Claim for Disability Pension and/or Application for Increase in ...
Claim for Disability Pension and/or Application for Increase in ...
Claim for Disability Pension and/or Application for Increase in ...
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PART FTobacco <strong>and</strong> AlcoholIMPORTANT - Some conditions may be caused, contributed to, <strong>or</strong> aggravated by tobacco <strong>or</strong> alcohol consumption. Iftobacco <strong>or</strong> alcohol consumption is relevant to any of the conditions your are now claim<strong>in</strong>g, m<strong>or</strong>e <strong>in</strong><strong>f<strong>or</strong></strong>mation may beneeded by the person h<strong>and</strong>l<strong>in</strong>g your claim. Please tick the relevant boxes below so that the c<strong>or</strong>rect questionnaire canbe sent to you <strong>or</strong> your representative.21 Have you ever smoked?No Yes What type of tobacco product did the veteran use?CigarettesPipeCigarsTobacco22 Have you filled out a smok<strong>in</strong>gquestionnaire previously?No Yes Can’t remember23 Have you ever consumedalcohol?NoYes24 Have you filled out an alcoholquestionnaire previously?No Yes Can’t rememberPART GReasons <strong>f<strong>or</strong></strong> this application <strong>f<strong>or</strong></strong> <strong>in</strong>creaseTo be completed only if previously accepted disabilities have become w<strong>or</strong>se.25 Which of your accepteddisabilities have become w<strong>or</strong>ses<strong>in</strong>ce they were last assessed bythe Department <strong>and</strong> <strong>in</strong> what way?If <strong>in</strong>sufficient space, please attach a separate sheet.9
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