DATE:          TIME (24hr): 

Please "click" on any condition or symptom which you have had or a clinician has told you that you have had since 1990.

1. Has your doctor ever told you that you have any of the following conditions? Please check all that apply:
High blood pressure
Low blood pressure
Heart murmur or mitral valve prolapse
Angina, heart attack, or coronary heart disease
Arrhythmia or irregular heart beat
Peripheral neuropathy
Spinal cord injury
Asthma or reactive airway disease
Pneumonia or pleurisy (painful breathing)
Sleep apnea
Allergies, nasal polyps, or hay fever
Kidney or bladder stones
Arthritis or gout
Broken bones or joint surgery or back surgery
Blood transfusions
Anemia or thalassemia
Leukemia or lymphoma or Hodgkin’s disease
Hepatitis or liver disease or cirrhosis
Pancreatitis or colitis
Heat exhaustion or heat stroke or frostbite
Fibromyalgia
Multiple Chemical Sensitivity
Lupus or sarcoidosis
Depression
Schizophrenia
Hives or allergic dermatitis
Skin cancer other than melanoma
Other cancer
Congestive heart failure or fluid on the lungs
Stroke or mini-stroke or Transient Ischemic Attack
Dementia or Alzheimer’s disease
Cognitive disorder
Brain injury
Meningitis
Huntington’s disease
Parkinson’s disease
Poor circulation, varicose veins or blood clots
Seizures or epilepsy
Migraines
Multiple sclerosis
Emphysema or chronic lung disease
Chronic bronchitis
Silicosis or asbestosis
Chronic sinusitis
Benign prostatic hypertrophy (enlarged prostrate)
Hearing loss
Repeated kidney or bladder infections
Chronic back pain, sciatica or herniated disk
HIV positive test/AIDS
Sickle cell disease or trait
Problems with blood clotting or bleeding
Malnutrition
Ulcer or reflux or hiatal hernia
Gall bladder disease or stones
Irritable bowel syndrome
Diabetes or high blood sugar
Chronic fatigue syndrome
Lyme disease
Thyroid disease or goiter
Post-traumatic stress disorder
Panic attacks or anxiety disorder
Bipolar disorder
Alcohol abuse or alcoholism
Substance abuse
Attention deficit/hyperactivity disorder
Learning disorder or dyslexia
Psoriasis or eczema
Melanoma
Temporomandibular joint disorder (TMJ)
Mononucleosis
Other (please inform the nurse)

2. Number of surgeries that you have had:

    0 []
    1 []        2 []       3 []       4 []         5 []
    6 []        7 []       8 []       9 []       10 []
  11 []      12 []     13 []     14 []       15 []
  16 []      17 []     18 []     19 []     20+ []

3. Please indicate if any of these symptoms started during or after your deployment to the Persian Gulf, and have been a problem for you for at least six months:
Fatigue
Feeling unwell after physical exercise or exertion
Problems getting to sleep or staying asleep
Not feeling rested after you sleep
Pain in your joints
Stiffness in your joints
Pain in your muscles
Body pain, where you hurt all over
Headaches
Feeling dizzy, lightheaded or faint
Eyes very sensitive to light
Blurred or double vision
Numbness or tingling in your extremities
Tremors or shaking
Low tolerance for heat or cold
Night sweats
Having physical or mental symptoms after breathing in certain smells or chemicals
Skin rashes
Other skin problems
Diarrhea
Nausea or upset stomach
Abdominal pain or cramping
Difficulty breathing or catching your breath
Frequent coughing when you don’t have a cold
Wheezing in your chest
Difficulty concentrating
Difficulty remembering recent information
Trouble finding words when speaking
Feeling down or depressed
Feeling irritable or having angry outbursts
Feeling moody
Feeling anxious

TEXT to send to your clinical file, instructions:

   STEP 1: Place your mouse cursor over the text below and LEFT CLICK
   STEP 2: select all text = Ctrl+A
   STEP 3: copy all text = Ctrl+C
   STEP 4: Initiate SECURE MESSAGE to your clinician
   STEP 5: LEFT CLICK in the text area of the SECURE MESSAGE
   STEP 6: Paste the text into the text area = Ctrl+V
   STEP 7: Send the message to your clinician