Agent Orange QuestionnaireThank you for your inquiry.  Please complete the 
questionnaire that follows the text of this message  regarding your possible 
participation in an “Agent Orange” lawsuit.  Fill out the questionnaire and 
return it to us as soon as possible so we can process your information and 
update you as to the progress and the status of the litigation.  Thank you for 
your time and interest.  
Sincerely,
Dean Baller
Legal Assistant
Smoger & Associates
Oakland, CA 94602
(510) 531-4529
(510) 531-4377 (fax)
dean@texasinjurylaw.com

AGENT ORANGE QUESTIONNAIRE
Name:______________________________________
 Address:______________________________________________
City:__________________________________________________
State:_________________________________________________
Zip:___________________________
Home Phone:____________________________________________
Cell Phone:______________________________________________
Work Phone:_____________________________________________
Fax:____________________________________________________
E-mail:__________________________________________________
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.
Name:___________________________________________________
Address:________________________________________________  
Phone #:________________________________________________
Dates of Vietnam 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?
 

Do you smoke?                          Did you smoke?                            
              How much?
Are you currently receiving or seeking VA or SS disability?  When did you first 
apply?
 

Have you had a claim for Veteran’s benefits rejected?  By the Board of Veterans 
Appeals? When-Has the decision been issued within the past 12 months?
 

Were you aware of or did you participate in the original Agent Orange lawsuit or 
settlement? Please describe?
 

Are you or have you been 100% disabled?
 

 If so, when were you first 100% disabled? 
 

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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please notify the sender immediately, and destroy this message and all copies 
and backups thereof.  Thank you.