Page 1 - Personal/Military/Medical History

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GULF WAR ILLNESSES AND EXPOSURES TO INCLUDE CIVILIANS AND OTHER VETERAN ERA EXPOSURES - YOUR PERSONAL HISTORY (page 1)

Your help in completing this survey will help to support our efforts in compiling a complete and total representation of the veteran community of exposures and illnesses. Only a sampling of veterans ever received a thorough evaluation (mental and physical) after they returned home and the government is not providing a complete and thorough investigation, nor disclosure into reports from DoD, VA, and IOM. Most reports from the government have been sanitized or completely inaccurate.

In the past, civilians who may have been spouses or working for the government and in the theatre have not been included in any reports, even though some civilians worked in support missions and came into contact with environmental exposures. We invite all civilians (civil servants, contractors, spouses, etc.) who may have been married to veterans and/or working in the theatre of operations (or area of responsibility) to participate in this survey.

There are 5 pages of surveys in total. So, make a pot of coffee (or your favorite beverage), get comfortable, and help us to compile a thorough data-gathering survey, which will be open for viewing and not hidden from the veterans who have a stake in knowing the answers which has been kept secret from us on our own health due to exposures.

There will be an oppertunity for you to offer your suggestions, or just to vent on the last page.

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).

Gender

Male

Female

PERSONAL HISTORY - Answering these questions to the best of your ability may shed light as to how experience in combat (or other traumatic events) and toxic exposures affect the quality of your health, emotional well-being, your family, and your job. These questions are not meant to judge you in any way.

These answers may be answered by ALL DEPLOYED AND NON-DEPLOYED PERSONNEL (including civilians married to veterans, or who were employed with the government in the theatre of operations or whose job supported the war mission and may have come into contact with toxic exposures, or who may have had adverse reactions to vaccines).

	No personal identity is needed to answer these questions.
Veteran's current age
Kind of job worked during activation/deployment (MOS, AFSC, etc.)
Date/year which you, the veteran, began to experience symptoms and condtions from exposures
Marital status when deployed (married, single, divorced, widowed). Example answer for change of marital status in multiple deployments and/or marriages: "married, widowed"
Age(s) when deployed. Example answer for change of ages in multiple deployments: "25 years old, 29 years old"
Number of deployments
Current marital status (married, single, divorced, widowed)
Number of marriages to date
Number of divorces to date
Number of significant relationships to date
Number of jobs held since discharge
Are you employed now?
Number of biological children born to the veteran BEFORE each deployment
Number of biological children born to the veteran AFTER each deployment
Number of biological children with disabilities born to the veteran BEFORE each deployment
Number of biological children with disabilities born to the veteran AFTER each deployment
Number of still births born to the veteran before each deployment
Number of still births born to the veteran after each deployment

If applicable, which are you? We are looking for answers from either females themselves, or someone who lived with them in an intimate relationship during or after the time(s) of exposures who may have experienced adverse/painful sexual problems or difficult pregnancies in the questions below.

I am:

Female veteran

Wife of veteran

Ex-wife of veteran

Girlfriend of veteran

Ex-girlfriend of veteran

Husband of female veteran (answering in behalf of the female partner)

Ex-husband of female veteran (answering in behalf of the female partner)

Boyfriend of female veteran (answering in behalf of the female partner)

Ex-boyfriend of female veteran (answering in behalf of the female partner)

PERSONAL HISTORY- Data gathered on female veterans or other females in an intimate relationship with male veterans.
FEMALE OB/GYN HISTORY ONLY Keep in mind that these questions are optional to answer and that your personal identification is confidential, however answering these questions as completely and honestly as possible gives a more accurate account of how toxins may have affected any complications. Husbands or boyfriends may answer these questions if they know the answers and are no longer living with the female they were living with during their military service.

	FEMALE OB/GYN HISTORY ONLY (including female veterans and any female civilians married to veterans, or females employed with the government in the theatre of operations or whose job supported the war mission and may have come into contact with environmental toxic exposures or adverse reactions to vaccines).
Female's current age
Age(s) when deployed or exposed to toxins
Number of pregnancies before deployment/activation exposures
Number of pregnancies after deployment/activation exposures
Number of miscarriages before deployment/activation exposures
Number of miscarriages after deployment/activation exposures
Number of still births before deployment/activation exposures
Number of still births after deployment/activation exposures
Other OB/GYN problems before deployment/activation (if 'yes', what kind(s))
Other OB/GYN problems after deployment/activation (if 'yes', what kind(s))
Number of abortions before deployment or activation
Number of abortions after deployment or activation

Answer the following to the best of your knowledge. You need only to answer the era(s)/column(s) that apply to you. There are 12 eras/columns listed, so please scroll down the find the eras/columns that apply to you. (Vietnam, Gulf War, Operation Iraqi Freedom, Operation Enduring Freedom, Bosnia, Afghanistan, Other era/campaign, Civilian, SHAD, Agent Orange, Edgewood Test Veterans, Ionizing Radiation Veterans)

	VIETNAM				GULF WAR				OPERATION IRAQI FREEDOM				OPERATION ENDURING FREEDOM
	YES	NO	NOT SURE	N/A	YES	NO	NOT SURE	N/A	YES	NO	NOT SURE	N/A	YES	NO	NOT SURE	N/A
Are you a veteran of more than one era? If so, please answer "yes" to all eras pertaining to you.
Did you deploy to the theatre (or area of responsibility?)
Did you receive a pre-deployment examination?
Did you receive a post-deployment examination?
Have you registered with any of the VA Environmental Agents Registries? (Agent Orange, SHAD, Gulf War, etc.)
Did you have any diagnosed mental health issues before deployment? (like having PTSD from a previous deployment)
Do you have unusual symptoms and conditions after your service during or after your deployment(s)?
Have these conditions been evaluated by a doctor?
Was your doctor working for DoD, MoD, or the VA?
Do you feel that your condition(s) were chalked up to PTSD before any diagnostic/lab tests were done to rule out neurological conditions from your exposures?
Have you been seen by a private doctor for any symptoms or conditions (due to active military service) after you came back from deployment?
Do you have private insurance?
Have any of your children been born with Autism, Spina Bifida, or other defects since returning from military service where you were exposed to toxins?

Answer the following to the best of your knowledge. You need only to answer the era(s)/column(s) that apply to you.

	BOSNIA				AFGHANISTAN				OTHER ERA/CAMPAIGN				CIVILIAN
	YES	NO	NOT SURE	N/A	YES	NO	NOT SURE	N/A	YES	NO	NOT SURE	N/A	YES	NO	NOT SURE	N/A
Are you a veteran of more than one era? If so, please answer "yes" to all eras pertaining to you.
Did you deploy to the theatre (or area of responsibility?)
Did you receive a pre-deployment examination?
Did you receive a post-deployment examination?
Have you registered with any of the VA Environmental Agents Registries? (Agent Orange, SHAD, Gulf War, etc.)
Did you have any diagnosed mental health issues before deployment? (like having PTSD from a previous deployment)
Do you have unusual symptoms and conditions after your service during or after your deployment(s)?
Have these conditions been evaluated by a doctor?
Was your doctor working for DoD, MoD, or the VA?
Do you feel that your condition(s) were chalked up to PTSD before any diagnostic/lab tests were done to rule out neurological conditions from your exposures?
Have you been seen by a private doctor for any symptoms or conditions (due to active military service) after you came back from deployment?
Do you have private insurance?
Have any of your children been born with Autism, Spina Bifida, or other defects since returning from military service where you were exposed to toxins?

Answer the following to the best of your knowledge. You need only to answer the era(s)/column(s) that apply to you.

	SHAD				AGENT ORANGE				EDGEWOOD TEST VETERANS				IONIZING RADIATION VETERANS
	YES	NO	NOT SURE	N/A	YES	NO	NOT SURE	N/A	YES	NO	NOT SURE	N/A	YES	NO	NOT SURE	N/A
Are you a veteran of one or more than one of these era/exposures? If so, please answer "yes" to all eras pertaining to you.
Are you the spouse or civilian employee/contractor who worked in these toxic environments?
Did you deploy to the theatre (or area of responsibility?)
Did you receive a pre-deployment examination?
Did you receive a post-deployment examination?
Have you registered with any of the VA Environmental Agents Registries? (Agent Orange, SHAD, Gulf War, etc.)
Did you have any diagnosed mental health issues before deployment? (like having PTSD from a previous deployment)
Do you have unusual symptoms and conditions after your service during or after your deployment(s)?
Have these conditions been evaluated by a doctor?
Was your doctor working for DoD, MoD, or the VA?
Do you feel that your condition(s) were chalked up to PTSD before any diagnostic/lab tests were done to rule out neurological conditions from your exposures?
Have you been seen by a private doctor for any symptoms or conditions (due to active military service) after you came back from deployment?
Do you have private insurance?
Have any of your children been born with Autism, Spina Bifida, or other defects since returning from military service where you were exposed to toxins?

YOUR ANSWER WILL BE VIEWABLE TO THE PUBLIC, HOWEVER YOUR PERSONAL IDENTITY WILL NOT BE REQUIRED OR DISCLOSED.
For both men and women: Have you had a vasectomy, tubalygation, hysterectomy, or other means of sterilization? If so, was this done before or after any children were born that may have been affected by your exposure(s)? Explain here.

YOUR ANSWER WILL BE VIEWABLE TO THE PUBLIC, HOWEVER YOUR PERSONAL IDENTITY WILL NOT BE REQUIRED OR DISCLOSED.
Please explain any disabilities, deaths, or other complications that you, your spouse, or your children have which you feel are a result of experiences or exposures during wartime exposures. This may included suspected adverse reactions to vaccines. If you or your family were examined by a doctor, please state the conditions and Dr's opinion and diagnosis reported.

FOR EVERYONE:
Have you had a thorough workup and/or consultation in the following areas? Answer the following to the best of your knowledge. You need only to answer the era(s)/column(s) that apply to you.

	VA				DoD				PRIVATE DOCTOR				OTHER MEDICAL RESOURCE (Tricare, MoD, etc.)
	YES	NO	NOT SURE	N/A	YES	NO	NOT SURE	N/A	YES	NO	NOT SURE	N/A	YES	NO	NOT SURE	N/A
Allergy and/or Immunology
Audiology
Cardiology
Dentistry
Dermatology
Ear, Nose, and Throat
Endocrinology
Gastroenterology
Hemotology and/or Oncology
Infectious Disease and/or Parasitology
Nephrology
Neurology
Occupational Medicine
Pulmonary
Psychiatry
Psychology and/or Psychometric Testing
Rheumatology

Use this area to explain any findings from your workups and/or consultations.

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

If you wish to be publicly recognized as a participant in this survey, please enter your real or username in the space below. This is an optional block, so you are NOT required to complete it, however, some people want to be recognized for their efforts.

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Please be certain that you have answered all questions to the best of your ability before hitting the "Submit" button. You will not be able to change your answers or come back to finish this form unless you have "logged in" at the very top of this form! Please go to the next survey after you submit this form: Survey #2

Air Force	Air National Guard
Air Force Reserves	Army
Army National Guard	Army Reserves
Marines	Marine Reserves
Navy	Navy Reserves
Coast Guard	Coast Guard Reserves
Spouse or family member	Civilian contractor

United Kingdom	United States	Afghanistan	Australia
Bahrain	Bangladesh	Canada	Czechoslovakia
Denmark	Egypt	France	Germany
Italy	Kuwait	Oman	Pakistan
Portugal	Qatar	Saudi Arabia	Spain
Syria	Turkey	The United Arab Emirates	Other