Form 10-0048 Former POW Medical History

OMB No. 2900-0427
Average Burden: 90 Minutes

Former POW Medical History
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction
Act of 1995. The public reporting burden for this collection of information is estimated to average 90 minutes per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Respondents should be aware that notwithstanding any other provision of law, no
person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. This is intended to provide your
physician with a detailed history and physical for use during a physical examination. You are not required to answer these questions. Failure to provide the data will have no adverse effect on
benefits to which you might otherwise be entitled.

PLEASE TYPE OR PRINT YOUR ANSWERS IN INK. DO NOT COMPLETE SHADED AREAS. WHEN YOU NEED MORE SPACE, CONTINUE
YOUR REMARKS ON A BLANK SHEET OF PAPER.

2. SOCIAL SECURITY NO.

SECTION A. IDENTIFYING DATA

(This is a mandatory field.)

1. NAME (Last, First, Middle)

(mandatory)

1a. ADDRESS (Street, City, State, Zip Code)

3. VA CLAIM NUMBER

4. AGE
B. ON CAPTURE

A. PRESENT

C. ON REPATRIATION D. ON DISCHARGE

5. ACTIVE MILITARY SERVICE (Check all that apply)
ARMY
NAVY
MARINE CORPS

AIR FORCE

COAST GUARD

OTHER (Specify)
6. DATE OF INDUCTION INTO
ACTIVE MILITARY SERVICE

7. DATE OF MILITARY DISCHARGE

9. LAST MILITARY IDENTIFICATION NUMBER

8. SPECIFY TYPE OF MILITARY
DISCHARGE

(mm/dd/yyyy)
10. COMPLETE
EACH BLOCK

RANK/GRADE

BRANCH OF
SERVICE

11. MARITAL STATUS

(Check appropriate categories)

A. AT TIME OF
INDUCTION
B. AT TIME OF CAPTURE

A. AT TIME OF INDUCTION

C. AT TIME OF
REPATRIATION

B. AT TIME OF CAPTURE

D. AT TIME OF
MILITARY DISCHARGE

C. AT TIME OF REPATRIATION

12. NAME(S) OF COUNTRY(IES) IN WHICH YOU WERE A
PRISONER

D. AT PRESENT

13. PRISONER OF WAR CATEGORY (Check all that apply)
WWI

WWII (Europe)

VIETNAM

OTHER (Specify)

WWII (Pacific)

CHINA, BURMA, INDIA

PACIFIC

SOUTHEAST ASIA

OTHER (Specify)

SECTION B. HISTORY OF CAPTIVITY

16. WERE YOU CAPTURED ALONE

17C. DID THE GROUP REMAIN
INTACT DURING CAPTIVITY

17D. HOW MANY OF YOUR ORIGINAL
GROUP SURVIVED CAPTIVITY

YES

NO

17A. WERE YOU CAPTURED IN A
GROUP
YES
NO
IN A BATTLE

DURING AN
ADVANCE
19A. WERE YOU INJURED DURING CAPTURE
ORDERED TO
(If yes, described how you were injured)
SURRENDER BY
A HIGHER US OR
YES
NO
ALLIED AUTHORITY
19B. DESCRIBE YOUR INJURY(IES) (If you do not have enough space, continue in item 62.)

20. WHAT TYPE OF WORK DID YOU DO IN CAPTIVITY (Check all that apply)
NONE

FARM

CONSTRUCTION

MINE

DOCK

FACTORY

VA FORM
JUN 2006 (R)

10-0048

Separated

Widowed

KOREA

EUROPE

17B. IF SO, HOW LARGE WAS THE GROUP

DURING ISOLATION OF
YOUR UNIT
DURING A RETREAT

DURING ISOLATION
FROM YOUR UNIT
AIRCRAFT WAS SHOT DOWN

OTHER (Specify)

SHIP WAS CAPTURED/SUNK

21A. DID YOU PARTICIPATE IN A
PLAN TO ESCAPE
YES

NO

21C. IF SO, WERE YOU SUCCESSFUL
YES

23. NAME(S) OF PRISON(S) (Check here if you do not know)

Divorced

18. CIRCUMSTANCES OF CAPTURE (Check all that apply)

NO

OTHER (Specify)

Married

14. THEATER(S) IN WHICH YOU PARTICIPATED (Check all that apply)
KOREAN

15. APPROXIMATE DATE OF
CAPTURE
(mm/dd/yyyy)

YES

Single

21B. DID YOU MAKE AN ACTIVE ATTEMPT TO
ESCAPE
YES

NO

22. LENGTH OF CAPTIVITY IN MONTHS

NO

24. LOCATION(S) OF PRISON(S) (Check here if you do not know)

EXISTING STOCK OF VA FORM 10-0048, AUG 2003, MAY BE USED

PAGE 1

25. EXPERIENCES DURING
CAPTURE

YES

NO. OF
TIMES

NO

NO. OF
DAYS

A. INTIMIDATION

YES

26. ISOLATION IN CLOSE QUARTERS

NO. OF
TIMES

NO

NO. OF
DAYS

A. PRISON SHIPS
IF YOU WERE ON A PRISON SHIP, WAS
IT ATTACKED

B. BEATlNGS

B. RAILROAD CARS

C. WITNESSED BEATINGS

IF YOU WERE HELD IN A RAILROAD
CAR, WAS IT ATTACKED

D. PHYSICAL TORTURE
E. WITNESSED PHYSICAL
TORTURE

C. SOLITARY CONFINEMENT

F. PSYCHOLOGICAL TORTURE
(Brain Washing)

D. OTHER (Specify)

27. WERE ATTEMPTS MADE TO USE
YOU FOR PROPAGANDA PURPOSES
YES

29.WOUNDS AND INJURIES DURING CAPTIVITY (Check all that apply)

28. WOULD YOU BE WILLING TO DISCUSS WITH
THE INTERVIEWING MEDICAL EXAMINER YOUR
RELATIONSHIP WITH YOUR FELLOW POW'S

NO

YES

NO

NONE

HEAD

CHEST

ABDOMEN

BACK

ARMS

LEGS

OTHER (Specify)

30. I AM UNABLE TO FUNCTION OR WORK BECAUSE OF PSYCHOLOGICAL OR EMOTIONAL STRESS

31A. DID YOU EXPERIENCE

YES

NO

A. PROLONGED PERIODS OF FEAR AND ANXIETY

31B. DID YOU EXPERIENCE

B. THOUGHTS OF SUICIDE

D. LONELINESS AND ISOLATION FROM OTHER
POW'S

C. ATTEMPTS AT SUICIDE

E. PERIODS OF NIGHTMARES, CONFUSION,
OR DELIRIUM DURING CAPTIVITY

D. OTHER (Specify)

33. EXPOSURE TO
HEAT
BEFORE
IN
CAPTURE CAPTIVITY (Check those you
experienced.)

A. NONE

A. NONE

B. FROSTBITE

B. HEAT
EXHAUSTION

C. TRENCHFOOT

C. LOSS OF
CONSCIOUSNESS

E. IMMERSION IN
COLD WATER

YES

(If yes, please explain)

NO. OF
TIMES

NO

NO. OF
DAYS

A. FORCED MARCHES

C. PROLONGED PERIODS OF FEELINGS OF
HELPLESSNESS

D. IMMERSION FOOT
OR HAND

NO

WERE YOUR FORCED MARCHES ATTACKED

B. PROLONGED PERIODS OF DEPRESSION

32. EXPOSURE TO
COLD (Check those
you experienced)

YES

INDICATE NO. OF
TIMES PER DAY

IN
BEFORE
CAPTURE CAPTIVITY

34. RADIATION EXPOSURE (Explain specifically)

35. COMMUNICATIONS

CHECK ONE

A. DID YOU RECEIVE NEWS FROM HOME
B. HOW OFTEN
C. WAS THIS SIGNIFICANT

D. OTHER (Specify)

F. OTHER (Specify)

NO

YES

RARELY

OCCASIONALLY

NO

YES

36. DIETARY HISTORY Estimate weight in pounds
ON ENTERING
SERVICE

LOWEST WEIGHT IN
CAPTIVITY

PRESENT

37. IF YOU WISH, BRIEFLY DESCRIBE ONE OF YOUR WORST EXPERIENCES AS A CAPTIVE

VA FORM
JUN 2006 (R)

10-0048

PAGE 2

38. ADEQUACY OF DIET DURING CAPTIVITY (Check appropriate box for each category)
AVERAGE DAILY DIET

INADEQUATE

NONE

ADEQUATE

NONE

AVERAGE DAILY DIET

A. WATER

H. DAIRY PRODUCTS

B. BROTH

I. MEAT

C. SOUP WITH PIECES OF FISH, MEAT, OR POULTRY

J. NUTS

D. BREAD

K. FISH

E. LEGUMES (Peas/Beans)

L. FRUITS

F. RICE

M. VEGETABLES

G. POTATOES

N. MILLET (Small seeded cereals and
grasses)

INADEQUATE

ADEQUATE

OTHER (Specify)
39. SPECIFIC DISEASES ACQUIRED DURING CAPTIVITY (Check appropriate box for each category)
DISEASE

YES

NO

DISEASE

YES

NO

DISEASE

YES

NO

DISEASE

DYSENTERY

TUBERCULOSIS

SKIN DISEASE

BERIBERI

MALARIA

WORMS

VITAMIN DEFICIENCY

DIPHTHERIA

PNEUMONIA

SCABIES

PELLAGRA

YES

NO

YES

NO

OTHER (Specify)

40. DID YOU EXPERIENCE ANY OF THE FOLLOWING DURING CAPTIVITY (Check appropriate box for each category)
YES

NO

YES

NO

YES

NO

CHEST PAINS

CAVITIES

SUNBURN

FEVER

RAPID HEART BEATS

TOOTH ABSCESS

SKIN ULCERS

FREQUENT URINATION

SKIPPED OR MISSED
HEART BEATS

LOSS OF TEETH

BOILS

BLOODY URINE

IMPAIRED VISION

SORES AT THE ANGLES
OF THE MOUTH

PALE SKIN

KIDNEY STONE

POOR NIGHT VISION

SORE TONGUE

BREAST LUMPS

UNSTEADY GAIT

PARTIAL BLINDNESS

EXCESSIVE THIRST

NAUSEA

SWELLING IN THE
JOINTS

EYE ULCERS

SWOLLEN GLANDS

VOMITING

SWELLING OF THE
LEGS AND/OR FEET

HEARING DISORDER

SKIN RASHES

DIARRHEA

SWELLING OF THE
MUSCLES

BLEEDING GUMS

BLISTERS

EPISODE(S) OF JAUNDICE

BROKEN BONES

TOOTHACHE

DRY SCALY SKIN

CHILLS

BURNS

NUMBNESS, TINGLING, OR
PAIN IN THE FINGERS OR
FEET (EIectric/Burning Foot)

NUMBNESS OR WEAKNESS
IN THE ARMS OR LEGS

ACHES OR PAINS IN THE
MUSCLES AND/OR JOINTS

PSYCHOLOGICAL OR
EMOTIONAL
PROBLEMS

41. AVAILABILITY OF MEDICAL TREATMENT
DURING CAPTIVITY
A. MEDICAL TREATMENT WAS ADEQUATE

YES

NO

(lF YES, QUALITY)
GOOD FAIR

POOR

42. OPERATIONS PERFORMED DURING YOUR PERIOD OF CAPTIVITY
NONE
AMPUTATIONS ONLY (Specify)

B. SURGICAL TREATMENT WAS ADEQUATE
OTHER (Specify)
C. DENTAL TREATMENT WAS ADEQUATE
VA FORM
JUN 2006 (R)

10-0048

PAGE 3

SECTION C. HISTORY OF RELEASE FROM CAPTIVITY AND REPATRIATION
43. APPROXIMATE DATE
YOUR CAPTORS LOST
CONTROL

45. BRIEFLY DESCRIBE THE CONDITIONS OF YOUR RELEASE AND RESCUE

44. APPROXIMATE DATE
YOU WERE RETURNED TO
FRIENDLY CONTROL

46. IN YOUR OPINION, HOW THOROUGH WERE THE REPATRIATION EXAMINATIONS 47. DID US AUTHORITIES BRIEF YOU ON
(Including medical and psychological debriefing and counseling)
EVENTS WHICH OCCURRED WHILE YOU
WERE IN CAPTIVITY
GOOD
FAIR
INADEQUATE
NONE
YES
NO
49A. DID THE VA GIVE YOU
A DISABILITY RATING
AFTER REPATRIATION
YES
NO

49C. WHAT WAS THE DISABILITY

49B. IF YES, WHAT WAS
THE PERCENTAGE

50B. IF YES, DID YOU RECEIVE A DENTAL RATING

50A. DID YOU EVER APPLY TO THE VA FOR DENTAL
CARE BENEFITS BASED ON YOUR FORMER POW STATUS
YES

NO

YES

50C. WHAT WAS THE RATING

NO

51. DO YOU FEEL THAT YOU WERE PROMOTED TO THE RANK YOU WOULD HAVE
BEEN/ SHOULD HAVE BEEN IF YOU HAD NOT BEEN CAPTURED
YES

48. WERE YOU SATISFIED WITH
THE WAY YOU WERE TREATED
ON REPATRIATION
YES
NO

NO

52. DID YOU RECEIVE THE MEDALS YOU BELIEVE YOU DESERVED
YES

NO

SECTION D. ADJUSTMENT TO POST WAR LIFE
53A. DID YOU CONTINUE MILITARY 53B. IF YES, HOW MANY ADDITIONAL YEARS
SERVICE AFTER REPATRIATION
DID YOU SERVE
YES

NO

54A. DID YOU PERFORM RESERVE 54B. IF YES, HOW MANY YEARS DID YOU
DUTY
SERVE
YES

NO

55A. DID YOU ATTEND SCHOOL
AFTER RELEASE FROM ACTIVE
DUTY
YES
NO

55B. WHAT WAS YOUR HIGHEST EDUCATIONAL 55C. NUMBER OF YEARS YOU
ATTAINMENT
ATTENDED SCHOOL

56B. WAS THIS THE FIRST
CIVILIAN SECTOR JOB YOU EVER
HAD

57A. DID YOU RETURN TO THE SAME JOB YOU
HELD BEFORE ENTERING THE MILITARY

YES

NO

YES

57B. HOW MANY YEARS HAVE
58A. HOW MANY DIFFERENT JOBS HAVE
YOU WORKED SINCE DISCHARGE YOU HELD SINCE REPATRIATION
FROM THE MILITARY

NO

58B. WHAT WAS THE LONGEST
59. DID YOU FIND IT DIFFICULT TO ADJUST TO
PERIOD OF CONTINUOUS EMPLOY- CIVILIAN LIFE
MENT SINCE REPATRIATION
YES

56A. HOW SOON AFTER DISCHARGE DID
YOU ENTER CIVILIAN EMPLOYMENT

NO

60B. BRIEFLY DESCRIBE YOUR PRESENT STATE OF HEALTH

60A. HOW WOULD YOU DESCRIBE YOUR PRESENT STATE OF HEALTH
EXCELLENT

GOOD

FAIR

POOR

61. DESPITE THE MANY NEGATIVE ASPECTS OF YOUR POW STATUS, WERE
THERE ANY POSITIVE ASPECTS TO YOUR EXPERIENCE
(If Yes, Please Specify)
YES
NO

62. PLEASE ADD ANY ADDITIONAL COMMENTS YOU WISH TO MAKE

63. SIGNATURE

64. DATE
(mm/dd/yyyy)

VA FORM
JUN 2006 (R)

10-0048

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