Symptom Survey (Part Two)

	If you are now taking the continuation of symptoms survey, we complement you for taking an interest in your own health and for the benefit of a whole group of veterans that we will be able to give summary data for those that participate.  The more surveys filled out the better, so help spread the word please. QUESTION POSSIBLE ANSWERS Constipation Quest:  SURV-09-01 Yes No Unsure Not Checked Diarrhea Quest:  SURV-09-02 Yes No Unsure Not Checked Bloating Quest:  SURV-09-03 Yes No Unsure Not Checked Changes in Exercise Endurance Quest:  SURV-09-04 Muscles Tire Faster Out of Breath Faster Tire and Short Breath No Change Unsure Not Checked Sleep Problems Quest:  SURV-09-05 Yes No Unsure Not Checked Excess Sleeping Quest:  SURV-09-06 Yes No Unsure Not Checked Keep Waking Up - Non-restful Sleep Quest:  SURV-09-07 Yes No Unsure Not Checked Have to Take Naps Frequently Quest:  SURV-09-08 Yes No Unsure Not Checked Can't Sleep Through the Night Quest:  SURV-09-09 Yes No Unsure Not Checked Frequent Urination Quest:  SURV-09-10 Yes No Unsure Not Checked Have to get up at night and Urinate Quest:  SURV-09-11 Yes No Unsure Not Checked Doesn't Feel Like I Am Emptying Quest:  SURV-09-12 Yes No Unsure Not Checked Stream Flow Change Quest:  SURV-09-13 Yes No Unsure Not Checked Dribbling Quest:  SURV-09-14 Yes No Unsure Not Checked Urgency Increase Quest:  SURV-09-15 Yes No Unsure Not Checked Incontinent Quest:  SURV-09-16 Yes No Unsure Not Checked Loss Of Sensation On Abdomen Quest:  SURV-09-17 Yes No Unsure Not Checked Back Flank Pain Quest:  SURV-09-18 Yes No Unsure Not Checked Sexual Problems Quest:  SURV-09-19 Yes No Unsure Not Checked Lack of Sensation Quest:  SURV-09-20 Yes No Unsure Not Checked Painful Intercourse Quest:  SURV-09-21 Yes No Unsure Not Checked (Male) Burning Semen Please skip the questions that do not match your gender. Quest:  SURV-09-22 Yes No Unsure Not Checked Genital Itch Quest:  SURV-09-23 Yes No Unsure Not Checked (Female) Vaginal Discharge Quest:  SURV-09-24 Yes No Unsure Not Checked (Female) Miscarriages Quest:  SURV-09-25 Yes No Unsure Not Checked (Female) Abnormal Periods Quest:  SURV-09-26 Yes No Unsure Not Checked (Female) Early Cessation of Menstrual Period Quest:  SURV-09-27 Yes No Unsure Not Checked (Female) Excessive Bleeding Quest:  SURV-09-28 Yes No Unsure Not Checked (Female) Excessive Bleeding With Periods Quest:  SURV-09-29 Yes No Unsure Not Checked Ringing in Ears Quest:  SURV-09-30 Yes No Unsure Not Checked Noise Sensitive Quest:  SURV-09-31 Yes No Unsure Not Checked Can't Seem to Hear As Well Quest:  SURV-09-32 Yes No Unsure Not Checked Hyper-acute to Sounds (Jump at sounds) Quest:  SURV-09-33 Yes No Unsure Not Checked Vision Distortions occur at: Quest:  SURV-09-34 Night Time Day Time Both None Visual Acuity Problems Quest:  SURV-09-35 Yes No Unsure Not Checked Blurring Vision Quest:  SURV-09-36 Yes No Unsure Not Checked Frequent Changes in Vision Quest:  SURV-09-37 Yes No Unsure Not Checked Dark Circles Under Eyes Quest:  SURV-09-38 Yes No Unsure Not Checked Swollen Eyelids Quest:  SURV-09-39 Yes No Unsure Not Checked See Spots or Flashes Quest:  SURV-09-40 Yes No Unsure Not Checked Sensitive To Light Quest:  SURV-09-41 Yes No Unsure Not Checked Extreme Sensitivity To Light Quest:  SURV-09-42 Yes No Unsure Not Checked Temporary Blindness Quest:  SURV-09-43 Yes No Unsure Not Checked Night Vision Changes Quest:  SURV-09-44 Yes No Unsure Not Checked Dark Vision Loss Quest:  SURV-09-45 Yes No Unsure Not Checked Loss of Smell Quest:  SURV-09-46 Yes No Unsure Not Checked Lose of Taste Quest:  SURV-09-47 Yes No Unsure Not Checked Metallic Taste Quest:  SURV-09-48 Yes No Unsure Not Checked Reaction to Odors/Fumes Quest:  SURV-09-49 Yes No Unsure Not Checked Smell Things When Others Do Not Quest:  SURV-09-50 Yes No Unsure Not Checked Difficulty Swallowing Quest:  SURV-09-51 Yes No Unsure Not Checked Gag On Food/Water Quest:  SURV-09-52 Yes No Unsure Not Checked Hoarse/Raspy Voice Quest:  SURV-09-53 Yes No Unsure Not Checked Excess Salivation Quest:  SURV-09-54 Yes No Unsure Not Checked Dry Mouth Quest:  SURV-09-55 Yes No Unsure Not Checked Sores In and Around Mouth or Nose Quest:  SURV-09-56 Yes No Unsure Not Checked Gum Bleeds Quest:  SURV-09-57 Yes No Unsure Not Checked Loose Teeth Quest:  SURV-09-58 Yes No Unsure Not Checked Teeth Chipping Quest:  SURV-09-59 Yes No Unsure Not Checked Teeth Breaking Quest:  SURV-09-60 Yes No Unsure Not Checked Crowns Deteriorating Quest:  SURV-09-61 Yes No Unsure Not Checked Losing Fillings Quest:  SURV-09-62 Yes No Unsure Not Checked Nose Bleeds Quest:  SURV-09-63 Yes No Unsure Not Checked Coughing Frequently Quest:  SURV-09-64 Yes No Unsure Not Checked Dry Irritated Coughing Quest:  SURV-09-65 Yes No Unsure Not Checked Coughing up Large Amounts Quest:  SURV-09-66 Yes No Unsure Not Checked Shortness Of Breath Quest:  SURV-09-67 Yes No Unsure Not Checked Abnormal Beating of Heart Quest:  SURV-09-68 Yes No Unsure Not Checked Can Not Seem to Get Enough Air Quest:  SURV-09-69 Yes No Unsure Not Checked Bruise Easily Quest:  SURV-09-70 Yes No Unsure Not Checked Cold Sensitive Quest:  SURV-09-71 Yes No Unsure Not Checked Heat Sensitive Quest:  SURV-09-72 Yes No Unsure Not Checked Hot Flashes Quest:  SURV-09-73 Yes No Unsure Not Checked High Blood Pressure Quest:  SURV-09-74 Yes No Unsure Not Checked Low Blood Pressure Quest:  SURV-09-75 Yes No Unsure Not Checked Dizziness When Laying Down Quest:  SURV-09-76 Yes No Unsure Not Checked Hit With Unexpected Dizziness Quest:  SURV-09-77 Yes No Unsure Not Checked Abnormal Change in Blood Counts Quest:  SURV-09-78 Yes No Unsure Not Checked Red Blood Cell count in comparison to prewar are: Quest:  SURV-09-79 Elevated Decreased Unsure Not Checked White Blood Cell count in comparison to prewar are: Quest:  SURV-09-80 Elevated Decreased Unsure Not Checked Abnormal Hormone Levels Quest:  SURV-09-81 Yes No Unsure Not Checked Abnormal Liver Values Quest:  SURV-09-82 Yes No Unsure Not Checked Abnormal Kidney Values Quest:  SURV-09-83 Yes No Unsure Not Checked Increase in Cholesterol Values Quest:  SURV-09-84 Yes No Unsure Not Checked Abnormal Neurological Diagnostic Tests Quest:  SURV-09-85 Yes No Unsure Not Checked After deployment to desert did you have sand particles coming out of your nose? Quest:  SURV-09-86 Yes No Unsure Not Checked After deployment to desert did you notice sand particles in your sputum or productive cough? Quest:  SURV-09-87 Yes No Unsure Not Checked After deployment to desert did you notice sand particles when cleaning your ears? Quest:  SURV-09-88 Yes No Unsure Not Checked After deployment to desert did you noticed dry and irritated eyes? Quest:  SURV-09-89 Yes No Unsure Not Checked We would appreciate your completing all of the following but only those with (Required) must be filled in. 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: *Select State* Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming APO/FPO AA APO/FPO AE APO/FPO AP    Country: * Select Country * Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua Argentina Armenia Aruba Australia Austria Azerbaijan Azores Bahamas Bahrain Bangladesh Barbados Barbuda Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire Bosnia-Herzegovina Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burma Burundi Caicos Islands Cambodia Cameroon Canada Canary Islands Cape Verde Islands Cayman Islands Central African Republic Ceylon Chad Channel Islands Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Corsica Costa Rica Cote d'Ivoire (Ivory Coast) Crete Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador England Equitorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Falkland Islands Federated States of Micronesia Fiji Finland Formosa (Taiwan) France French Guiana French Polynesia Futuna Islands Gabon Gambia Georgia Germany Ghana Gibraltar Great Britain Greece Greenland Grenada Grenadines Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Holland Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland, Republic of Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea (North) Korea (South) Kosrae, Micronesia Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Maderia Islands Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Miquelon Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands Netherlands Antilles Nevis New Caledonia New Zealand Nicaragua Niger Nigeria Niue (New Zealand) Norfolk Island Northern Ireland Northern Mariana Islands Norway Okinawa Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Portugal Puerto Rico Qatar Reunion Romania Rota Russia Rwanda Saba Saint Barthelemy Saint Christopher Saint Croix Saint Eustatius Saint John Saint Kitts Saint Lucia Saint Maarten Saint Martin Saint Pierre Saint Thomas Saint Vincent Saipan San Marino Sao Tome Saudi Arabia Scotland Senegal Seychelles Siam (Thailand) Sierra Leone Singapore Slovak Republic (Slovakia) Slovenia Solomon Islands Somalia Somaliland (Somalia) South Africa South Georgia South Korea Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syrian Arab Republic Tahiti Taiwan Tajikistan Tanzania Thailand Tibet (China) Tinian Tobago Togo Tokelau Tonga Tortola Trinidad Truk Tunisia Turkey Turkmenistan Turks Islands Tuvalu Uganda Ukraine Union Island United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City State Venezuela Vietnam Virgin Gorda Virgin Islands (British) Virgin Islands (US) Wake Island Wales Wallis Islands Western Sahara Western Samoa Yap Yemen Yugoslavia Zaire Zambia Zanzibar (Tanzania) Zimbabwe Day Telephone:    (Optional) Evening Telephone:    (Optional) I am completing this survey as a: Active Combat Veteran Active Duty Military Retired Veteran Disabled Veteran Reservist National Guard Friend or Associate Concerned Citizen Civilian Contractor Active Duty Spouse Retired Duty Spouse Disabled Duty Spouse Deceased Veterans' Spouse Inactive Duty Spouse Active Duty Child Retired Duty Child Disabled Duty Child Inactive Duty Child Deceased Veterans' Child    Combat Year:  None 1950's 1960's 1970's 1980's 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007   (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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