Separation Health Assessment - Part A Self-Assessment

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SEPARATION HEALTH ASSESSMENT - PART A SELF-ASSESSMENT

PRIVACY ACT STATEMENT

This statement serves to inform you, as required by the Privacy Act of 1974, as amended, of the purpose for collecting personal information and how that

information will be stored and used.

AUTHORITY: Title 10, United States Code (U.S.C.) § 1145, Health Benefits; Department of Defense (DoD) Instruction 6040.46, “Separation History and Physical

Examination for DoD Separation Health Assessment Program”; 5 U.S.C. § 301, Departmental Regulations; 10 U.S.C. § 136, Under Secretary of Defense for

Personnel and Readiness; Public Law 104-191, Health Insurance Portability and Accountability Act (HIPAA) of 1996; 10 U.S.C., Chapter 55, Medical and Dental

Care; DoD Manual 6025.18, “Implementation of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule in DoD Health Care Programs”; and

Executive Order 9397 (relating to Federal agency use of Social Security Numbers), as amended.

PURPOSE: The information collected is used to assist the DoD and/or Department of Veterans Affairs (VA) examiners in assessing the health and wellness

status of individuals separating from active duty as well as to determine disqualifying medical condition(s) for medical retention and/or compensation.

ROUTINE USES: These records may specifically be disclosed outside the DoD as a routine use pursuant to 5 U.S.C. § 552a(b)(3) as follows: to contractors and

others performing or working for the Federal Government when necessary to accomplish an agency function related to this System of Records; to the

Department of Health and Human Services, other Federal agencies, and academic institutions for the purposes of public health activities and conducting

research; and to the VA for the purpose of providing medical care, to determine the eligibility for benefits, to coordinate cost sharing activities, and to facilitate

collaborative research activities between DoD and VA.

Any protected health information (PHI) in your records may be used and disclosed generally as permitted by the HIPAA Rules, as implemented within DoD.

Permitted uses and disclosures of PHI include, but are not limited to, treatment, payment, and healthcare operations.

DISCLOSURE: Voluntary. If you choose not to provide the requested information, there may be an administrative delay; however, no penalty may be imposed.

PART A - SERVICE MEMBER IDENTIFICATION AND SELF-ASSESSMENT

SECTION I - IDENTIFICATION

NOTE TO THE SERVICE MEMBER: Please complete the following subsections.

IDENTIFIER

# Question Response

1 Name

SSN (Social Security Number)

3 DoD ID Number

Today's Date (self-assessment date)

(YYYYMMDD)

1. CONTACT INFORMATION

# Question Response

1 Current Address

2 Work Telephone Number

3 Personal Telephone Number

4 Government Email

5 Personal Email

6 Preferred method of contact Mail Work Phone Personal Phone Government Email Personal Email

2. PERSONAL INFORMATION

# Question Response

Date of Birth (DoB)

(YYYYMMDD)

2 Age

3 Ethnicity Hispanic/Latino Not Hispanic/Latino

Race (mark all that apply)

American Indian or Alaskan Native

Asian

Black or African American

White

Native Hawaiian or Other Pacific Islander

Unknown

Choose not to answer

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Birth Gender (biological sex)

Female Male Non-binary

6 Gender Identity

Female

Male

Non-binary

Transgender male (Female to Male)

Transgender female (Male to Female)

Other:

Choose not to answer

Administrative Gender (gender identified on official military

records)

Female Male

3. OCCUPATIONAL INFORMATION

# Question Response

1 Service

Army

Navy

Marine Corps

Air Force

Space Force

Coast Guard

Other:

2 Component Active Duty Reserve National Guard

3 Duty Status

Active Component Active Duty – AGR

Active Duty – non AGR Not on active duty

Usual Occupation (most recent day-to-day job)

What is your military occupational code (for example: MOS,

AOC, AFSC, NEC, or Designator Code)?

4. EXAMINATION INFORMATION

# Question Response

Exam Date (if known)

(YYYYMMDD)

2 Purpose of Exam

Separation from period of active service

Separation from military service

Medical Board

Retirement

Other:

Provide date or anticipated date of release from Active

Duty

(YYYYMMDD)

Do you intend to file a claim, or have you already filed a

claim, for disability compensation with the Veterans

Benefits Administration?

Yes

No (if no, skip to question 6)

5 Select the type of claim program/process

Fully Developed Claim (FDC) Program

IDES (Integrated Disability Evaluation System) (select this option only if you have been

referred to IDES by your Military Service)

BDD (Benefits Delivery at Discharge) (select this option only if you meet the criteria for the

BDD program)

Standard Claim Process

Not sure

6 Have you ever filed a disability claim with the VA? Yes No

Have you had a physical exam within 12 months before

your separation date?

Yes No

Unsure (if no or unsure, skip to Section II)

Date of exam

(YYYYMM)

Type of exam (for example: School, Flight, Special Duty)

Would you like that exam reviewed to determine if it is

sufficient to meet the separation health assessment

requirements?

Yes No

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SECTION II - REPORT OF MEDICAL HISTORY

Please complete all information in the following medical history questionnaire before your appointment for a Separation Health Assessment (SHA) Clinical

Assessment. Your responses will help us understand your current health status and wellness. For each response, briefly describe the history, including dates,

as indicated and applicable. If you are submitting a VA claim, then an appropriate evaluation, to include examinations and completion of any necessary Disability

Benefits Questionnaires (DBQs), will be completed at a later date in order to ensure that the available information is sufficient for rating purposes.

Note: “Qualifying military service” includes: active duty; on orders 30 days or more in support of contingency operation(s); on continuous active duty orders for

180 days or more. This includes active duty, any period of active duty for training, and any period of inactive duty.

1. GENERAL MEDICAL REVIEW

# Question Response

1 List your current medications, including supplements.

Date of your most recent military service medical

assessment/physical exam

(YYYYMMDD)

Compared to your last military service medical

assessment/physical exam, your overall health is:

The Same Better Worse

If better or worse, explain:

Overall, how would you rate your health during the PAST

MONTH?

The Same Better Worse

If better or worse, explain:

During the PAST MONTH, did you have physical health

problems (illness or injury) that made it difficult for you to

do your work or other regular daily activities?

Yes No

If yes, explain:

Do you currently require hearing aids, special medical

supplies, Continuous Positive Airway Pressure (CPAP),

adaptive equipment, assistive technology devices, and/or

other special accommodations?

Yes No

If yes, explain:

Have you had any surgery since your last health

assessment/exam? (Include privately paid elective

surgeries.)

Yes No

If yes, explain:

Since your last health assessment/exam, has a health care

provider recommended surgery(s) that you have not had

(whether you are planning to have it or not)?

Yes No

If yes, explain:

Since your last health assessment/exam, have you

received care or treatment for any medical and/or mental

health condition(s) from a CIVILIAN or NON-MILITARY

facility? This includes privately paid treatments and/or

procedures (for example: photorefractive keratectomy

(PRK), wisdom teeth removal, vasectomy, botox).

Yes No

If yes, explain:

Have you suffered from any injury or illness while on active

duty for which you did not seek medical care (to include

mental health)?

Yes No

If yes, explain:

During qualifying military service, have you ever experienced:

Allergies, including environmental and occupational

allergies, and adverse reaction to serum, food, insect

stings, or medicine.

Yes No

If yes, explain:

11 High or bad cholesterol

Yes No

If yes, explain:

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12 Tuberculosis

Yes No

If yes, explain:

13 Coughing up blood

Yes No

If yes, explain:

14 Asthma

Yes No

If yes, explain:

15 Bronchitis

Yes No

If yes, explain:

16 Chronic cough or cough at night

Yes No

If yes, explain:

Wheezing, shortness of breath, or difficulty breathing

(other than asthma)

Yes No

If yes, explain:

Other lung problems (for example: Chronic Obstructive

Pulmonary Disease (COPD), chronic bronchitis,

pneumonia, emphysema)

Yes No

If yes, explain:

19 Sinusitis

Yes No

If yes, explain:

20 Thyroid trouble or goiter

Yes No

If yes, explain:

21 Ear, nose, or throat trouble

Yes No

If yes, explain:

Frequent indigestion or heartburn (reflux)

Yes No

If yes, explain:

Stomach or intestinal problems (for example: ulcer)

Yes No

If yes, explain:

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Kidney problems (for example: stones, infection)

Yes No

If yes, explain:

Liver problems (for example: hepatitis, cirrhosis)

Yes No

If yes, explain:

26 Constipation, loose bowels, or diarrhea

Yes No

If yes, explain:

27 Gallbladder trouble or gallstones

Yes No

If yes, explain:

28 Hernia

Yes No

If yes, explain:

29 Rectal disease, hemorrhoids, or blood from rectum

Yes No

If yes, explain:

30 Frequent or painful urination or blood in urine

Yes No

If yes, explain:

31 High or low blood sugar

Yes No

If yes, explain:

32 Sugar or protein in urine

Yes No

If yes, explain:

33 Diabetes

Yes No

If yes, explain:

34 Recent unexplained gain or loss of weight

Yes No

If yes, explain:

35 A head injury, memory loss, or amnesia

Yes No

If yes, explain:

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Recurring headaches/ migraines; frequent or severe

headaches

Yes No

If yes, explain:

37 Periods of dizziness, fainting, or loss of consciousness

Yes No

If yes, explain:

Mental health problems (for example: depression, anxiety,

Post-Traumatic Stress Disorder (PTSD), worry, or other

mental health diagnosis)

Yes No

If yes, explain:

Neurological problems (for example: stroke, seizures,

convulsions, epilepsy, fits, tremor)

Yes No

If yes, explain:

40 Paralysis

Yes No

If yes, explain:

Meningitis, encephalitis, or other neurological infection or

disorder

Yes No

If yes, explain:

42 Rheumatic fever

Yes No

If yes, explain:

43 Prolonged bleeding

Yes No

If yes, explain:

Blood problems (for example: hemophilia, sickle cell

disease)

Yes No

If yes, explain:

Immune system problems (for example: HIV,

chemotherapy, radiation)

Yes No

If yes, explain:

46 Angina, also called angina pectoris

Yes No

If yes, explain:

47 Congestive Heart Failure

Yes No

If yes, explain:

48 Pain, pressure, or discomfort in your chest

Yes No

If yes, explain:

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49 Palpitations, pounding heart, or abnormal heartbeat

Yes No

If yes, explain:

Heart murmur or valve problem (for example: mitral valve

prolapse)

Yes No

If yes, explain:

51 Coronary heart disease

Yes No

If yes, explain:

Heart attack (also called myocardial infarction)

Yes No

If yes, explain:

53 High blood pressure

Yes No

If yes, explain:

54 Low blood pressure

Yes No

If yes, explain:

Skin diseases (other than cancer)

Yes No

If yes, explain:

Cancer (other than skin)

Yes No

If yes, explain:

57 Skin cancer

Yes No

If yes, explain:

2. JOINT, SPINE, & MUSCULO-SKELETAL SYSTEM

# Question Response

During qualifying military service, have you ever experienced pain and/or injury in the following:

1 Head and Neck

Yes No

If yes, explain:

2 Back and Chest

Yes No

If yes, explain:

3 Shoulder/Arm

Yes No

If yes, explain:

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4 Elbow/Forearm

Yes No

If yes, explain:

5 Wrist/Hand/Fingers

Yes No

If yes, explain:

6 Hip/Thigh

Yes No

If yes, explain:

7 Leg/Knee

Yes No

If yes, explain:

8 Ankle/Foot/Toes

Yes No

If yes, explain:

3. HEALTH & WELLNESS

# Question Response

Do you currently use tobacco products (cigarettes, cigars,

pipes, etc.), electronic nicotine products (e-cigarette/JUUL,

e-hookah, vape-pen, vaporizer, tank system, other similar

nicotine products), smokeless tobacco products (chewing

tobacco, snuff, dip, snus (pronounced as “snoose”), or

dissolvable tobacco)?

Yes No

If yes, explain:

Have you smoked at least 100 cigarettes in your entire life?

(Note: A pack typically contains 20 cigarettes)

Yes No

If no, skip to question 5.

During the past 12 months, have you ever tried to stop

smoking?

Yes No

If yes, explain:

Have you ever had a serious health problem that was

caused or made worse by smoking?

Yes No

If yes, explain:

During the past 12 months, how often were you exposed to

secondhand smoke indoors (home, work, vehicle, etc.), a

mixture of smoke that comes from the burning end of a

tobacco product (cigarettes, cigars, pipes, etc.), or vapor

indoors from a person using an e-cigarette/JUUL, e-

hookah, vape-pen, vaporizer, tank system, or other similar

nicotine product?

Daily

Less than daily

Not at all

Do you have any concerns with past use of recreational

drugs or misuse of prescription drugs?

Yes No

If yes, explain:

4. HEARING

# Question Response

During qualifying military service have you ever had, or do

you now have, persistent or recurring noises in your head

or ears? (for example: ringing, buzzing, humming)

Yes No

If yes, explain:

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During qualifying military service have you ever had, or do

you now have, a change in your hearing that impacts duty

performance?

Yes No

If yes, explain:

3 Do you currently, or have you ever worn, a hearing aid?

Yes No

If yes, explain:

During your deployment or during military training, were

you exposed to loud noises, to include blasts, that resulted

in a temporary or permanent decrease in hearing and/or

ringing, humming, buzzing sounds in your ears or head?

Yes No

If yes, how many times? For how long? Describe exposure and any symptoms you are still

experiencing.

5. VISION

# Question Response

Do you wear corrective lenses (glasses or contacts)?

Yes No

If yes, explain:

During qualifying military service, have you ever experienced:

2 Eye disorder or trouble

Yes No

If yes, explain:

3 Surgery to correct vision

Yes No

If yes, explain:

4 Loss of vision in either eye

Yes No

If yes, explain:

Double vision (diplopia)

Yes No

If yes, explain:

6 Change in your vision that impacts your duty performance

Yes No

If yes, explain:

6. HEAD INJURY

# Question Response

During qualifying military service:

As a result of any injury or event, did you receive a jolt or

blow to your head that IMMEDIATELY resulted in:

Yes No Not Applicable

If yes, check all that apply:

Losing consciousness ("knocked out")?

Losing memory of events before or after the injury?

Seeing stars, becoming disoriented, functioning differently, or nearly blacking out?

How many total times did you receive a jolt or blow to your

head?

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Have you ever experienced a head injury, concussion, or

Traumatic Brain Injury (TBI)?

Yes No

If yes, explain:

As a result of any injury or event, where you received a jolt

or blow to your head, or were diagnosed with a TBI:

Have you had prolonged symptoms that have not

resolved?

Yes No

If yes, explain:

Are you currently experiencing any prolonged symptoms

that have not resolved?

Yes No

If yes, explain:

7. ENVIRONMENTAL/OCCUPATIONAL

This section covers various potentially hazardous occupational and environmental exposures during qualifying military service. Exposures may have occurred

while deployed, in training, or during other assignments. Consider your potential exposure to: burn pits, oil well fires, burning trash, dust storms, air pollution,

explosions, fuels/fumes, pesticides/insecticides, cleaning agents, solvents, heavy metals/depleted uranium, nerve agents/gases, protective medication and

vaccines (for example: Pyridostigmine Bromide (PB), Lariam (Mefloquine) pills), persistent chemicals such as PCBs, asbestos, radiation, unusual food/drinking

water exposures, contaminated water, and personal hygiene exposures (for example: swimming, showering, etc.).

# Question Response

Were you potentially exposed to any occupational/

environmental hazards (described above) while in a

qualifying military duty service?

Yes No Unsure

If yes or unsure, provide details here:

Have you been based or stationed at a location where an

open burn pit was used?

Yes No Unsure

If yes or unsure, provide details here:

Have you been potentially exposed to toxic airborne

chemicals or other airborne contaminants?

Yes No Unsure

If yes or unsure, provide details here:

If 2 or 3 is “Yes” or “Unsure,” have you enrolled in the

Airborne Hazards and Open Burn Pit Registry?

Yes No Not Applicable

Federal law requires eligible members to enroll in the

Airborne Hazards and Open Burn Pit Registry or to opt-out.

If eligible choose one:

(See below for more information on the registry.)

I wish to: enroll opt out Not Applicable

While deployed, were you potentially exposed to other

deployment-related hazards?

Yes No Unsure

If yes or unsure, provide details here:

During any part of your qualifying military service, were you

exposed to any of the following? (check all that apply)

Medications to prevent malaria/ malaria prophylaxis, including Mefloquine

A vaccine with a possible complication

Firefighting foam

Solvents or other chemicals that may have caused skin reactions, breathing problems, or

other concerns

Fuels

Contaminated water

Radiation (include any possible exposure to depleted uranium)

Other exposures of possible concern not listed here

Embedded shrapnel

Unsure

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NAME DOD ID NUMBER

If you checked any exposures, including “unsure,” listed in

question 7, please explain your exposure concerns in the

right column, being as specific as possible.

Provide details of exposure concerns here:

Are you currently participating in any specialty occupational

exposure examinations?

Yes No

If yes, explain:

During qualifying military service, have you ever experienced:

10 A blast or explosion?

Yes No

If yes, explain:

A vehicular accident/crash (any vehicle including aircraft)?

Yes No

If yes, explain:

12 A fragment wound or bullet wound?

Yes No

If yes, explain:

The Airborne Hazards and Open Burn Pit Registry

Are you eligible to participate? AHOBPR is open to Service members and Veterans who deployed to contingency operations in the Southwest Asia theater of

operations at any time on or after August 2, 1990, or Afghanistan or Djibouti on or after September 11, 2001. These regions include the following countries,

bodies of water, and the airspace above these locations: Iraq, Afghanistan, Kuwait, Saudi Arabia, Bahrain, Djibouti, Gulf of Aden, Gulf of Oman, Oman, Qatar,

and the United Arab Emirates; and waters of the Persian Gulf, Arabian Sea, Red Sea, Uzbekistan, and Syria. The VA will use deployment data provided by DoD

to determine your eligibility. You can join the AHOBPR even if:

• You do not think you were exposed to specific airborne hazards.

• You are not experiencing symptoms or illnesses you think are related to exposures.

• You have not filed a VA claim for compensation benefits or applied for VA health care.

• You are still an active duty Service member, reservist, or have returned to active service.

Visit www.publichealth.VA.gov/airbornehazards to learn more about airborne hazards and the AHOBPR.

If you are not eligible for the AHOBPR but are concerned about your exposures, you can still apply for VA health care and file a claim for compensation and

benefits.

8. DENTAL

# Question Response

Do you currently have any dental problems that need to be

evaluated?

Yes No

If yes, explain:

2 Have you ever been diagnosed or treated for oral cancer?

Yes No

If yes, explain:

During qualifying military service, have you ever experienced:

A dental examination where you were told you had a

Temporomandibular Disorder (TMD) or

Temporomandibular Joint (TMJ) problem?

Yes No

If yes, explain:

4 Your jaw locked open and you could not close the jaw?

Yes No

If yes, explain:

Loss of a portion of the bone in your upper or lower jaw

due to trauma or disease such as osteomyelitis or

necrosis?

Yes No

If yes, explain:

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6 Loss of any teeth because of service-related trauma?

Yes No

If yes, explain:

Physical (anatomical) loss or injury to your mouth, lips, or

tongue?

Yes No

If yes, explain:

9. WOMEN'S HEALTH / FEMALE REPRODUCTIVE ORGANS Not Applicable

# Question Response

During qualifying military service, have you ever:

Been diagnosed with and/or treated for any of the following

disorders? (check all that apply)

Fibroids (leiomyomas)

Endometriosis

Date (YYYYMMDD):

Diagnosed by laparoscopy?

Yes

Unsure

Rectocele or cystocele

Polycystic Ovarian Syndrome (PCOS)

Infertility/difficulty getting pregnant

Recurrent miscarriage (2 or more

pregnancy losses)

Ovarian cancer

Cervical cancer

Uterine/endometrial cancer

Breast cancer

Bone loss or osteoporosis

Frequent urinary tract infections

Urinary or fecal incontinence (leaking

urine or stool)

Please provide additional details for all marked disorders in

question 1 (for example: date diagnosed, treatment,

medications, and treatment center).

Had any of the following surgeries or injuries? (check all

that apply)

Breast surgery or breast biopsy

Hysterectomy (uterus removed)

Other uterine surgery (C-section, dilation

and curettage (D&C), endometrial

ablation, removal of fibroids, or other

uterine surgery)

Oophorectomy (ovaries removed)

One ovary

Both ovaries

Other ovarian surgery

Removal of ovarian cyst

Treatment of ovarian torsion (twisting)

Tubal surgery including tubal ligation

Surgery for urinary/ fecal incontinence

(leaking urine/stool)

LEEP or cervical cone biopsy

Vaginal/vulvar surgery or injury

Please provide additional detail for all marked surgeries in

question 3 (for example: date diagnosed, treatment center).

5 Pregnancy. List all pregnancies and associated outcomes and conditions.

Date

(YYYYMMDD)

Vaginal Delivery C-Section

Miscarriage (loss

before 20 weeks)

Stillbirth (loss at or

after 20 weeks)

Ectopic

(Tubal)

Termination

(Abortion)

Complications*

(Depression or

Anxiety)

Other**

List dates, outcomes, treatment location, and complications, if any.

*Complications include, but are not limited to: depression, anxiety, high blood pressure in pregnancy, preeclampsia, etc.

**Provide additional information, as necessary (for example: gestational diabetes).

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Have you ever had:

A breast cancer screening (mammogram)?

If yes, when was your last screening?

Yes No

Unsure (if no or unsure, skip to question 8)

(YYYYMM)

An abnormal mammogram result? Yes No

Unsure (if no or unsure, skip to question 8)

If yes, when did the abnormal result occur? What was the

abnormal result?

(YYYYMM)/Result

If applicable, when did you receive treatment or follow-up

care? What was the treatment or follow-up care?

(YYYYMM)/Treatment or Follow-up Care

A cervical cancer screening (Pap and/or HPV test):

If yes, when was your last screening?

Yes No

Unsure (if no or unsure, skip to question 10)

(YYYYMM)

An abnormal result showing cancer or pre-cancer or a

positive HPV test?

Yes No

Unsure (if no or unsure, skip to question 10)

If yes, when did the abnormal result occur? What was the

abnormal result?

(YYYYMM)/Result

If applicable, when did you receive treatment or follow-up

care? What was the treatment or follow-up care?

(YYYYMM)/Treatment or Follow-up Care

Are you currently:

Are you still having menses (periods)? Yes No Unsure

If yes, what was the date of your last menstrual period?

(YYYYMMDD) (skip to question 11)

If no or unsure, why are you not having menses (periods)?

Postmenopausal (no periods for 12 months or more)

Hysterectomy

Hormonal suppression (pills/ring/patch/shot/ IUD)

Pregnant

Lactating (breastfeeding)

Other

If you remember, what was the date of your last menstrual

period?

(YYYYMM)

Experiencing any of the following? (check all that apply)

Pelvic pain

Current or recent genital lesions

(sores on or near your vaginal

area)

Pelvic inflammatory disease,

uterus prolapse, or displacement

Pain during intercourse

Leakage of urine affecting work/

social activities

Leakage of stool

Low libido (reduced interest in sex)

Bleeding after menopause

If yes, explain:

10. MENTAL HEALTH SCREENING QUESTIONNAIRES

NOTE TO THE SERVICE MEMBER: Please respond to the following screening questionnaires. Your responses will be reviewed by the Examining Clinician,

and additional questions may be asked.

10.1. POST-TRAUMATIC STRESS DISORDER (PTSD) SCREEN

# Question Response

Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. In the past month, have you...

Had nightmares about the event(s) or thought about the

event(s) when you did not want to?

Yes No

Tried hard not to think about the event(s) or went out of

your way to avoid situations that reminded you of the

event(s)?

Yes No

3 Been constantly on guard, watchful, or easily startled? Yes No

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Felt numb or detached from people, activities, or your

surroundings?

Yes No

Felt guilty or unable to stop blaming yourself or others for

the event(s) or any problems the event(s) may have

caused?

Yes No

10.2 DEPRESSION SCREEN

# Question Response

Over the last 2 weeks, how often have you been bothered by any of the following problems?

1 Little interest or pleasure in doing things? Not At All Several Days More Than Half the Days Nearly Every Day

2 Feeling down, depressed, or hopeless? Not At All Several Days More Than Half the Days Nearly Every Day

10.3. ALCOHOL USE SCREEN

# Question Response

How often did you have a drink containing alcohol in the

past year?

Never Monthly or less 2-4 times a month

2-3 times per week 4 or more times a week

How many drinks containing alcohol did you have on a

typical day when you were drinking in the past year?

1 or 2 3 or 4 5 or 6

7 to 9 10 or more

For men: How often did you have six or more drinks on one

occasion in the past year?

Never Less than monthly Monthly

Weekly Daily, or almost daily

For women: How often did you have four or more drinks on

one occasion in the past year?

Never Less than monthly Monthly

Weekly Daily, or almost daily

Before submitting, please review your responses to ensure they are accurate and complete.

Signature of Service member

Date of signature (YYYYMMDD)

Comments/Additional Remarks:

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CUI (when filled in)

Separation Health Assessment (SHA) Disability Benefits

Questionnaire - Part A Service Member Identification and Self-

Assessment

NAME DOD ID NUMBER

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