Veteran'S Interview Form - Client Information
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3VETERAN’S INTERVIEW FORM
CLIENT INFORMATION
Name:
_________________________________________ Date: ________________________
Address:
______________________________________________________________________
______________________________________________________________________
Telephone:
Home: ___________________ Work: _________________ Other: ________________
Email: ___________________________________ SS#: _____________________________________
Date of Birth: ________________________ Place of Birth: __________________________________
Case #: _____________________________ Branch of Service: _______________________________
Service # (if known): __________________ Dates of Service: From: ___________ To: ___________
What was the veterans job while in the service? ___________________________________________
Were any combat medals/awards issued? Yes: ____ No: ____
Examples:
combat action ribbon, combat infantry/medal award, Navy Cross, Silver Star,
Bronze Star (with V device), Air Medal (with V device)
If yes, which ones: ____________________________________________________________
____________________________________________________________________________
Was the Veteran ever a POW? Yes: ____ No: ____
If yes, when and where: ________________________________________________________
____________________________________________________________________________
Did the Veteran seek medical treatment while in the service for any condition/injury?
Yes: ____ No: ____
If yes, please describe what type of treatment: _______________________________________
If yes, what the treatment: Impatient: ____ Outpatient: ____
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M:\VA\Veterans Interview Form 2.docx
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