Gulf War Veteran Surveys
Diagnosed Illness Survey
Diagnosed Illness Survey Please help us assemble statistics on the type of health damage combat veterans are suffering from.  Family members are welcome to complete the surveys if the veteran cannot do it themselves.
Click for Details

QUESTION POSSIBLE ANSWERS
During military service I was exposed to:
Select those most likely the cause of your problems.

Please use comment box at the foot for unusual details
or the Contact Us button for missing survey options.

Quest:  Survey02AAA
 Depleted Uranium Residue
Radioactive Surface Exposure
Sarin or Chemical Agents
Suspected Biological Agents
Agent Orange
Other Herbicides
Experimental Vaccines
PB Tablets
Burning Oil Smoke
Insect Borne Diseases
DEET Insecticide
Excess Sand and/or Dust
Contaminated Equipment
Other Detrimental Items
Nothing Identifiable
Were you exposed to more than one of the above?
Quest:  Survey02AAB
 Yes
No
Unsure
None
Were you provided any form of protection against the agents or contamination above?
Quest:  Survey02AAC
Yes
Nothing Provided		 Sometimes
Unsure
Masks Special Clothing
Decontamination Vacinations
Tablets/Medication Monitoring
 Other Provisions: 
My military service was in:
Quest:  Survey02AAD
Atomic Bomb Testing (Before 1963)
Operation Shad (1963-1973)
The Vietnam War (1957-1975)
Operation Ernest Will (Iraq Gulf 1987-1988)
Operation Desert Storm (Iraq 1990-1991)
Operation Restore Hope (Somalia 1992-2006)
Operation Joint Endeavor (Bosnia 1995-1998)
Operation Joint Forge (Bosnia 1998-2004)
Operation Enduring Freedom (2001-2006)
Operation Iraqi Freedom (2003-2006)
Other Combat Areas
Non-Combat Areas
Your connection to combat related health damage?
Please indicate your status with the following medical problems.
Quest:  SURV-02AB
 Combat Area Veteran
Non Deployed Veteran
Combat Veteran Spouse
Family Member
Other
Respondent is?
Quest:  SURV-02AD
 Still able to work
Unable to work
Hospitalized
Deceased
Have you had Cancers?
Quest:  SURV-02AE
 Yes
No
Partially
Not Sure
If so, what type of Cancer?
Please add more details in Comments at foot.
Quest:  SURV-02AF
 Skin Cancer
Lung Cancer
Brain Cancer
Kidney Cancer
Intestinal Cancer
Lymph/Spleen Cancer
Liver Cancer
Breast Cancer
Other
When was the cancer diagnosed?
You may skip the questions that do not apply.
Quest:  SURV-02AG
 1990-1991
1992-1999
2000-2004
2005 or later
Have you had Cardiac problems?
Quest:  SURV-02AH
 Yes
No
Unsure
Not checked
If so, what type of Cardiac problems?
Please provide more details in comment panel below
Quest:  SURV-02AI
 Heart Attack
Irregular Heart Beat
Enlarged Heart
Damaged Valves
High Blood Pressure
Low Blood Pressure
Erratic Blood Pressure
or
When was the Cardiac condition diagnosed?
Quest:  SURV-02AJ
 1990-1991
1992-1999
2000-2004
2005 or later
Have you had Thyroid or Parathyroid problems?
You should be checked for Hashimoto's Thyroiditis.
Quest:  SURV-02AK
 Yes
No
Unsure
Not checked
When was the Thyroid condition diagnosed?
Quest:  SURV-02AL
 1990-1991
1992-1999
2000-2004
2005 or later
Have you had kidney, liver or gallbladder problems?
Quest:  SURV-02AM
 No
Kidney
Liver
Gallbladder
When was the condition diagnosed?
Quest:  SURV-02AN
 1990-1991
1992-1999
2000-2004
2005 or later
Autoimmune Disfunctions (Immunity System Disorders)
Please note the specific disorder at the foot and complete the Symptom Surveys.
Quest:  SURV-02AO
 Diagnosed by VA
Private Diagnosis
Suspected
No Symptoms
Diabetes due to combat exposure?
Quest:  SURV-02AP
 Diagnosed by VA
Private Diagnosis
Suspected
No Symptoms
Very Progressive
Respiratory (Lung) Problems
Quest:  SURV-02AQ
 Diagnosed by VA
Private Diagnosis
Suspected
No Symptoms
Neurological Problems
Quest:  SURV-02AR
 Diagnosed by VA
Private Diagnosis
Suspected
No Symptoms
Lupus
Quest:  SURV-02AS
 Diagnosed by VA
Private Diagnosis
Suspected
No Symptoms
Ebstein - Barr Virus
Quest:  SURV-02AT
 Diagnosed by VA
Private Diagnosis
Suspected
No Symptoms
Irritable Bowel Syndrome or Inflamatory Bowel Disease
Quest:  SURV-02AU
 Diagnosed by VA
Private Diagnosis
Suspected
No Symptoms
Mycoplasma Incognitus
Quest:  SURV-02AV
 Diagnosed by VA
Private Diagnosis
Suspected
No Symptoms
Fibromyalgia (Joints stiff and painful)
Quest:  SURV-02AW
 Diagnosed by VA
Private Diagnosis
Suspected
No Symptoms
CFDS (Chronic Fatigue Syndrome)
Quest:  SURV-02AX
 Diagnosed by VA
Private Diagnosis
Suspected
No Symptoms
Have you had vision problems?
Quest:  SURV-02AY
 No
Blurred Vision
See Spots
Dimming Vision
Distorted Vision
Light Sensitivity
See Spots
Eye Pain
or
Have you had dental problems?
Include Details at Foot
Quest:  SURV-02AZ
 No
Loose Teeth
Fast Decay
Brittle Teeth
Gum Problems
Bleeding Gums
Mouth Pain
or
Other Problems
Please explain below
Quest:  SURV-02BA
 Diagnosed by VA
Private Diagnosis
Suspected
No Symptoms
When were the conditions diagnosed?
Quest:  SURV-02BB
 1990-1991
1992-1999
2000-2004
2005 or later
What medical group worked with you and provided the best results?
Quest:  SURV-02BE
 DOD Facility Doctors
VA Facility Doctors
Private Clinic Doctors
Private Physician
Other
Are you satisfied with the diagnostic work up you got at VA?
Quest:  SURV-02BG
 Yes
No
Unsure
Not Used
Have you been to any of the Gulf War Illness Centers?
Quest:  SURV-02BH
 Yes
No
Unsure
Didn't Know Existed

We would appreciate your completing all of the following but only those with (Required) must be filled in.
Privacy Policy
Your E-Mail Address:
     (Required)  Must be a valid E-Mail address.		 Your E-Mail address is required to ensure the results are valid.  Our policies forbid using it beyond this site.
Full Name: Age:  
Street Address: (Current Address)
City or Town:
State and Zip Code:   
Country:
Day Telephone:    (Optional)
Evening Telephone:    (Optional)
I am completing this survey as a:    Combat Year:    (Required)
Gender: Male  Female   (Required)  
Unit During War:  (1990-2006)
Unit Locations:  (1990-2006)
Position or Job:
Explain symptoms in your own words and add any comments you would like to make:
Yes   No Please keep me up to date on what's happening.

Home Page Survey Index Page Contact Us
  Copyright & Trademark 2006-2012 by BIZynet
All Rights Reserved
BIZyCart Version 19.32
 BIZyCart Ecommerce Server