Personal Statement Format

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Along with my previous article 'The Value of a Personal Statement', this Format for a Personal Statement should be of value;

Personal Statement Format

Name:  John Doe


Contact Info:  Address XXXXXXXXXX

                         Phone: (XXX)XXX-XXXX



Condition Facts:  Detailed information concerning how you got the condition.  Was there an exposure that resulted in a disease (ie asbestos developing into mesothelioma.  Note exposure is not in itself compensable unless a condition develops into a condition.) What is the accident or injury (ie broke/sprained knee on obstacle course) leading to current diagnosis. What is the stressor for your mental condition (ie combat, personal trauma such as witnessing a serious accident or military sexual trauma.  The more detailed information such as date and time of the incident the better. 

Treatment in Service:  As closely as possible document what treatment you received for the condition.  Such as follows:  Fort Jackson SC –Emergency Room visit 4 Jun 2001 – Knee trauma from playing flag football.  Twisted knee in pile up.  Put in a cast.

Pope AFB – Treated by Dr. Welby for knee giving out.  Given therapy and Ibuprofen.

Norfolk NAS _ Treated by Dr. Kildare for knee swelling.  Took xrays and provided with Percocet.  Given profile from exercise for 6 weeks.


Treatment out of service:  Again documenting the type treatment your received and as accurate a detail as possible. 

Hope Medical Center – Boston – Dr. Strange did ex-rays and assigned me to therapy (List dates of Therapy)

Johnson and Johnson Orthopedics – Dr. Smith performed knee replacement surgery 9 Aug 2003.  Put on 8 weeks therapy.

Johnson and Johnson Orthopedics – Dr. SmithFollow up to surgery.  Given handicap paperwork for handicap sticker.

The same can be done for all other conditions. Just list the treatments and dates.


Symptoms:  Download the DBQ for the specific condition and go through the questions.  Your list of symptoms should be taken off the DBQ and answer the questions.  So for a knee you would list what you experience.  Things such as follows:  My symptoms are sharp pains when I bend my knee (on a 1 to 10 it’s a 7).  Climbing up and down steps causes pain.  At times my knee gives out and I have fallen.  I can only move me knee so far.  My doctor says I have arthritis and when it is cold my knee aches.

Note for mental conditions it is imperative you include all of the symptoms.  If you only have five or six symptomslisted but actually have more you experience then it is likely you won’t get what you are entitled.  The need to list any and ALL symptoms is imperative.  Also providing a word description its equally imperative.  A sample of how to list symptoms is as follows:  One of my symptoms is memory loss – I have trouble remembering important dates and events.  I have forgotten birthdays and anniversaries.  If I don’t write down an appointment or put it in my phone then I will forget it.  I have forgotten the names of friends I used to hang out with. 

Another symptom is panic attacks – I have panic attacks more than twice a week.  When I am having a panic attack my chest hurts, my heart is racing, I sweat even if I have a fan blowing on me, my vision gets blurry, my stomach hurts and I get diarrhea.

And so on.


How the Symptoms affect your social and economic lifestyle:And finally you have to let the rater and C&P examiner know how this affects your life.  This is the part that is not covered by a DBQ but is important for you case since that is why you are compensated, because it affects your life in other areas.

For example, “my lack of trust for people and being suspicious of their actions makes it hard for me to make friends and I have family members I no longer speak to.”  Another example, “my anger makes it hard for me to work for certain people.  I find it hard to work with these people and have had several fights at work.”


The more detailed and specific you are in the statement the clearer it will be to the rater.

You can also see 'The Value of a Personal Statement' to read its importance.

Christopher Edwards