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GULF WAR ILLNESSES AND EXPOSURES TO INCLUDE CIVILIANS AND OTHER VETERAN ERA EXPOSURES - EXPOSURES EXPERIENCED (page 2)

Branch of military or civilian status. If you are both, a veteran and a spouse of a veteran, answer only for yourself as a veteran. Spouses or families of deceased or severely disabled veterans may answer questions they know about in behalf of their deceased or disabled veteran family member.
Era of conflicts or operations you served in.











Your country of origin/citizenship (not the country you were deployed to).

ENVIRONMENTAL AGENTS ISSUES

These links may be helpful for you to review:
http://www1.va.gov/agentorange/
VHA GULF WAR HANDBOOK 1303.2 http://tinyurl.com/2abuo3
http://www.va.gov/WRIISC-DC/
http://www1.va.gov/environagents/
http://www1.va.gov/environagents/docs/DUWORKSHEET2006.doc
http://www.autoimmune.com/SubcommitteeRFGarry24Jan02.html
http://www.autoimmune.com/GWSGen.html
http://www.gulfwarvets.com/insight5.htm
http://www.immed.org/illness/clinical_testing.html
http://www.immuno-sci-lab.com/mycoplas.html
http://www.immuno-sci-lab.com/contact.html
http://www.immuno-sci-lab.com/microbiology_pamphlet1199.html

 
 YESNONOT SUREN/A
Have you been evaluated by an Environmental Agents doctor?
Have you been through the WRIISC (War -Related Illness and Injury Center) programs?
Were you ever tested for DU exposure? If so, explain the results in the block below.
Have you registered with any of the environmental registries? (Gulf War, Agent Orange, etc.)
Have you completed a Phase I examination? If so, explain the results in the block below.
Have you completed a Phase II examination? If so, explain the results in the block below.
Have you been tested for the presence of Squalene in your body? If so, explain the results in the block below.
Have you been tested for the presence of Mycoplasma (fermentans incognitus)? If so, explain the findings in the block below.
Have you been treated with doxycycline? If so, explain the results in the block below.
Do you feel you had adequate personal equipment to protect you during hostile or evironmental exposures? (MOPP gear, flack jackets, goggles, face masks, etc.)
Did you have adequate armour/ammunitions and weapons?
Did you have adequate equipment? (tanks, humvees, tents, etc.)
Did you receive adequate training for your deployment?

Explain the results of any testing or treatment(s) here.
DO YOU HAVE PROBLEMS WITH ANY OF THESE POST WAR/DEPLOYMENT SYMPTOMS AND CONDITIONS?































































YOUR ANSWER WILL BE VIEWABLE BY THE PUBLIC, HOWEVER YOU ARE NOT REQUIRED TO DISCLOSE ANY PERSONAL IDENTITY.
Explain any other symptoms or conditions you feel have not been addressed here. If you have been tested for the presence of depleted uranium, squalene, or mycoplasma, please use this space to report your findings.
IDENTIFY THE KINDS OF EXPOSURES YOU MAY HAVE EXPERIENCED BELOW:



















YOUR ANSWER WILL BE VIEWABLE BY THE PUBLIC, HOWEVER YOU ARE NOT REQUIRED TO DISCLOSE ANY PERSONAL IDENTITY.
Explain any other exposures or experiences you feel have not been addressed here.

VACCINES RECEIVED
  YesNoDon't know
Anthrax
PB (Pyridostigmine Bromide) Tablets
Anti-malarial tablets
Small Pox
Yellow Fever
Botulism
Hepatitis A
Hepatitis B
Tetanus
Typhoid
Cholera
Influenza
Measles
Meningococcal
Mumps
Botulinum toxoid
Plague
Polio
Rubella
Adenovirus (types 4 and 7)


Shot record and vaccine injury/side effects. See this link for vaccine injury criteria:
http://tinyurl.com/ysjcwk
  YESNON/A
Do you have a copy of your shot record?
Did you experience any adverse reactions to your vaccinations?
Were you hospitalized for adverse side effects or vaccine injury?

Describe any side effects you experienced after vaccination or taking prophylactic vaccines (PB tablets or anti-malarial tablets).
Review the information in this link for the kinds of testing authorized by the VA for the related conditions in the Uniform Case Assessment Protocol (UCAP):  http://tinyurl.com/3apqgw
 
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