Please return forms to:
Smoger & Associates, PC
3175 Monterey Blvd., Suite #3 to submit or request a copy of
Oakland, CA 94602 this form.
Fax: (510) 531-4377
You may email:
Click here to download the form.
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 ever taken any medications known as Zyprexa or Bextra?
Have you smoked? How many packs per day and for what period of
Are you currently receiving or seeking VA or SS disability? When
did you first apply?
Have you made a claim for Veteran’s benefits related to your
Agent Orange exposure? Has the
claim been approved or rejected? When was it approved or
Were you aware of or did you participate in the original Agent
Orange lawsuit or settlement?
Are you or have you been 100% disabled?
If so, when were you first 100% disabled and for what periods of
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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