Instructions:
? In order to make your health evaluation more complete, please take the time to complete this questionnaire carefully and accurately.
? We realize some questions may seem repetitive, but they help us to give a thorough evaluation.
Section B: Military History and Combat experiences
Tours of Duty
B.1. Tell us about your most recent tour of duty
.
a) Date of arrival in theater? ___/___/____ b) Country (ies) _________________________________
c) Date of your departure from theater? ___/___/____ d) Your branch? _________________________
e) Component? ___________________________ f) Rank? _______________________________
g) Your MOS? ___________________________
h) Were your actual duties different from the MOS? No Yes, if so please explain ___________________
i) What military units did you serve in? (specify complete unabbreviated title ? company, battalion)____________________
j) Were you? Combat arms Combat support Combat service support
k) In what areas did you serve? Combat zone Other land area Sea duty Other Don?t Know
Other (specify, i.e., Air Force, ground crew)__________________________
l) Did you ever go out on combat patrols or have other very dangerous duties?
No 1-3 times 4-12 times 13-50 times 51 or more times
m) Were you ever under enemy fire (including Scuds and other rockets)?
Never 1 Day Less than a week 1-4 weeks 4 weeks or more
n) What percentage of the people in your unit was killed, wounded or missing in action?
None 1-25% 26-50% 51-75% 76% or more
o) How often were you in imminent danger of being injured or killed?
Never 1-2 times 3-12 times 13-50 times 51 or more times
p) Did you seek or receive medical attention during this deployment? No Yes ? How many times? ____
Please explain _______________________________________________________________________________________
During this deployment?
q) The members of my unit were cooperative with each other.
Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree
r) The members of my unit knew that they could depend on each other
Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree
s) The members of my unit stood up for each other.
Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree
B.2. Tell us about your second most recent tour of duty. The above tour was my only deployment to a combat theater.
a) Date of arrival in theater? ___/___/____ b) Country (ies) _________________________________
c) Date of your departure from theater? ___/___/____ d) Your branch? _________________________
e) Component? ___________________________ f) Rank? _______________________________
g) Your MOS? ___________________________
h) Were your actual duties different from the MOS? No Yes, if so please explain ___________________
i) What military units did you serve in? (specify complete unabbreviated title ? company, battalion)____________________
j) Were you? Combat arms Combat support Combat service support
k) In what areas did you serve? Combat zone Other land area Sea duty Other Don?t Know
Other (specify, i.e., Air Force, ground crew)__________________________
l) Did you ever go out on combat patrols or have other very dangerous duties?
No 1-3 times 4-12 times 13-50 times 51 or more times
n) Were you ever under enemy fire (including Scuds and other rockets)?
Never 1 Day Less than a week 1-4 weeks 4 weeks or more
n) What percentage of the people in your unit was killed, wounded or missing in action?
None 1-25% 26-50% 51-75% 76% or more
o) How often were you in imminent danger of being injured or killed?
Never 1-2 times 3-12 times 13-50 times 51 or more times
p) Did you seek or receive medical attention during this deployment? No Yes ? How many times? ____
Please explain _______________________________________________________________________________________
During this deployment?
q) The members of my unit were cooperative with each other.
Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree
r) The members of my unit knew that they could depend on each other
Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree
s) The members of my unit stood up for each other.
Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree
B.3. Tell us about your third most recent tour of duty. The above tours were my only deployments to combat theaters.
a) Date of arrival in theater? ___/___/____ b) Country (ies) _________________________________
c) Date of your departure from theater? ___/___/____ d) Your branch? _________________________
e) Component? ___________________________ f) Rank? _______________________________
g) Your MOS? ___________________________
h) Were your actual duties different from the MOS? No Yes, if so please explain ___________________
i) What military units did you serve in? (specify complete unabbreviated title ? company, battalion)____________________
j) Were you? Combat arms Combat support Combat service support
k) In what areas did you serve? Combat zone Other land area Sea duty Other Don?t Know
Other (specify, i.e., Air Force, ground crew)__________________________
l) Did you ever go out on combat patrols or have other very dangerous duties?
No 1-3 times 4-12 times 13-50 times 51 or more times
o) Were you ever under enemy fire (including Scuds and other rockets)?
Never 1 Day Less than a week 1-4 weeks 4 weeks or more
n) What percentage of the people in your unit was killed, wounded or missing in action?
None 1-25% 26-50% 51-75% 76% or more
o) How often were you in imminent danger of being injured or killed?
Never 1-2 times 3-12 times 13-50 times 51 or more times
p) Did you seek or receive medical attention during this deployment? No Yes ? How many times? ____
Please explain _______________________________________________________________________________________
During this deployment?
q) The members of my unit were cooperative with each other.
Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree
r) The members of my unit knew that they could depend on each other
Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree
s) The members of my unit stood up for each other.
Strongly Disagree Disagree Neither Agree nor Disagree Agree Strongly Agree
Traumatic Brain Injury screen
B.4: During any of your OEF/OIF deployment(s) did you experience any of the following events?
a. Blast or explosion, IED (improvised explosive device), RPG (rocket propelled grenade), land mine, grenade, etc???. No Yes
b. Vehicular accident/crash (any vehicle, including aircraft or watercraft) ?????????.......................... No Yes
c. Fragment wound or bullet wound above the shoulders??.?????????............................................ No Yes
d. Fall??..??????????????????????????????????????? No Yes
e. Blow to head (head hit by falling/flying object, head hit by another person, head hit against something, etc.).. No Yes
f. Other injury to head???????????????????????????????????? No Yes
g. If yes, please specify _________________________________________________________________________________
B.5: Did you have any of these symptoms IMMEDIATELY afterwards:
a. Being dazed, confused or "seeing stars"????????????????????..??... No Yes
b. Losing consciousness/"knocked out" for less than a minute???????????..?..?..? No Yes
c. Losing consciousness/"knocked out" for 1-20 minutes?????????????..???? No Yes
d. Losing consciousness/"knocked out" for longer than 20 minutes?????????..???? No Yes
e Not remembering the event???????????????????????..?..??? No Yes
f. Told you had a concussion???????????????????????..???...? No Yes
g. Head injury (visible head wound) ????????????????????..??...?? No Yes
B.6: Did any of the following problems begin or get worse afterwards?
a. Memory problems or lapses?????????????????????..?????.? No Yes
b. Balance problems or dizziness??????????.??????????..?????? No Yes
c. Sensitivity to bright light????????????????????????..????.. No Yes
d. Irritability???????????????????????????????..???.. No Yes
e. Headaches????????????????????????????????..??. No Yes
f. Sleep problems????????????????????????????????... No Yes
g. Ringing in ears?????????????????????..???..???????? No Yes
B.7: In the past week, have you had any of the following symptoms?
a. Memory problems or lapses?????????..????????????????.?? No Yes
b. Balance problems or dizziness?????????..???????????????.?? No Yes
c. Sensitivity to bright light?????????????..???????????????. No Yes
d. Irritability????????????????????..?????..????????? No Yes
e. Headaches?????????????????????..????????????? No Yes
f. Sleep problems?????????????????????..????????.??? No Yes
g. Ringing in ears???????????????????????..?..???????? No Yes
B.8: Other than during your OEF/OIF deployment(s), have you ever experienced an event that resulted in your being dazed, losing consciousness or being unable to remember the event? ???????????????.. No Yes
If yes, please briefly describe the event ______________________________________________________________________
______________________________________________________________________________________________________
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Last update: 12/23/2010
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