Gulf War Veteran Surveys
Symptom Survey (Part One)
Symptom Survey (Part One) This Survey is for the Veterans to fill out in order to become more aware of their own bodies.  The results we get from each of you that take it will give us percentages that we can use in reports to media and to elected officials. You, the Veteran, benefit by taking a close review of what is occurring in your own body.  It might be good if you print it off and start your own medical file.
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:  Survey08AAA
 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:  Survey08AAB
 Yes
No
Unsure
None
Were you provided any form of protection against the agents or contamination above?
Quest:  Survey08AAC
Yes
Nothing Provided		 Sometimes
Unsure
Masks Special Clothing
Decontamination Vacinations
Tablets/Medication Monitoring
 Other Provisions: 
My military service was in:
Quest:  Survey08AAD
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
Respondent is?
Select what is most likely the cause of your problems.
Quest:  SURV-08-02
 Still able to work
Unable to work
Hospitalized
Deceased
Other
What is your Age Group?
Quest:  SURV-08-03
 30 to 39
40 to 49
50 to 59
60 or over
Lost My Career Due to Health Problems
Quest:  SURV-08-05
 Yes
No
Unsure
Not Checked
Had to Change Job Position due to Health Problems
Quest:  SURV-08-06
 Yes
No
Unsure
Not Checked
Spouse Had To Take Over More Responsibilities
Quest:  SURV-08-07
 Yes
No
Unsure
Not Checked
Have you separated/divorced due to illness since your service?
Quest:  SURV-08-08
 Yes
No
Unsure
Not Checked
Select what is most likely the cause of your problems.
Quest:  SURV-08-09
 Depleted Uranium Residue
Radioactive Surface Exposure
Sarin or Chemical Agents
Suspected Biological Agents
Agent Orange
Other Herbicides
Experimental Vaccines
PB Tablets
Insect Borne Diseases
DEET Insecticide
Excess Sand and/or Dust
Contaminated Equipment
Other Detrimental Items
Nothing Identifiable
Other
Headaches
Quest:  SURV-08-11
 Yes
No
Unsure
Not Checked
Night Sweats
Quest:  SURV-08-12
 Yes
No
Unsure
Not Checked
Fainting
Quest:  SURV-08-13
 Yes
No
Unsure
Not Checked
Unexpected Falls/Tripping
Quest:  SURV-08-14
 Yes
No
Unsure
Not Checked
Problem Walking
Quest:  SURV-08-15
 Yes
No
Unsure
Not Checked
Seizures
Quest:  SURV-08-16
 Yes
No
Unsure
Not Checked
Tremors
Quest:  SURV-08-17
 Yes
No
Unsure
Not Checked
Depressed
Quest:  SURV-08-18
 Yes
No
Unsure
Not Checked
Mood Swings
Quest:  SURV-08-19
 Yes
No
Unsure
Not Checked
Hyperactive
Quest:  SURV-08-20
 Yes
No
Unsure
Not Checked
Irritability/Flashes Of Anger
Quest:  SURV-08-21
 Yes
No
Unsure
Not Checked
Repeating Things
Quest:  SURV-08-22
 Yes
No
Unsure
Not Checked
Blackouts
Quest:  SURV-08-23
 Yes
No
Unsure
Not Checked
Forgetfulness
Quest:  SURV-08-24
 Yes
No
Unsure
Not Checked
Short Term Memory Loss
Quest:  SURV-08-25
 Yes
No
Unsure
Not Checked
Get Lost in Familiar Area
Quest:  SURV-08-26
 Yes
No
Unsure
Not Checked
Drop In IQ
Quest:  SURV-08-27
 Yes
No
Unsure
Not Checked
Loss of Logic Sequencing Ability
Quest:  SURV-08-28
 Yes
No
Unsure
Not Checked
Trouble Reading And Remembering
Quest:  SURV-08-29
 Yes
No
Unsure
Not Checked
Trouble With Math
Quest:  SURV-08-30
 Yes
No
Unsure
Not Checked
Trouble With Spelling
Quest:  SURV-08-31
 Yes
No
Unsure
Not Checked
Trouble With Writing
Quest:  SURV-08-32
 Yes
No
Unsure
Not Checked
Course Work Problem
Quest:  SURV-08-33
 Yes
No
Unsure
Not Checked
Stopping in middle of discussion and forgetting were you were?
Quest:  SURV-08-34
 Yes
No
Unsure
Not Checked
Loss of Facts You Knew Before
Quest:  SURV-08-35
 Yes
No
Unsure
Not Checked
Loss of Coordination
Quest:  SURV-08-36
 Yes
No
Unsure
Not Checked
Hard Time Waking Up
Quest:  SURV-08-37
 Yes
No
Unsure
Not Checked
Misplacing Items
Quest:  SURV-08-38
 Yes
No
Unsure
Not Checked
Forget Names
Quest:  SURV-08-39
 Yes
No
Unsure
Not Checked
Decreased Attention Span
Quest:  SURV-08-40
 Yes
No
Unsure
Not Checked
Loss of Balance
Quest:  SURV-08-41
 Yes
No
Unsure
Not Checked
Changes in Reflexes/Feelings have:
Quest:  SURV-08-42
 Increased
Decreased
Unsure
Stayed Normal
Changes in Reflexes/Feelings effect:
Quest:  SURV-08-43
 Left Side
Right Side
Both Sides
Stayed Normal
Restless Jerking Leg
Quest:  SURV-08-44
 Yes
No
Unsure
Not Checked
Generalized Weakness occurs:
Quest:  SURV-08-45
 With Pain
Without Pain
Unsure
Stays Normal
Progressive Limb Weakness
Quest:  SURV-08-46
 Yes
No
Unsure
Not Checked
Facial Eye Twitching
Quest:  SURV-08-47
 Yes
No
Unsure
Not Checked
Difficulty Speaking (halting or slurred speech)
Quest:  SURV-08-48
 Yes
No
Unsure
Not Checked
Anxiety Attacks
Quest:  SURV-08-49
 Yes
No
Unsure
Not Checked
Poor Concentration
Quest:  SURV-08-50
 Yes
No
Unsure
Not Checked
Easily Agitated
Quest:  SURV-08-51
 Yes
No
Unsure
Not Checked
Paranoid Thoughts
Quest:  SURV-08-52
 Yes
No
Unsure
Not Checked
Suicide Thoughts
Quest:  SURV-08-53
 Yes
No
Unsure
Not Checked
Body Weight since exposure:
Quest:  SURV-08-54
 Losing Weight
Gaining Weight
Erratic Weight
Stable
Not Checked
Flu Like Symptoms
Quest:  SURV-08-55
 Yes
No
Unsure
Not Checked
Swollen Lymph Nodes
Quest:  SURV-08-56
 Yes
No
Unsure
Not Checked
Temperature Deregulation
Quest:  SURV-08-57
 Yes
No
Unsure
Not Checked
Food Intolerance
Quest:  SURV-08-58
 Yes
No
Unsure
Not Checked
Excessive Thirst
Quest:  SURV-08-59
 Yes
No
Unsure
Not Checked
Skin Problems
Quest:  SURV-08-60
 Yes
No
Unsure
Not Checked
Lumps Under Skin
Quest:  SURV-08-61
 Yes
No
Unsure
Not Checked
Burning Skin
Quest:  SURV-08-62
 Yes
No
Unsure
Not Checked
Itching
Quest:  SURV-08-63
 Yes
No
Unsure
Not Checked
Flushed/Hives
Quest:  SURV-08-64
 Yes
No
Unsure
Not Checked
Reaction To Jewelry
Quest:  SURV-08-65
 Yes
No
Unsure
Not Checked
Discolored Nails
Quest:  SURV-08-66
 Yes
No
Unsure
Not Checked
Ridges in Nails
Quest:  SURV-08-67
 Yes
No
Unsure
Not Checked
Rashes
Quest:  SURV-08-68
 Yes
No
Unsure
Not Checked
Hair Loss
Quest:  SURV-08-69
 Yes
No
Unsure
Not Checked
Premature Graying of Hair
Quest:  SURV-08-70
 Yes
No
Unsure
Not Checked
Muscle Fatigue occurs:
Quest:  SURV-08-71
 With Exertion
Without Exertion
Unsure
Seems Normal
Generalized Muscle Weakness
Quest:  SURV-08-72
 Yes
No
Unsure
Not Checked
Severe Muscle Cramps
Quest:  SURV-08-73
 Yes
No
Unsure
Not Checked
Muscle Aches/Pains
Quest:  SURV-08-74
 Yes
No
Unsure
Not Checked
Muscle Twitching
Quest:  SURV-08-75
 Yes
No
Unsure
Not Checked
Tight/Stiff Muscles
Quest:  SURV-08-76
 Yes
No
Unsure
Not Checked
Joint Aches/Pain
Quest:  SURV-08-77
 Yes
No
Unsure
Not Checked
Stiff Joints
Quest:  SURV-08-78
 Yes
No
Unsure
Not Checked
Swelling Joints
Quest:  SURV-08-79
 Yes
No
Unsure
Not Checked
Arthritis Like Symptoms
Quest:  SURV-08-80
 Yes
No
Unsure
Not Checked
Pain Neck/Shoulder
Quest:  SURV-08-81
 Yes
No
Unsure
Not Checked
Upper Back Pain
Quest:  SURV-08-82
 Yes
No
Unsure
Not Checked
Middle Back Pain
Quest:  SURV-08-83
 Yes
No
Unsure
Not Checked
Lower Back Pain
Quest:  SURV-08-84
 Yes
No
Unsure
Not Checked
Extremity Pain
Quest:  SURV-08-85
 Yes
No
Unsure
Not Checked
Swelling Hands and Feet
Quest:  SURV-08-86
 Yes
No
Unsure
Not Checked
Tingling in Extremities
Please complete this section and then do Part Two for us.
Quest:  SURV-08-87
 Yes
No
Unsure
Not Checked

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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.

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