical Services. Yes No (A veteran is an individual who served on active-duty in the Armed Forces or other qualifying government organizations of the United States and was discharged with other than a dishonorable discharge. Other qualifying service can include the Coast Guard, Merchant Marines, Military Cadets and other special World War II combatants. National Guard or Reserve members are not veterans unless called to active duty.) 4. Person #2 is a current spouse of a living veteran and needs Medical Services Yes No 5. Person #2 is a surviving spouse of a deceased veteran and needs Medical Services. Yes No (Definition of Surviving Spouse: Person was deemed married to and lived with the veteran continuously until the veterans death and is currently single and has not remarried since Nov1, 1990.)6. Did the veteran – or if applicable both veterans – serve at least 90 days during a period of war?World War II -- December 7, 1941 through December 31, 1946 Yes Korean Conflict -- June 27, 1950 through January 31, 1955 Yes Vietnam Era -- August 5, 1964 through May 7, 1975 Yes 7. Is the veteran or surviving spouse of a deceased veteran receiving a service-connected monthly disability payment or monthly indemnity (DIC) payment from VA? Yes No 8. If the veteran served in-country (or in the inland waters thereof) in Vietnam, is the veteran currently disabled with any sort of chronic medical condition, cancer or other wasting disease? Yes No 9. Is Vietnam Vet getting payments or medical assistance from VA for condition above? Yes No 10. If person(s) above are receiving or anticipating Medical Services indicate where. (Check for Each Person) In Own Home Home of Someone Else Independent Living Assisted Living Nursing Home 11. If person(s) above need Medical Services and other types of care support, how much PER MONTH will or do these CARE SERVICES COST?Person #1 Person #2 12. Does person(s) above own a home? (Indicate which type of housing) Home Equity Value a single-family dwelling multi-family dwelling condo manufactured home 13. If person or persons above own a home, are one or both of them currently living in the home and expecting to live there for at least 3 to 6 months from now? Yes No 14. Combined total household MONTHLY income amount for the listed persons above 15. Combined household amount of investments, savings & bank accounts for persons above 16. A family member other than a spouse provides Medical Services to person(s) above. Yes No Phone(Required)Email