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About Us
About Timothy Taylor
What We Do
In the Community
Testimonials
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Resources
Refer a Veteran
Intake Questionnaire
Contact Us
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(832) 449-6069
Intake Questionnaire
Taylor Veteran Services
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Intake Questionnaire
Intake Questionnaire
First Name:
Last Name:
Character of Discharge
Honorable
Medical
General (Other Than Honorable)
Dishonorable
Not sure
Email:
Phone:
Branch of service
Army
Navy
Marines
Air Force
Space Force
Army Reserves
Coast Guard
Other
Current Disability Rating
I don't know
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%- Non P&T
100& P&T
Referral Source
Please list any conditions you are experiencing
Anxiety
Adjustment Disorder
Allergic Rhinitis (Hay Fever)
Amputation(s)
Anemia
Ankle Condition(s)
Arthritis
Asthma
Arm Condition(s)
Bronchitis
Back Condition(s)
Cancer
Cardiovascular Condition(s)
Carpal Tunnel Syndrome (CTS)
Cervical Condition(s)
Chronic Conjunctivitis
Chronic Fatigue Syndrome (CFS)
Degenerative Disc Disease (DDD)
Depression
Diabetes
Diabetic Retinopathy
Diverticulitis
Erectile Dysfunction
Eye Condition(s)
Feet Condition(s)
Fibromyalgia
Gastroesophageal Reflex Disease (GERD)
Gout
Heart Condition(s)
Hearing Loss
Hemorrhoids
Hiatal Hernia
Hip Condition(s)
Hypertension (High Blood Pressure)
Hypothyroidism
Irritable Bowel Syndrome (IBS)
Knee Condition(s)
Limited Motion of the Jaw (TMD / TMJ)
Major Depressive Disorder
Migraines (Headaches)
Neck Condition(s)
Nerve (Sciatica) Condition(s)
Nephrolithiasis (Kidney Stones)
Peripheral Neuropathy
Plantar Fasciitis
Post-Traumatic Stress Disorder (PTSD)
Prostate Gland Condition(s)
Pulmonary Condition(s)
Radiculopathy
Respiratory Condition(s)
Rhinitis
Scars
Skin Condition(s)
Shin Splints
Shoulder Condition(s)
Sinusitis
Sleep Apnea
Somatic Symptom Disorder
Throat Condition(s)
Tinnitus
Traumatic Brain Injury (TBI)
Urinary Incontinence
Varicose Veins
Vertigo
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