You are our primary concern.

When you choose Veterans Nexcare, you will be working with real licensed mental and medical healthcare providers. We will will use this information to track your progress

Veteran's Wellness Questionnaire

Please complete this questionnaire prior to your appointment with our healthcare provider.

Name *

First

Last

Email *

1. Do you currently experience symptoms such as nightmares, flashbacks, hypervigilance, or intrusive thoughts related to your military service? *

Not at all.
Sometimes.
All the time.

2. How would you rate your overall emotional well-being on a scale of 1 to 10?

Selected Value: 0

0=Suicidal | 10 All is well

3. Do you feel you have a strong support system among family, friends, or fellow veterans? *

Very strong support.
Some support.
No support

4. Are there any ongoing medical conditions you're dealing with? *

5. On a scale of 0-5, what has been your pain level this week without any medication?

Selected Value: 0

0 = No pain | 5 = Unbearable pain

6. Have you sought professional help for your mental health and medical concerns? *

7. How satisfied are you with the help that you are receiving from your current providers? *

Very satisfied
Somewhat satisfied
Not satisfied

8. Do you feel that your current providers understand your needs? *

Yes
Somewhat
No

If you do not get the help that you need, what would be the most likely outcome? (Check all that apply.) *

Nothing.
I will continue to suffer in silence.
I may lose the ability to work and provide for myself and my family.
I fear I could be homeless
I fear I could be placed in an institution.
I fear I could cause harm to myself or others.
I would feel hopeless, and most likely give up.

1309 St. Johns Bluff Rd. N. Suite 6,
Jacksonville FL 32225
877-564-6664 Ext. 3

Monday - Friday:
11:00AM - 3:00PM

Veterans Nexcare is a community outreach program of One Mission Inc. Global Outreach a 501(c)(3) non profit organization