Yes No Veteran’s Administration (VA) Medical Services Yes No Employer-Provided Health Insurance Yes No Health Insurance obtained through COBRA Yes No State Health Insurance for Adults Yes No Private Pay Health Insurance Yes No Indian Health Services Program Yes No Other – Specify: __________________________________________ Do you have a disabling condition? Yes No Client Doesn’t Know Client Refused Data Not Collected Disability Type Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently Documentation of the disability and severity on file? Currently Receiving Treatment or Services? Physical Yes No Client Doesn’t Know Client Refused Yes No Client Doesn’t Know Client Refused  Yes No  Yes No Developmental Yes No Client Doesn’t Know Client Refused Yes No Client Know Client Refused  Yes No  Yes No Chronic Health Condition Yes No Client Doesn’t Know Client Refused Yes No Client Doesn’t Know Client Refused  Yes No  Yes No HIV/AIDS Yes No Client Doesn’t Know Client Refused Yes No Client Doesn’t Know Client Refused  Yes No  Yes No Mental Health Problem Yes No Client Doesn’t Know Client Refused Yes No Client Know Client Refused  Yes No  Yes No Alcohol Abuse Yes No Client Doesn’t Know Client Refused Yes No Client Doesn’t Know Client Refused  Yes No  Yes No Drug Abuse Yes No Client Doesn’t Know Client Refused Yes No Client Know Client Refused  Yes No  Yes No Both Alcohol and Drug Abuse Yes No Client Doesn’t Know Client Refused Yes No Client Know Client Refused  Yes No  Yes No Residential Move-in Date (RRH ONLY): _______/________/_____________ VETERAN INFORMATION: Year Entered Military Service: _____________________
Year Separated from Military Service: ____________________ Branch of the Military:  Army  Air Force  Navy  Marines  Coast Guard  Client Doesn’t Know  Client Refused Discharge Status:  Honorable  General under honorable conditions  Under other than honorable conditions  Dishonorable  Uncharacterized  Client Doesn’t Know  Client Refused Theatre of Operations: World War II  Yes  No  Client Doesn’t Know  Client Refused Korean War  Yes  No  Client Doesn’t Know  Client Refused Vietnam War  Yes  No  Client Doesn’t Know  Client Refused Persian Gulf War (Operation Desert Storm)  Yes  No  Client Doesn’t Know  Client Refused Afghanistan (Operation Enduring Freedom)  Yes  No  Client Doesn’t Know  Client Refused Iraq (Operation Iraqi Freedom)  Yes  No  Client Doesn’t Know  Client Refused Iraq (Operation New Dawn)  Yes  No  Client Doesn’t Know  Client Refused Other Peace-keeping Operations or Military Interventions (such as Lebanon, Panama, Somalia, Bosnia, Kosovo)  Yes  No  Client Doesn’t Know  Client Refused Percent of AMI:  Less than 30%  30% to 50%  Greater than 50% Last Permanent Address: Street Address___________________________ City ______________________ State ________ Zip Code _______________ Last Permanent Address Data Quality:  Full Address Reported  Incomplete or Estimated Address Reported  Client Doesn’t Know  Client Refused  Data Not Collected Last Grade Completed:  Less than Grade 5  Grades 5-6  Grades 7-8  Grades 9-11  Grade 12  School program does not have grade levels  GED  Some College  Associate Degree  Bachelor’s Degree  Graduate Degree  Vocational Certification  Client Doesn’t Know  Client Refused  Data Not Collected VAMC Station Number: __________________ Number of Visits to Emergency Room in the Past Year:  0  1-2  3-5  6-10  11-20  more than 20  Client Doesn’t Know  Client Refused  Data Not Collected