Kansas Gulf War Veterans Health Project

Kansas Gulf War Veterans Health Project - Questionnaire
(to be completed by a trained clinician)

ID CODE:

Please answer these questions as completely as possible.
If you are not sure of the answer to any question, please give your best estimate.
If you have no idea of the correct answer, indicate by writing “DON’T KNOW” in the blank.
If you prefer not to answer any question, indicate by writing “NO ANSWER” in the blank.

The Persian Gulf Region

Questions About Your Military Service Between August, 1990 and July, 1991

	No - Yes
1. Did you deploy to the Persian Gulf region any time between August, 1990 and July, 1991?

2. In what month and year did you first arrive in the region?

3. In what month and year did you last leave the region?

While in the Persian Gulf region, were you ever located in ...... ?	NO, I was never there	YES 1-6 Days	I was 7-30 days	there for: 31 days or more days
a. Saudi Arabia: Eastern area (area A on map)
b. Bahrain (area B on map)
c. Kuwait (area C on map)
d. Iraq (area D on map)
e. Saudi Arabia: Northern area (area E on map)
f. Saudi Arabia: Central area (area F on map)
g. Saudi Arabia: Western area (area G on map)
h. At sea: in the Persian Gulf (area H on map)
i. At sea: other (specify__________________)
j. Other location (specify__________________)

--------------------------------------------------------------------------------------
5. While you were in the Persian Gulf region, did you experience any of the following?

[Please mark NO or YES and time for each]	NO	YES 1-6 Days	I was 7-30 days	there for: 31 days or more days
a. Saw smoke from oil well fires
b. Heard chemical alarms sounded
c. Had SCUD missile explode within one mile of you
d. Was directly involved in ground combat
e. Was directly involved in air combat
f. Saw American or Allied troops who had been badly wounded or killed
g. Saw Iraqis or civilians who had been badly wounded or killed
h. Came into contact with prisoners of war
i. Saw dead animals
j. Came into direct contact with dead animals
k. Saw destroyed enemy vehicles
l. Came into direct contact with destroyed enemy vehicles
m. Came into direct contact with American vehicles hit by friendly fire
n. Used pesticide cream or spray on your skin
o. Wore a uniform treated with pesticides
p. Wore a flea collar
q. Saw the area in which you lived fogged or sprayed with pesticides
r. Received one or more shots in the arm while in theater
s. Received one or more shots in the buttocks while in theater
t. Took pyridostigmine pills (also called NAPP pills) (Little white pills in a foil package, used to protect against nerve gas.)
u. Used or came into contact with freshly applied CARC paint (Chemical Agent Resistant Coating)
v. Had less than four hours of sleep in a 24-hour period

	Last Month	Life Time
	Intensity 0 1 2 3 4	Intensity 0 1 2 3 4
6. In August, 1990, what was your branch of service?
7. In August, 1990, were you in the enlisted ranks, or an officer?
8. In August, 1990, were you in the Regular military, the Reserves, or the National Guard?

9. What type of unit did you serve with while in the Persian Gulf area?
10. What was your primary military occupation while in the Gulf area?

(CAPS maximum score = 136)

0    -  19      normal
20  -  39      mild
40  -  59      moderate
60  -  69      severe
80 and above    extreme

Site constructed and maintained by: J. Wesson Ashford, M.D., Ph.D.
Electronic mail address: washford@medafile.com
Forms and papers provided on this site may be copyright protected by their authors or publishers.
HTML code copyright by J. Wesson Ashford, M.D., Ph.D., to retain rights for use.
Dr. Ashford is licensed to practice medicine in the states of California and Kentucky.
Last update: 06/27/2011