Health Surveillance For A New Generation Of U.s. Veterans
Health Surveillance for a New Generation of U.S. Veterans
Questionnaire
HEALTH SURVEILLANCE FOR A NEW GENERATION OF U.S. VETERANS
OMB: 2900-0722
OMB Number 2900-XXXX
Estimated burden: 30-45 minutes
Health Surveillance for a New Generation of U.S. Veterans
Questionnaire
Sponsored by
U.S. Department of Veterans Affairs
PRIVACY ACT STATEMENT
The information requested on this survey is solicited under authority of 38 U.S.C. Section 7303. It is being collected to assist VA in learning more about the health of recent veterans and will help VA to provide better medical care. The information you supply will be confidential and protected by the provisions of the Privacy Act of 1974 (5 U.S.C. 552a) and specifically the VA system of records entitled 34VA12, “Veteran, Patient, Employee and Volunteer Research and Development Project Records – VA.” Releases of the information may only be made with your consent or as identified in a “routine use” of the system of records. Routine uses include releases of statistical data and non-identifying data for research and associated administrative purposes. Disclosure is voluntary; failure to furnish the requested information will have no adverse effect on any VA benefit to which you may be entitled.
PAPERWORK REDUCTION ACT INFORMATION: This information is collected in accordance with the clearance requirements of section 3507 of the Paperwork Reduction Act of 1995. Accordingly, VA may not conduct or sponsor, and you are not required to respond to, a collection of information unless it displays a valid OMB control number. VA anticipates that the time expended by all individuals who complete this survey will average 30-45 minutes. This includes the time it will take to read instructions, gather the necessary facts, and fill out the survey. The information requested on this survey will be used to help VA assess the health status of veterans and plan health care services. A response to this survey is voluntary.
HEALTH SURVEILLANCE FOR A NEW GENERATION OF U.S. VETERANS
1. Please check all locations in which you served in the past 5 years prior to separation from active
duty:
O Afghanistan O SW Asia - Other O North America
O Iraq O Bosnia/Kosovo O Central America
O Kuwait O Europe O South America
O Qatar O Africa O On a ship
O Turkey O Other ________________________________
2. Please check your total number of deployments in the past 5 years prior to separation from active
duty:
Operation Iraqi Operation Enduring
Freedom Freedom Other ___________________________________________
O 1 O 1 O 1 Name of operation of your most recent deployment
O 2 O 2 O 2
O 3 O 3 O 3
O 4 O 4 O 4
O 5 or more O 5 or more O 5 or more
3. In what component(s) have you served? (Check all that apply.)
O Active Duty
O Reserve
O National Guard
4. What branch(es) did you serve with? (Check all that apply.)
O Air Force
O Army
O Coast Guard
O Marine Corps
O Navy
5. What was your most recent job in the military?________________________________________
6a. Did you serve in Afghanistan or neighboring countries in support of Operation Enduring
Freedom or in Iraq or elsewhere in the Persian Gulf in support of Operation Iraqi Freedom?
O No IF NO, continue to question #7.
O Yes
6b. IF YES, what was your period of last deployment:
From ____/____/____ to ____/____/____
Month Day Year Month Day Year
7. What were you doing most of the past 12 months?
O Working outside the home
O Looking for work and unemployed
O On active duty
O Student
O Homemaker/Caring for family
O Retired
O On disability/Unable to work
O Own small business
O Other(Please specify:___________)
8. Have you received a letter from the VA secretary or other VA office informing you of programs
and benefits that you may be entitled to through VA?
O
No O
Yes O
Don’t remember
9. Do you belong to a Veterans Group(s) such as Veterans of Foreign Wars of the Untied States (VFW)
or The American Legion?
O No O Yes
IF YES, which one(s)?
_____________________________________________________________________
10a. During the past 12 months how many clinic or doctor visits have you made because you had a
health problem? (exclude routine visits for vaccinations, physical examinations, etc.)
O None No. of visits 10b. Please explain reasons for visit or diagnoses.
________ 1.______________________________________
2.______________________________________
3.______________________________________
4.______________________________________
11a. During the past 12 months how many times have you been hospitalized overnight or longer?
O None No. of hospitalizations 11b. Please explain reasons for hospitalization or diagnoses.
________ 1.______________________________________
2.______________________________________
3.______________________________________
4.______________________________________
12. What health care coverage do you have (check all that apply):
O Department of Defense’s TRICARE
O Private insurance
O Medicaid
O Other individual or group plan
O VA
O Medicare
O None
13a. Have you used VA health care services since you were separated from active duty?
O No O Yes IF YES, continue to question #14.
13b. IF NO, why? (Answer and then skip to question #16.)
O I prefer to use other health care coverage
O I do not wish to use VA health care services because of concerns
about quality of care
O I do not know if I am eligible
O VA health care services are not in a convenient location for me
O Other (Please specify: ___________________________________)
14. What are the main reasons you enrolled? (Check all that apply.)
O To obtain regular or routine health care;
O To obtain specialist healthcare;
O To obtain dental care;
O To obtain prescription medications, eye glasses, hearing aids, or other devices;
O To obtain mental health care;
O To obtain special emphasis care such as for a spinal cord injury, traumatic brain injury, blind
rehabilitation, prosthetics, etc.;
O To receive nursing home care;
O To obtain home health care
15. All things considered, how satisfied are you with your health care in VA?
O Completely satisfied
O Very satisfied
O Somewhat satisfied
O Neither satisfied nor dissatisfied
O Somewhat dissatisfied
O Very dissatisfied
O Completely dissatisfied
16. About how tall are you without shoes? ______(feet) ______(inches)
17. About how much do you weigh without shoes? ______ (pounds)
*If currently pregnant, please give your usual weight before becoming pregnant
18. In general, would you say your health is:
O Excellent O Very good O Good O Fair O Poor
-
19a. Has your doctor ever told you that you
have any of the following conditions?
NO YES
19b. If yes, in what year
were you first diagnosed?
YEAR
1.
Arthritis of any kind
__________
2.
Skin cancer
__________
3.
Any other cancer(specify type:________________________)
__________
4.
Cirrhosis of the liver
__________
5.
Hepatitis
__________
6.
Any other liver trouble
__________
7.
Irritable bowel syndromeor colitis (irritation of the colon)
__________
8.
Diabetes
__________
9.
Repeated seizures,convulsions, or blackouts
__________
-
19a. Has your doctor ever told you that you
have any of the following conditions?
NO YES
19b. If yes, in what year
were you first diagnosed?
Year
10. Migraines
__________
11.
Coronary heart disease
or artery disease
__________
12.
Hypertension
__________
13.
Stroke
__________
14.
Sinusitis
__________
15.
Bronchitis__________
16.
Asthma
__________
17.
Frequent bladder
infections
__________
18.
Significant hearing loss
__________
19.
Multiple sclerosis
__________
20.
Chronic Fatigue Syndrome
__________
21.
Posttraumatic Stress
Disorder
__________
22.
Depression
__________
23.
Sleep apnea
__________
24.
Traumatic Brain Injury
__________
20a. Did you experience any of the following events while serving in the military?
(Check all that apply.) 20b. Number
of times
O Blast or Explosion (IEF, RPG, Land Mine, Grenade, etc.) ____
O Motor vehicle, aircraft, or water transportation accident ____
O Fragment wound or bullet wound above the shoulders ____
O Fall ____
O Injury from sports/physical training ____
O Other injury (Please specify: _______________________) ____
O No, none of the above (Skip to question #24)
21. Did you have any of these IMMEDIATELY afterwards?
(Check all that apply.)
O Losing consciousness/ “knocked out” IF YES: About how long were you unconscious? ___ min.
O Being dazed, confused, or “seeing stars”
O Not remembering the event
O Concussion
O Head injury
O No, none of the above (Skip to question #24)
22. Did any of the following problems begin or get worse afterwards?
(Check all that apply.)
O Memory problems or lapses
O Balance problems or dizziness
O Sensitivity to bright light
O Irritability
O Headaches
O Sleep problems
O Hearing problems
O Other problems (Please specify:________________________)
O No, none of the above (Skip to question #24)
23. In the past week, have you had any of the following symptoms?
(Check all that apply.)
O Memory problems or lapses
O Balance problems or dizziness
O Sensitivity to bright light
O Irritability
O Headaches
O Sleep problems
O Trouble concentrating
O Hearing problems
O None of the above
24a. Has your doctor ever told you that you had a head injury?
O No O Yes (IF NO, continue to question #25)
24b. Have you received treatment from a doctor or other health professional for a head injury?
O No O Yes (IF NO, continue to question # 25)
24c. Has this treatment been helpful?
O No O Yes
24d. Were you prescribed medicine?
O No O Yes (Please specify:________________________________)
25. This question contains a list of comments made by people after stressful life events. Please read each item and mark how frequently these comments were true for you DURING THE PAST 4 WEEKS. If it did not occur during the past 4 weeks, please mark the “not at all” column.
25. In the past 4 weeks, have you had … ? NOT A LITTLE QUITE AT ALL BIT MODERATELY A BIT EXTREMELY |
stressful experiences from the past. |
stressful experiences from the past. |
experiences were happening again. |
happened that reminds you of stressful experiences from the past. |
of stressful experiences from the past. |
used to enjoy. |
people. |
unable to have loving feelings for those close to you. |
9. Feeling as if your future will
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asleep. |
outbursts. |
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or on guard. |
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15. Having physical reactions when experiences from the past. |
experiences from the past, or avoid having feelings about them. |
they remind you of stressful experiences from the past. |
26. If you have any of the symptoms listed above, do you think they are related to your military
experiences, other traumatic events in your life, or both?
O Military experiences only
O Other traumatic life events only
O Both
O Don’t know
27. Over the past 4 weeks, how often have you been bothered by any of the following problems?
|
Not at all |
Several days |
More than half the days |
1. Feeling nervous, anxious, on edge, or worrying a lot about different things If you checked “Not at all”, go to question #28. |
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2. Feeling restless so that it is hard to sit still
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3. Getting tired very easily
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4. Muscle tension, aches, or soreness
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5. Trouble falling asleep or staying asleep
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6. Trouble concentrating on things, such as reading a book or watching TV |
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7. Becoming easily annoyed or irritable
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28. Over the past 2 weeks, how often have you been bothered by any of the following problems? |
Not at all |
Several days |
More than half the days |
Nearly every day |
1. Little interest or pleasure in doing things
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2. Feeling down, depressed, or hopeless
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3.
T much |
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4. Feeling tired or having little energy
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5. Poor appetite or overeating
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6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down |
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7.
T the newspaper or watching television |
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8. Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual |
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9. Thoughts that you would be better off dead or of hurting yourself in some way |
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29. Have you taken a prescribed medication for a physical or psychological/emotional condition in the
past year?
O No O Yes
IF YES, specify name(s) of medication(s)
______________________________________________
______________________________________________
______________________________________________
______________________________________________
30. Since return from your deployment, have you had serious conflicts with your spouse, family
members, or close friends that continue to cause you worry or concern?
O No O Yes O Unsure
31. How often do you get into arguments with others at work?
O Very Often O Often O Sometimes O Rarely O Never
32. The following questions are about activities you might do during a typical day. Does
your health now limit you in these activities? If so, how much?
-
Yes, limited a lot
Yes, limited a little
No, not limited at all
a. Moderate activities, such as moving a table,
pushing a vacuum cleaner, bowling, or
playing golf
b. Climbing several flights of stairs
33. During the past 4 weeks, how much of the time have you had any of the following
problems with your work or other regular daily activities as a result of your physical
health?
-
All of the time
Most of the time
Some of the time
A little of the time
None of the time
a. Accomplished less than you
would like
b. Were limited in the kind of
work or other activities
34. During the past 4 weeks, how much of the time have you had any of the following
problems with your work or other regular daily activities as a result of any emotional
problems (such as feeling depressed or anxious)?
-
All of the time
Most of the time
Some of the time
A little of the time
None of the time
a. Accomplished less than you
would like
b. Did work or other activities
less carefully than usual
35. These questions are about how you feel and how things have been with you during the
past 4 weeks. For each question, please give the one answer that comes closest to the
way you have been feeling. How much of the time during the past 4 weeks…
-
All of the time
Most of the time
Some of the time
A little of the time
None of the time
a. have you felt calm and
peaceful?
b. did you have a lot of
energy?
c. have you felt downhearted
and depressed?
36. During the past 4 weeks, how much of the time has your physical health or emotional
problems interfered with your social activities (like visiting friends, relatives, etc.)?
O All of the O Most of the O Some of the O A little of O None of the
time time time the time time
37. While you were deployed, do you believe you were
exposed to or did you experience any of the following? No Yes
1. Dust and sand O O
2. Burning trash/feces O O
3. Diesel, kerosene and/or other petrochemical fumes O O
4. Skin exposure to JP8, diesel, or other petrochemical fuel O O
5. Smoke from oil fires O O
6. Solvents or degreasers O O
7. Paint operations (vehicles or equipment) O O
8. Insect repellant (spray, lotion, or cream applied to your skin) O O
9. Pesticide-treated uniforms O O
10. Depleted uranium (DU) (handling DU munitions) O O
11. Ate local food other than provided by Armed Forces O O
12. Contact with Prisoners of War (POWs) O O
13. Exposure to Loud Noises O O
14. Radiation O O
15. Industrial pollution O O
16. Other exposure which you consider harmful O O
(Please describe.) ________________________________________________________
38. During any of your deployments, were you wounded or injured by hostile actions?
O No O Yes
39. Did you see anyone wounded, killed or dead during any deployment? (Check all that apply.)
O No O Yes – coalition O Yes – enemy O Yes- civilian
40. Were you engaged in direct combat where you discharged your weapon?
O No O Yes (O land O sea O air)
41. During any of your deployments, did you ever feel that you were in great danger of being killed?
O No O Yes
42. When you were in the military, did you ever receive uninvited or unwanted sexual attention (i.e.,
touching, cornering, pressure for sexual favors, or inappropriate verbal remarks, etc…)?
O No O Yes
43. When you were in the military, did anyone ever use force or the threat of force to have sex with you
against your will?
O No O Yes
44. Did you ever contract a sexually transmitted disease as a result of military sexual trauma?
O No O Yes
45. Did you receive any of the following vaccinations just before or during deployment?
No Yes
1. Smallpox (leaves a scar on the arm) O O
2. Anthrax series O O
3. Rabies O O
46a. Did you take medications to prevent malaria?
O No O Yes
46b. If YES, please indicate which medicines you took and whether you took them as directed.
(Mark all that apply)
Anti-malarial medications Took as Directed
O Chloroquine (Aralen®) O No O Yes
O Doxycycline (Vibramycin®) O No O Yes
O Mefloquine (Larium®) O No O Yes
O Primaquine O No O Yes
O Other:_________________________ O No O Yes
47a. Have you smoked cigarettes in the past 12 months?
O No O Yes IF
YES, 47b. How many cigarettes do you smoke per day? _______
47c. How old were you when you first started
smoking? _______
(AGE)
IF NO, 47d. Have you ever smoked cigarettes even occasionally?
O
No O Yes IF YES, 47e.
When did you last stop? ________
(YEAR)
48. How often do you have a drink containing alcohol?
O Never O Monthly or O 2 to 4 times O 2 to 3 times O 4 or more
less a month a week times a week
49. How many drinks containing alcohol do you have on a typical day when you are drinking?
O 1 or 2 O 3 or 4 O 5 or 6 O 7 to 9 O 10 or more
50. How often do you have 5 or more drinks on one occasion?
O Never O Less than monthly O Monthly O Weekly O Daily or almost daily
-
51. Have any of the following happened to you more than once in
the past 6 months?
NO
YES
1. You drank alcohol even though a doctor suggested that you
stop drinking because of a problem with your health
2. You drank alcohol, were high from alcohol, or hung over
while you were working, going to school, or taking care of
children or other responsibilities
3. You missed or were late for work, school, or other activities
because you were drinking or hung over
4. You had a problem getting along with other people while you
were drinking
5. You drove a car after having several drinks or after drinking
too much
52. How often do you use seat belts when you drive or ride in a car?
O Always O Nearly always O Sometimes O Seldom O Never
O Don’t know / Not sure O Never drive or ride in a car
53. During the past 4 weeks, how many times did you ride with a driver who had perhaps too much
to drink?
____ Number of times
O None
O Don’t know / Not sure
54. Do you ride a motorcycle?
O No O Yes
55. Do you usually drive:
O 20 miles per hour or more over the speed limit
O about 15 miles per hour over the speed limit
O about 10 miles per hour over the speed limit
O about 5 miles per hour over the speed limit
O at or below the speed limit.
56. Have you been in a vehicle crash while in the United States during the past 3 years?
O No
O Yes
O Don't know
57. For Operation Iraqi Freedom/Operation Enduring Freedom veterans: If you answered yes to the previous question, did any of these crashes occur after you came back from deployment?
O No O Yes
How many?________________________________
58. Were you driving or was someone else driving during your most recent crash?
O I was driving
O Someone else
-
59. Within the past 3 years, have you:
NO
YES
1. Gotten a ticket for speeding
2. Gotten a warning for speeding
3. Gotten a ticket for any other moving violation (such as running a
red light or stop sign)
4. Been convicted of DWI or DUI
5. Had your car insurance canceled or premiums increased as a
result of claims or points
60. Not including blood donations, in what month and year was your last HIV test?
____(Month)______(Year)
O Don't know or Not sure
O Never tested
61. During the past 12 months, how many people have you had sex with?
O None
O One
O More than one (give number________)
62. Have you been treated for a sexually transmitted disease or venereal disease in the past 12 months
(for example, gonorrhea, syphilis, herpes, chlamydia, etc.)?
O No
O Yes
63a. In the past 12 months, have you had sex with someone who is not your main partner or whom you
do not consider to be your main partner?
O No
O Yes
63b. If "Yes," thinking back to the last time you had sex with that person, was a condom
used?
O No
O Yes
64. Have you ever tried for a period of 12 months or longer for you or your partner to become
pregnant?
O No (Skip to question #67)
O Yes (Continue with question #65)
65a. Did you or your partner eventually get pregnant or did you stop trying?
O Got pregnant O Stopped trying
65b. Did your partner with the pregnancy serve in Operation Iraqi Freedom or Operation Enduring
Freedom?
O No O Yes
65c. Did you seek any medical help while trying?
O No (Skip to question #67)
O Yes (Continue with question #66)
66. Did the medical provider find any of the following reasons to explain why you or your partner were
having difficulty getting pregnant?
O Problems with ovulation
O Blocked tubes
O Endometriosis
O Semen or sperm problems
O Other (Please specify.)________________________________________________
O No reason found
67a. FOR WOMEN: Have you ever been pregnant?
O No (Skip to question #69)
O Yes (Continue with question #68)
67b. FOR MEN: Have you ever been the biological father in any pregnancy, regardless of whether
there was a live birth outcome from that pregnancy?
O No (Skip to question #69)
O Yes (Continue with question #68)
68) Please provide information on all of your or your partner’s(s’) pregnancies. For multiple birth outcomes, make a separate entry for each (e.g., 2 entries for twins). If you are uncertain about a detail, please provide your best estimate:
Pregnancy |
Outcome |
Date of Pregnancy Outcome |
Birth Weight (If live birth) |
Length of pregnancy |
Birth Defects |
Medical Conditions and Health Habits During Pregnancy |
Did your partner serve in OIF or OEF? |
1 |
O Single Live Birth O Multiple births (please fill out one row for each) O Miscarriage O Abortion O Stillbirth O Ectopic or tubal O Molar pregnancy O Other: ________
|
___/___/_____ MM DD Year |
___lbs _____oz O Not applicable
|
Months _________ or Weeks__________ |
O No O Yes ( please describe): ________ _________________ _________________ O Not applicable
|
O Diabetes O High blood pressure O Premature labor O Maternal smoking O Maternal drinking O Infection(s) O Prenatal care
|
O No O Yes
|
2 |
O Single Live Birth O Multiple births (please fill out one row for each) O Miscarriage O Abortion O Stillbirth O Ectopic or tubal O Molar pregnancy O Other: ________
|
___/___/_____ MM DD Year |
___lbs _____oz O Not applicable
|
Months _________ or Weeks__________ |
O No O Yes ( please describe): ________ _________________ _________________ O Not applicable
|
O Diabetes O High blood pressure O Premature labor O Maternal smoking O Maternal drinking O Infection(s) O Prenatal care
|
O No O Yes
|
3 |
O Single Live Birth O Multiple births (please fill out one row for each) O Miscarriage O Abortion O Stillbirth O Ectopic or tubal O Molar pregnancy O Other: ________
|
___/___/_____ MM DD Year |
___lbs _____oz O Not applicable
|
Months _________ or Weeks__________ |
O No O Yes ( please describe): ________ _________________ _________________ O Not applicable
|
O Diabetes O High blood pressure O Premature labor O Maternal smoking O Maternal drinking O Infection(s) O Prenatal care
|
O No O Yes
|
69. For women only: If any of these pregnancies were the result of military sexual trauma, please
specify: _________________________________________________________________________
70.) For women only: What forms of contraception have you used before, during, and after your service
in the military? Check all that apply:
-
Before the military
On active duty
After separation from active duty
Birth control pills
Birth control ring
Birth control patch
Condom
Tubal ligation
Partner’s vasectomy
Withdrawal
Depo-Provera
Calendar method
Diaphragm or cervical cap
IUD
“Morning after” pills
Foam/jelly
Progestin implant
None
Not sexually active
Other: (please specify)
__________________________
71. While on active duty, was it easy for you to get contraception if desired?
O No
O Yes
72a. While on active duty, did you use any hormonal methods to stop or control your period?
O No O Yes (please specify):__________________________(skip to question 72d.)
72b. Were you offered a hormonal method to stop or control your period by a health care
provider?
O No O Yes (skip to question 72d.)
72c. Would you have preferred to have a hormonal method to stop or control your period? O No O Yes
72d. Did you have access to sanitary supplies (i.e., pads, tampons) if needed? O No O Yes
72e. Are you currently using a hormonal method to stop or control your period?
O No O Yes (please specify):__________________________
73. Have you experienced any of the following problems before, during, or after active duty? Check all that
apply:
|
Before the military |
On active duty |
After separation from active duty |
Irregular periods
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Painful periods
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Abnormal PAP smear
|
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Pelvic inflammatory disease |
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Chronic pelvic pain
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Low sexual interest
|
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Painful intercourse
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Urinary tract infection
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74. Name: __________________________________ _____ _________________________ _____
Last Suffix First MI
75. Date of Birth: _____ / _____ / _________
Month Day Year
76. Last four digits of your social security number: ____ ____ ____ ____
77. Gender: O Male O Female
78. Current marital status
O Married or living with partner
O Married but separated from partner
O Single, never married
O Divorced
O Widowed
79. Current annual household income before tax:
O less than $35,000 O $75,000-$99,999
O $35,000-$49,999 O $100,000 - $149,999
O $50,000-$74,999 O $150,000 or more
80. What is the highest level of education that you have completed?
O High School degree/GED/or equivalent
O Some college, no degree
O Associate’s degree
O Bachelor’s degree
O Master’s, doctorate, or professional degree
81. Current contact information:
Home Phone: (________) _________--__________
Cell Phone: (________) _________--__________
E-mail address:_____________________________
Mailing address: ____________________________
____________________________
82. Point of contact who can always reach you:
Name:______________________________________
Phone: (________) _________--___________
E-mail address:______________________________
Mailing address: _____________________________
______________________________
| File Type | application/msword |
| File Title | LONGITUDINAL HEALTH STUDY OF |
| Author | va user |
| Last Modified By | vhawasebersm |
| File Modified | 2008-02-27 |
| File Created | 2008-02-27 |
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