You may also forward or distribute this form to any Vietnam veterans who are interested in participating. We need to evaluate each case on an individual basis and this form will provide us with the necessary information for each potential case. Thank you for your time and interest.
Smoger & Associates
(510) 531-4377 (fax)
AGENT ORANGE QUESTIONNAIRE
Claimant's Date of Birth:
Place of Birth:
Social Security #:
Please identify two individuals (relatives or friends) who will always know where to contact you
and do NOT reside with you:
Name: Address: Phone #: Email:
Dates of Viet Nam Service:
Branch of Service and rank:
Briefly describe where you served, your duties, and where you believe you might have been exposed to herbicides, including Agent Orange:
What Agent Orange related conditions are you suffering from (If you have cancer please describe the cell type and location):
When were you diagnosed with each?
Please list any family members related by blood who have suffered or are suffering from the medical conditions you describe above?
Have you smoked? How many packs per day and for what period of time?
Are you currently receiving or seeking VA or SS disability? When did you first apply?
Have you made a claim for Veteranís benefits related to your Agent Orange exposure? Has the claim been approved or rejected? When was it approved or rejected?
Were you aware of or did you participate in the original Agent Orange lawsuit or settlement? Please describe?
Are you or have you been 100% disabled?
If so, when were you first 100% disabled and for what periods of time?
Please feel free to add any additional comments you would like to make, or ask any questions you might have and we will get back to you.
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