Memo 1

31

HEALTH CARE USE SURVEY

Either based on your own experiences or what you have heard from others, rate your opinion of the following aspects of Veterans Administration (VA) health care. Please respond to the following items even if you have had no direct experience with VA care.

	Extremely Negative	Somewhat Negative	Neutral	Somewhat Positive	Extremely Positive
1. Availability of emergency medical services	1	2	3	4	5
2. Availability of primary care services	1	2	3	4	5
3. Availability of family planning and birth control services (e.g., contraception, fertility testing, etc.)	1	2	3	4	5
4. Availability of gynecological care	1	2	3	4	5
5. Availability of mental health services	1	2	3	4	5
6. Ability to get a female or male doctor, depending on your preference	1	2	3	4	5
7. Amount of privacy (e.g., presence of privacy curtains, screens, etc.)	1	2	3	4	5
8. Waiting time to get an appointment for a regular check-up	1	2	3	4	5
9. Waiting time to get an appointment when you’re sick	1	2	3	4	5
10. Waiting time at the pharmacy	1	2	3	4	5
11. The amount of paperwork that needs to be completed to receive care	1	2	3	4	5
12. Ability to get in touch with the medical staff by phone	1	2	3	4	5
13. Coordination of care across services	1	2	3	4	5
14. Availability of parking	1	2	3	4	5
15. Convenience of location	1	2	3	4	5
16. Safety of the location	1	2	3	4	5
17. Accessibility by public transportation	1	2	3	4	5
18. Hours when VA facilities are open	1	2	3	4	5
19. The cleanliness of VA facilities	1	2	3	4	5
20. Availability of information about VA benefits	1	2	3	4	5
21. Staffs’ knowledge of women’s health care needs	1	2	3	4	5
22. Staffs’ knowledge of health care needs of Veterans from your cohort (e.g., OEF/OIF veterans)	1	2	3	4	5
23. Staffs’ courtesy and respect toward patients	1	2	3	4	5
24. Doctors’ skill and expertise	1	2	3	4	5
25. Staffs’ ability to speak your native language	1	2	3	4	5
26. Staffs’ familiarity with Veterans’ unique health-care needs	1	2	3	4	5
27. Health-care providers’ attentiveness during appointments	1	2	3	4	5
28. Health-care providers’ interest in patients’ thoughts and opinions about their health care	1	2	3	4	5

To what extent do you agree or disagree with the following statements?

29. Work responsibilities make it difficult to get my health-care needs met.

___ Strongly agree ___ Somewhat disagree

___ Somewhat agree ___ Strongly disagree

___ Neither agree nor disagree ___ Not applicable

30. Childcare responsibilities make it difficult to get my health-care needs met.

___ Strongly agree ___ Somewhat disagree

___ Somewhat agree ___ Strongly disagree

___ Neither agree nor disagree ___ Not applicable

31. How much would you say you know about your VA benefits? Would you say you know:
    ___ Everything you need to know

___ Most of what you need to know

___ Some of what you need to know

___ A little of what you need to know

___ Almost none or none of what you need to know

32. To your knowledge, how long does it or would it take you to travel to the nearest VA facility to receive care?

…………………………………………………………………………………………………………

1 2 3 4 5 6 7

< 15 min 15-30 min 31–45 min 46–60 min 61–90 min > 90 min Don’t know

33. How much does or would the cost of traveling to the VA interfere with your ability to seek VA care?

…………………………………………………………………………………………………………

1 2 3 4

Not at all A little Moderately A great deal

34. How much does or would traveling through dangerous areas interfere with your ability to seek VA health-care?

…………………………………………………………………………………………………………

1 2 3 4

Not at all A little Moderately A great deal

Instructions: Please rate the extent to which you agree with the following statements about seeking mental health care. Please note that you do not have to be currently experiencing, or ever have experienced, a mental health problem to answer these questions.

For these items, the term “mental health problems” is used to refer to psychological problems that one may experience at different points in life, from more minor mental health problems such as temporary feelings of depression to more serious mental health illnesses, including posttraumatic stress disorder (PTSD) and substance use disorders.

The term “mental health care” is used in these items to refer to participating in therapy/counseling with a mental health provider (for example, a social worker or a psychologist) or receiving psychiatric medications from a mental health provider or a Primary Care Physician

1…………………………...2…..……………….....3…..………………...…..4……….………..5

Strongly Somewhat Neither agree Somewhat Strongly

disagree disagree nor disagree agree agree

1. A problem would have to be really bad for me to be willing to seek mental health care.

2. I would feel uncomfortable talking about my problems with a mental health provider.

3. If I had a mental health problem, I would prefer to deal with it myself rather than to seek treatment.

4. If I were to seek mental health treatment, I would be concerned that others would see it as proof that people like me are weak.

5. Most mental health problems can be dealt with without seeking professional help.

6. If I had a mental health problem, I would willingly seek professional help.

7. Seeing a mental health provider would make me feel weak.

8. I would think less of myself if I were to seek mental health treatment.

9. I would feel proud of myself if I were to seek mental health care.

10. I would be concerned that it would reflect negatively on other people like me if I were to seek mental health treatment.

11. If I were to seek mental health treatment, I would feel stupid that I couldn’t fix the problem on my own.

12. I wouldn’t want to share personal information with a mental health provider.

13. If I were to seek mental health treatment, I would worry that people would assume that my need for treatment was due to my gender, race, or some other aspect of my identity.

14. A mental health provider would think less of me if I were to tell them about my personal problems.

15. If I were to seek mental health treatment, I would worry that people’s judgments of me would be affected by my gender, race, or some other aspect of my identity.

Below are statements about the people around you and their feelings about mental health and mental health treatment. Instructions: Please indicate whether you agree or disagree with the following statements.

Yes/No

1. I have family members or friends who are knowledgeable about mental health problems and how to treat them.

2. My family or friends would encourage me to seek professional help if I were having a mental health problem.

3. Members of my military unit would be supportive if they knew I had sought professional treatment for mental health problems.

4. I have family members or close friends who have found mental health treatment helpful.

5. I’ve heard good things about VA care from other veterans who have used VA mental health services.

6. I’ve heard good things about VA care from people who work there.

Below are beliefs that people sometimes have about people with mental health problems. Instructions: Please rate the extent to which you agree with the following statements about mental health problems.

1…………………………...2…..……………….....3…..………………...…..4……….………..5

Strongly Somewhat Neither agree Somewhat Strongly

disagree disagree nor disagree agree agree

1. It is a sign of weakness to have a mental health problem.

2. Most people with mental health problems could get better if they really wanted to.

3. People with mental health problems cannot be counted on.

4. Many people who are mentally strong experience mental health problems.

5. I would not want to spend time with someone with mental health problems.

6. People with mental health problems often use their health problems as an excuse.

7. It is perfectly safe to be around people with mental health problems.

8. Only people who are flawed to begin with suffer from mental health problems.

9. I would be uncomfortable working with someone with mental health problems.

10. Most people who experience mental health problems are productive members of society.

11. Most people with mental health problems are just faking their symptoms.

12. I don’t feel comfortable around people with mental health problems.

13. It would be difficult to have a normal relationship with someone with mental health problems.

14. Most people with mental health problems are violent or dangerous.

15. People with mental health problems require too much attention.

16. People with mental health problems can’t take care of themselves.

17. Anyone who experiences enough stress might develop a mental health problem.

18. I would not want to be friends with someone with mental health problems.

19. I would be uncomfortable being in a romantic relationship with someone with mental health problems.

Below are some possible explanations for why people may have mental health problems. Instructions: Please rate the extent to which you agree with the following statements about mental health problems.

1…………………………...2…..……………….....3…..………………...…..4……….………..5

Strongly Somewhat Neither agree Somewhat Strongly

disagree disagree nor disagree agree agree

1. Most mental health problems are due to genetic or other biological factors resulting in a chemical imbalance or brain abnormality.

2. Most mental health problems are due to difficult life circumstances, such as a trauma or other stressful events.

3. People experience mental health problems because of personal weaknesses (for example, having weak character).

4. Which of the following causes do you believe best explains why people experience mental health problems? (Mark only one)

___ Genetic or other biological factors resulting in a biochemical imbalance or brain abnormality.

___ Experiencing difficult life circumstances, such as a trauma or other stressful events.

___ Personal weaknesses, such as having weak character or being weak-willed.

Either based on your own experiences or what you have heard from others, rate the extent to which you agree with the following statements about mental health care.

1……………………...2…..……………….....3…..………………...…..4……….………..5

Strongly Somewhat Neither agree Somewhat Strongly

disagree disagree nor disagree agree agree

1. Medications for mental health problems are ineffective.

2. Therapy/counseling can help people who are experiencing mental health problems.

3. Mental health treatment just makes things worse.

4. Mental health treatment can help people who are experiencing mental health problems.

5. Therapy/counseling generally doesn’t work.

6. Mental health providers (for example, therapists or counselors) cannot be trusted.

7. Mental health providers don’t really care about their patients.

8. Medications for mental health problems are safe.

9. Mental health treatment generally does not work.

10. Therapy/counseling does not really help for mental health problems.

11. Medications for mental health problems are too addictive to be worth taking.

12. Therapy/counseling is a useful way to deal with mental health problems.

13. People who seek mental health treatment are often required to undergo treatments they don’t want.

14. Medications for mental health problems have too many negative side effects.

15. Mental health providers often make inaccurate assumptions about patients based on their group membership (e.g., race, sex, etc.).

16. Therapy/counseling just makes things worse.

The next set of items refer to how people in your life would react *if* you were to have a mental health problem. Please note that you do not need to have a current mental health problem to complete these questions.

Instructions: Please rate the extent to which you agree with the following statements about family and friend relationships and mental health.

IF I HAD A MENTAL HEALTH PROBLEM AND FRIENDS/FAMILY KNEW ABOUT IT:

1…………………………...2…..……………….....3…..………………...…..4……….………..5

Strongly Somewhat Neither agree Somewhat Strongly

disagree disagree nor disagree agree agree

1. Friends and family would think less of me.

2. Friends and family would still respect me.

3. Friends and family would see me as weak.

4. Friends and family would feel uncomfortable around me.

5. Friends and family would be understanding.

6. Friends and family would not want to be around me.

7. Friends and family would think I was faking.

8. Friends and family would be afraid that I might be violent or dangerous.

9. Friends and family would be supportive of me.

10. Friends and family would think that I could not be trusted.

11. Friends and family would not want to spend time with me anymore.

12. Friends and family would avoid talking to me.

Instructions: Please rate the extent to which you agree with the following statements about career implications of mental health problems.

IF I HAD A MENTAL HEALTH PROBLEM AND PEOPLE AT WORK KNEW ABOUT IT:

1…………………………...2…..……………….....3…..………………...…..4……….………..5

Strongly Somewhat Neither agree Somewhat Strongly

disagree disagree nor disagree agree agree

1. My coworkers would think I am not capable of doing my job.

2. People at work would not want to be around me.

3. My supervisor would still think I am capable of handling my job.

4. My career/job options would be limited.

5. Co-workers would feel uncomfortable around me.

6. People at work would be supportive of me.

7. Co-workers would be uncomfortable working with me.

8. A supervisor might give me less desirable work.

9. People at work would still respect me.

10. A supervisor might treat me unfairly.

11. Co-workers would not want to spend time with me.

12. People at work would think I was faking.

13. Co-workers would avoid talking to me.

Instructions: Please rate the extent to which you agree with the following statements about veterans who use the VA.

For all items, the use of the term “VA health care” refers to the use of any and all health care services within the VA system, including both medical and mental health care services, for either general health care (example: annual physical exams) or for specific problems (example: treatment for a specific injury).

1…………………………...2…..……………….....3…..………………...…..4……….………..5

Strongly Somewhat Neither agree Somewhat Strongly

disagree disagree nor disagree agree agree

1. Most veterans who use VA care have serious mental health problems.

2. Most veterans who use VA care are pretty healthy.

3. Most veterans who use VA care exaggerate or fake their health problems.

4. Most veterans who use VA care are violent or dangerous.

5. Most veterans who use VA care are mentally weak.

6. Most veterans who use VA care are homeless.

7. Veterans who use VA care are productive members of society.

8. Most veterans who use VA care are poor.

Instructions: Please rate the extent to which you agree with the following statements about veterans who use the VA.

For all items, the use of the term “VA health care” refers to the use of any and all health care services within the VA system, including both medical and mental health care services, for either general health care (example: annual physical exams) or for specific problems (example: treatment for a specific injury).

1…………………………...2…..……………….....3…..………………...…..4……….………..5

Strongly Somewhat Neither agree Somewhat Strongly

disagree disagree nor disagree agree agree

1. My health-care needs are very different from most veterans who use VA care.

2. I share similar health concerns with most VA users.

3. My military experiences were very different from most veterans who use VA care.

4. Most VA health-care users have very different medical problems than I have.

5. I have a lot in common with most veterans who use VA care.

6. Most VA health-care users have more serious physical health problems than me.

7. Most VA health-care users have more serious mental health problems than me.

8. I fit in within the VA health-care setting.

Instructions: Please rate the extent to which you agree with the following statements about VA health care.

1………………..…...2…..……………….....3…..………………...…..4……….………..5

Strongly Somewhat Neither agree Somewhat Strongly

disagree disagree nor disagree agree agree

1. VA providers can be counted on to protect veterans’ private medical information.

2. Using VA health care could jeopardize my ability to get or keep a job.

3. My medical information at the VA would be kept private/confidential.

4. A current or potential employer (e.g., DoD, state police, civilian job) might be able to access my VA medical records.

5. Medical information at the VA is vulnerable to being accessed by “computer hackers.”

6. If I were to seek VA care, it would be difficult to keep it private.

7. My personal VA medical information might get out to other veterans.

8. VA health care providers who are not involved in my care might get access to my private information.

9. I would be uncomfortable having other people know I was at a VA health-care facility.

10. My spouse or partner might be told things about my VA medical care that I would not want them to know.

Instructions: Please rate the extent to which you agree with the following statements about VA health care.

1…………………………...2…..……………….....3…..………………...…..4……….………..5

Strongly Somewhat Neither agree Somewhat Strongly

disagree disagree nor disagree agree agree

1. I am just as deserving of VA health care services as other veterans.

2. There are other veterans who need VA health care much more than I do.

3. By using VA health care, I may take away resources from other veterans who need them more than I do.

4. I have as much right to use the VA for health care as other veterans.

5. My health problems aren’t serious enough to require VA care.

6. My health care needs are as important as those of other veterans who use VA care.

Instructions: Please rate the extent to which you agree with the following statements.

1…………………………...2…..……………….....3…..………………...…..4……….………..5

Strongly Somewhat Neither agree Somewhat Strongly

disagree disagree nor disagree agree agree

1. Being a veteran is a central part of who I am.

2. My status as a veteran is rarely on my mind.

3. I am proud to be a veteran.

4. When I meet other veterans, I prefer to keep my veteran status to myself.

5. I relate best to other veterans.

6. I like it when people know that I am a veteran.

7. I feel more connected to civilians than to other veterans.

8. I spend most of my time with other veterans.

Instructions: Please rate the extent to which you agree with the following statements.

1…………………………...2…..……………….....3…..………………...…..4……….………..5

Strongly Somewhat Neither agree Somewhat Strongly

disagree disagree nor disagree agree agree

1. VA health care services should be reserved for veterans who don’t have other alternatives.

2. Being a veteran means having experienced combat.

3. When I think of veterans, I think of older men who served in the 1970’s or earlier.

4. Only veterans who served during wartime should use VA services.

5. Being a veteran means having been activated for service from Active Duty.

6. Being a veteran means having served during wartime.

The following questions address significant life events that you may have experienced. Indicate how many times, if any, you have experienced each event.

_____never ____ once _____twice ­­­­­ _____3 times ____4 times ____5 times ____ more than 5 times

1. Have you ever experienced a natural disaster (a flood, hurricane, earthquake, etc.)?

2. Were you involved in a motor vehicle accident for which you received medical attention or that badly injured or killed someone?

3. Have you been involved in any other kind of accident where you or someone else was badly hurt? (examples: a plane crash, a drowning or near drowning, an electrical or machinery accident, an explosion, home fire, chemical leak, or overexposure to radiation or toxic chemicals)

4. Have you ever exposed to warfare or combat? (for example: in the vicinity of a rocket

attack or people being fired upon; seeing someone getting wounded or killed)

5. Have you experienced the unexpected and sudden death of a close friend or loved one?

6. Have you been robbed or witnessed a robbery, where the robber(s) used or displayed a weapon?

7. Have you ever been hit or beaten up and badly hurt by a stranger or someone you didn’t know very well?

8. Have you seen a stranger (or someone you didn’t know very well) attack or beat up another person and seriously injure or kill them?

9. Has anyone threatened to kill you or cause you serious physical harm?

10. While growing up: Were you physically punished in a way that resulted in bruises, burns, cuts, or broken bones?

11. While growing up: Did you witness family violence? (such as your father hitting your mother; or any family member beating up or inflicting bruises, bums or cuts on another family member)

12. Have you ever been slapped, punched, kicked, beaten up, or otherwise physically hurt by your spouse (or former spouse), a boyfriend/girlfriend, or some other intimate partner?

13. Before your 13th birthday: Did anyone who was at least 5 years older than you touch or fondle your body in a sexual way or make you touch or fondle their body in a sexual way?

14. Before your 13th birthday: Did anyone close to your age touch sexual parts of your body or make you touch sexual parts of their body against your will or without your consent?

15. After your 13th birthday and before your 18th birthday: Did anyone touch sexual parts of your body or make you touch sexual parts of their body—against your will or without your consent?

16. After your 18th birthday: Did anyone touch sexual parts of your body or make you touch sexual parts of their body-against your will or without your consent?

17. Has anyone stalked you—in other words: followed you or kept track of your activities—causing you to feel intimidated or concerned for your safety?

18. Have you or a loved one ever had a life threatening illness?

19. [For women:] Have you ever had a miscarriage?

20. [For women:] Have you ever had an abortion?

21. Have you experienced (or witnessed) any other events that were life threatening, caused serious injury, or were highly disturbing or distressing? (examples: being kidnapped or held hostage; lost in the wilderness; violent death of a pet; a serious animal bite; permanent physical injury to a loved one)

The statements below are about your combat experiences during your most recent deployment in support of OEF or OIF. As used in these statements, the term “unit” refers to those you lived and worked with on a daily basis during deployment. Please mark how often you experienced each circumstance.

While deployed:	Never	Once or twice	Several times over entire deployment	A few times each month	A few times each week	Daily or almost daily
1. I went on combat patrols or missions.	1	2	3	4	5	6
2. I took part in an assault on entrenched or fortified positions that involved naval and/or land forces.	1	2	3	4	5	6
3. I personally witnessed someone from my unit or an ally unit being seriously wounded or killed.	1	2	3	4	5	6
4. I encountered land or water mines, booby traps, or roadside bombs (for example, IEDs).	1	2	3	4	5	6
5. I was exposed to hostile incoming fire.	1	2	3	4	5	6
6. I was exposed to “friendly” incoming fire.	1	2	3	4	5	6
7. I was in a vehicle (for example, a “humvee,” helicopter, or boat) or part of a convoy that was attacked.	1	2	3	4	5	6
8. I was part of a land or naval artillery unit that fired on enemy combatants.	1	2	3	4	5	6
9. I personally witnessed enemy combatants being seriously wounded or killed.	1	2	3	4	5	6
10. I personally witnessed civilians (for example, women and children) being seriously wounded or killed.	1	2	3	4	5	6
11. I experienced combat-related injuries.	1	2	3	4	5	6
12. I fired my weapon at enemy combatants.	1	2	3	4	5	6
13. I think I wounded or killed someone during combat operations.	1	2	3	4	5	6
14. I was involved in locating or disarming explosive devices.	1	2	3	4	5	6
15. I was involved in searching or clearing homes, buildings, or other locations.	1	2	3	4	5	6
16. I participated in hand-to-hand combat.	1	2	3	4	5	6
17. I was involved in searching and/or disarming potential enemy combatants.	1	2	3	4	5	6

The next set of questions is again about your relationships with others during your most recent deployment in support of OEF or OIF (for example, other unit members, other unit leaders, civilians). Please mark how often you experienced each circumstance.

While I was deployed, the people I worked with…	Never	Once or twice	Several times	Many times
1. made crude and offensive sexual remarks directed at me, either publicly or privately.	1	2	3	4
2. spread negative rumors about my sexual activities.	1	2	3	4
3. tried to talk me into participating in sexual acts when I didn’t want to.	1	2	3	4
4. used a position of authority to pressure me into unwanted sexual activity.	1	2	3	4
5. offered me a specific reward or special treatment to take part in sexual behavior.	1	2	3	4
6. threatened me with some sort of retaliation if I was not sexually cooperative (for example, the threat of a negative review or physical violence).	1	2	3	4
7. touched me in a sexual way against my will.	1	2	3	4
8. physically forced me to have sex.	1	2	3	4

The following questions ask about your current health. Circle the response corresponding to the most appropriate option.

1) In general, would you say your health is:			Excellent		Very good		Good	Fair		Poor
2) Does your health now limit you in moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf?							No, not limited at all	Yes, limited a little		Yes, limited a lot
3) Does your health now limit you in climbing several flights of stairs?							No, not limited at all	Yes, limited a little		Yes, limited a lot
4) In the past four weeks, have you accomplished less than you would like as a result of your physical health?								Yes		No
5) In the past four weeks, have you been limited in your work or other activities as a result of your physical health?								Yes		No
6) In the past four weeks, have you accomplished less than you would like as a result of any emotional problems (such as feeling depressed or anxious)?								Yes		No
7) In the past four weeks, have you not done work or other activities as carefully as usual as a result of any emotional problems?								Yes		No
8) During the past four weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?		Not at all		A little bit		Moderately		Quite a bit		Extremely
How much of the time during the past four weeks…		None of the time	A little of the time		Some of the time		A good bit of the time		Most of the time		All of the time
9) …have you felt calm and peaceful?		1	2		3		4		5		6
10) …did you have a lot of energy?		1	2		3		4		5		6
11) …have you felt downhearted and blue?		1	2		3		4		5		6
12) …has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.?)		None of the time		A little of the time		Some of the time		Most of the time		All of the time

In the past four weeks…

13) how often did you engage in moderate physical activities, such as brisk walking, leisurely bicycling, tennis (doubles), pushing a lawn mower, gardening, ballroom dancing, etc.?

Never

Less than once per week

1-2 times per week

3-4 times per week

5 or more times per week

13a. On average, how many minutes did you exercise each time? _____ minutes

In the past four weeks…

14) how often did you engage in vigorous physical activities intensely enough to work up a sweat, such as jogging or running, swimming laps, tennis (singles), basketball, bicycling (faster than 10 m.p.h.), aerobic dancing, etc.?

Never

Less than once per week

1-2 times per week

3-4 times per week

5 or more times per week

14a. On average, how many minutes did you exercise each time? _____ minutes

In the past four weeks…

15) how often did you engage in exercise specifically to increase muscle strength or endurance, such as lifting weights, working with elastic bands, push-ups or sit-ups, or yoga?

Never

Less than once per week

Once per week

2-3 times per week

4 or more times per week

16) How much do you weigh? ______ pounds

17) About how tall are you without shoes? ____ feet ____ inches

Please answer the following questions about the time since you returned from your most recent deployment to OEF or OIF:

1) Have you had a need for medical care?

Never

Once or twice

A few times

Several times

Many times

2) Have you had a need for mental health care?

Never

Once or twice

A few times

Several times

Many times

The following is a list of conditions you may have experienced before and/or after your deployment in support of OEF or OIF. Indicate whether or not you have been told BY A HEALTH CARE PROFESSIONAL that you had a particular condition, and if you have, when you were told. Circle the appropriate response for each time period and each condition.

I have been told by a healthcare professional that I was suffering from…		Before most recent deployment	After most recent deployment	Within past 3 months
1) Heart disease		No / Yes	No / Yes	No / Yes
2) Chronic back pain		No / Yes	No / Yes	No / Yes
3) Spinal cord injury		No / Yes	No / Yes	No / Yes
4) Hypertension or high blood Pressure		No / Yes	No / Yes	No / Yes
5) Diabetes or high blood sugar		No / Yes	No / Yes	No / Yes
6) Allergic rhinitis (inflammation of the nose or its mucous membranes)		No / Yes	No / Yes	No / Yes
7) Arthritis or degenerative joint disease		No / Yes	No / Yes	No / Yes
8) Chronic gastrointestinal problems (examples: irritable colon, colitis)		No / Yes	No / Yes	No / Yes
9) Dyspnea (difficulty breathing)		No / Yes	No / Yes	No / Yes
10) Chronic sinusitis (severe sinus problems)		No / Yes	No / Yes	No / Yes
11) Depression		No / Yes	No / Yes	No / Yes
12) Posttraumatic Stress Disorder (PTSD)		No / Yes	No / Yes	No / Yes
13) Any other anxiety disorder other than PTSD (for example, panic disorder, generalized anxiety disorder)		No / Yes	No / Yes	No / Yes
14) Chronic Fatigue Syndrome		No / Yes	No / Yes	No / Yes
15) Asthma or bronchitis		No / Yes	No / Yes	No / Yes
16) Fibromyalgia or fibrositis (fatigue of muscles, muscle pain, joint pain, tenderness at specific points of body)		No / Yes	No / Yes	No / Yes
17) Migraines		No / Yes	No / Yes	No / Yes
18) Amnesia or severe memory loss		No / Yes	No / Yes	No / Yes
19) Sleep apnea or narcolepsy		No / Yes	No / Yes	No / Yes
20) Thyroid problem (examples: hypothyroidism or hyperthyroidism)		No / Yes	No / Yes	No / Yes
21) Cancer		No / Yes	No / Yes	No / Yes
22) Any other health condition not listed: Fill in the blank with condition.		No / Yes	No / Yes	No / Yes
a.		No / Yes	No / Yes	No / Yes
b.		No / Yes	No / Yes	No / Yes
c.		No / Yes	No / Yes	No / Yes
d.		No / Yes	No / Yes	No / Yes

The following statements refer to feelings you may have had since returning from your most recent deployment in support of OEF or OIF. Think about the event or events that were most disturbing to you while you were deployed and respond to the statements about experiences or feelings you have had in the past THREE monthS. Circle the number that best fits your choice.

In the past three months I have been bothered by...		Not at all	A little bit	Moderately	Quite a bit	Extremely
1) ...repeated, disturbing memories of my military experiences.		1	2	3	4	5
2) ...repeated, disturbing dreams of my military experiences.		1	2	3	4	5
3) ...suddenly acting or feeling as if my military experiences were happening again.		1	2	3	4	5
4) ...feeling very upset when something happened that reminded me of my military experiences.		1	2	3	4	5
5) ...trouble remembering important parts of my military experiences.		1	2	3	4	5
6) ...loss of interest in activities that I used to enjoy.		1	2	3	4	5
7) ...feeling distant or cut off from other people.		1	2	3	4	5
8) ...feeling emotionally numb, or being unable to have loving feelings for those close to me.		1	2	3	4	5
9) ...feeling as if my future will somehow be cut short.		1	2	3	4	5
10) ...trouble falling or staying asleep.		1	2	3	4	5
11) ...feeling irritable or having angry outbursts.		1	2	3	4	5
12) ...having difficulty concentrating.		1	2	3	4	5
13) ...being “super alert,” or watchful or on guard.		1	2	3	4	5
14) ...feeling jumpy or easily startled.		1	2	3	4	5
15) ...having physical reactions when something reminds me of my military experiences.		1	2	3	4	5
In the PAST THREE MONTHS, I have tried to:
16) ...avoid thinking about my military experiences, or avoid having feelings about them.		1	2	3	4	5
17) ...avoid activities or situations because they reminded me of my military experiences.		1	2	3	4	5

Next is a set of statements about feelings you may or may not have experienced in the Past three months. Read each statement and indicate the extent to which you agree or disagree with each statement by circling the number corresponding to your response choice.

In the past three months...		Strongly disagree	Somewhat disagree	Neither agree nor disagree	Somewhat agree	Strongly agree
1) ...I have felt sad.		1	2	3	4	5
2) ...I have felt discouraged about the future.		1	2	3	4	5
3) ...I have felt like a failure.		1	2	3	4	5
4) ...I haven’t gotten as much satisfaction out of things as I used to.		1	2	3	4	5
5) ...I have been disappointed in myself.		1	2	3	4	5
6) ...I have been critical of myself for my weaknesses or mistakes.		1	2	3	4	5
7) ...I have had thoughts about killing myself.		1	2	3	4	5

The following questions relate to your use of alcohol. Please mark the response corresponding to the most appropriate option.

1. Have you felt you ought to cut down on drinking?

(Mark all that apply)

___ No

___Yes, before I was deployed

___Yes, at some time after deployment

___Yes, in the last 3 months

2. Have people criticized your drinking?

(Mark all that apply)

___ No

___Yes, before I was deployed

___Yes, at some time after deployment

___Yes, in the last 3 months

3. Have you felt bad or guilty about your drinking?

(Mark all that apply)

___ No

___Yes, before I was deployed

___Yes, at some time after deployment

___Yes, in the last 3 months

4. Have you had a drink first thing in the morning to steady your nerves or get rid of a hangover (an “eye-opener”)?

(Mark all that apply)

___ No

___Yes, before I was deployed

___Yes, at some time after deployment

___Yes, in the last 3 months

In the past three months…

5. how often have you had a drink containing alcohol

Never

Monthly or less

2-4 times per month

2-3 times per week

4 or more times per week

In the past three months…

6. how many drinks containing alcohol have you had on a typical day when you were drinking?

Not applicable

1 or 2

3 or 4

5 or 6

7 to 9

10 or more

7. How often do you have six or more drinks if you are a man, or five or more drinks if you are a woman, on one occasion?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

The following questions relate to injuries you may have experienced during your most recent deployment.

1. Did you have any injury(ies) during your most recent deployment from any of the following? (Mark all that apply.)

___ Fragment

___ Bullet

___ Vehicular (any type of vehicle, including airplane)

___ Blast (for example, Improvised Explosive Device, RPG, Land mine, Grenade, etc.)

___ Fall

1a. If you had an injury, what was the date of the most serious injury? __________

2. Did any injury received while you were deployed result in any of the following? (Mark all that apply.)

___ Being dazed, confused or “seeing stars”

___ Not remembering the injury

___ Losing consciousness (knocked out) for less than a minute

___ Losing consciousness for 1-30 minutes

___ Losing consciousness for longer than 30 minutes

___ Symptoms of concussion afterward (such as headache, dizziness, irritability, etc.)

___ Head Injury

___ None of the above

3. Did you have or have you had any of the following symptoms from injuries noted in #1?

(Mark all that apply.)

	Right after injury?	Now?	Was the symptom a problem before injury?	If a problem before, did symptom worsen after injury?
a. Headaches
b. Dizziness
c. Memory problems
d. Balance problems
e. Ringing in the ears
f. Irritability
g. Sleep problems
h. Other; specify:

The following questions relate to your health benefits and your use of health care.

1. Do you receive disability benefits? (Mark all that apply.)

___ Yes, Disability payments from the VA ___ Yes, Disability Insurance from employer

___ Yes, SSI ___ Yes, Self-purchased disability insurance

___ Yes, SSDI ___ Yes, I get disability payments, but not sure where they come from

___ Yes, Worker’s compensation ___ No, I don’t receive any disability payments

2. Have you ever applied or are you currently applying for service-connected disability status from the VA?

___ Yes ___ No

2a. (If yes in past) Did you receive service-connected disability status?

___ Yes ___ No

2b. If yes, What is the total % disability rating you received? ___

2c. What % disability rating did you receive for disability related to your mental health? ___

2d. What % disability rating did you receive for disability related to your physical health? ___

3. Do you currently have physical health problems that require health care?

___ Yes ___ No ___ Don’t know

4. Do you currently have mental health problems that require health care?

___ Yes ___ No ___ Don’t know

5. Medicare is a health insurance program for people 65 years and older and people under age 65 who have certain disabilities. Are you currently covered by the Medicare program?

___Yes ___No ___Don’t know

6. Some people who are eligible for Medicare have additional health insurance coverage through a private insurance company. This is sometimes referred to as Medigap or Medicare Supplement, and it is different from insurance you might have through an employer or former employer. Are you currently covered by a Medigap or Medicare Supplement health insurance plan?

___Yes ___No ___Don’t know

7. Medicaid/Medi-Cal is a program that pays for health care for persons in need. It is different from Medicare, the program for persons 65 and older and persons under 65 with certain disabilities. Are you currently covered by Medicaid/Medi-Cal?

___Yes ___No ___Don’t know

8. Are you currently covered by CHAMPUS or TRICARE?

___Yes ___No ___Don’t know

9. Excluding VA health care benefits and Federal employee health benefits, are you currently covered by any other government-provided health insurance or health service plan? For example, Indian Health Service or military health care?

___Yes ___No ___Don’t know

10. Excluding programs named above, are you currently covered by private health insurance that you or someone else provides for you? For example, private insurance from an employer or union, Federal employee health benefits, or private insurance that someone bought directly from an insurance company? (Include plans obtained through someone who does not live in your household. Do not include plans provided by military employers.)

___Yes ___No ___Don’t know

11. In the PAST YEAR, did you receive the following types of care, either at a VA or non-VA Medical facility? Note that “inpatient care” refers to care that involves being admitted overnight at a medical facility and “outpatient care” refers to care received during the day. (Write numbers in all boxes that apply.)

	# of times you received this care at a VA facility	# of times you received this care from a doctor, hospital, or medical facility outside of the VA
a. outpatient medical care visits for routine exams, medical tests, shots, etc.
b. emergency room visit for medical problem
c. inpatient medical care (treatment requiring an overnight stay in a hospital or residential care facility)
d. outpatient mental health care (examples: counseling, therapy)
e. emergency room visit for mental health care
f. inpatient mental health care (mental health treatment requiring an overnight stay in a hospital or residential care facility)
g. inpatient care for alcohol abuse or detox
h. inpatient care for drug abuse or detox
i. outpatient care visits for alcohol abuse (examples: counseling, therapy)
j. outpatient care visits for drug abuse, excluding methadone clinic (examples: counseling, therapy)
k. methadone clinic visits
l. dental care visits
m. different medications prescriptions received, excluding refills

12. How likely would you be to seek VA physical health care if you needed treatment in the future?

___ Definitely would not ___ Probably would

___ Probably would not ___ Definitely would

13. How likely would you be to seek VA mental health care if you needed treatment in the future?

___ Definitely would not ___ Probably would

___ Probably would not ___ Definitely would

Listed below are a number of statements about how you think and do things. Please read each statement and decide how true or false it is for you, personally.  Circle the number that corresponds to your response.

		Very false	Somewhat false	Neither true nor false	Somewhat true	Very true
1) I’m always willing to admit it when I make a mistake.		1	2	3	4	5
2) No matter whom I’m talking to, I’m always a good listener.		1	2	3	4	5
3) I am always courteous, even to people who are disagreeable.		1	2	3	4	5
4) It is sometimes hard for me to go on with my work if I am not encouraged.		1	2	3	4	5
5) I sometimes feel resentful when I don’t get my way.		1	2	3	4	5
6) On a few occasions, I have given up doing something because I thought too little of my ability.		1	2	3	4	5
7) There have been times when I felt like rebelling against people in authority even though I knew they were right.		1	2	3	4	5
8) There have been occasions when I took advantage of someone.		1	2	3	4	5
9) I sometimes try to get even rather than forgive and forget.		1	2	3	4	5
10) I have never been irked when people expressed ideas very different from my own.		1	2	3	4	5
11) There have been times when I was quite jealous of the good fortune of others.		1	2	3	4	5
12) I am sometimes irritated by people who ask favors of me.		1	2	3	4	5
13) I have never deliberately said something that hurt someone’s feelings.		1	2	3	4	5

Please mark the appropriate response or fill in the required information.

1. What is your gender?

___ Male ___ Female

2. What is your age? ____

3. Are you of Hispanic or Latino origin or descent?

___ Yes, Hispanic or Latino ___ No, not Hispanic or Latino

4. In which of the following categories do you feel that you belong? (Please choose one or more categories.)

___ Pacific Islander or Native Hawaiian ___ Black or African/American

___ American Indian or Alaska Native ___ White

___ Asian

5. What is the highest level of education you have attained?

___ 8^th grade or less ___ Some college

___ Some high school ___ Four-year college graduate

___ High school graduate ___ Some graduate or professional school

___ Vocational or technical training ___ Graduate or professional degree

6. What is your current marital status? (Mark all that apply.)

___ Married ___ Widowed

___ Divorced ___ Separated

___ Living as a couple ___ Single/Never married

7. Do you have any children?

___ Yes ___ No

7a. If Yes, how many children do you have and what are their ages?

_______ # of children ____ child 3 age

____ child 1 age ____ child 4 age

____ child 2 age ____ child 5 age

8. Who do you live with? (Mark all that apply.)

___ My husband, wife or partner ___ Other relatives

___ My children ___ Other people who are not related to me

___ My parents or in-laws ___ No one else; I live alone

9. Are you currently… (Mark all that apply.)

___ Working for pay full–time (>30 hours/week)

___ Working for pay part–time (<30hours/week)

___ Working as a volunteer (no pay)

___ Student in high school, job training, or college degree program

___ Homemaker

___ Not working but actively looking for work

___ Not working and not looking for work

___ Retired

___ Unable to work

10. Which of the following categories best describes your 2010 household income before taxes?

___ $15,000 or less ___ $50,001 to $75,000

___ $15,001 to $25,000 ___ $75,001 to $100,000

___ $25,001 to $35,000 ___ Over $100,000

___ $35,001 to $50,000

11. Are you currently serving in the military either on active duty or with the National Guard or Reserves?

___ Yes

_ __ No If no, Skip to 12

11a. (If Yes) Are you currently:

___ Regular active duty

___ National Guard

___ Reserves

12. How long have you served in the military?

___ less than 1 year ___ 5-10 years

___ 1-2 years ___ over 10 years

___ 3-4 years

13. During what time period was your most recent deployment?

From ____/____/____ (month/day/year) To ____/____/____ (month/day/year)

13a. Are you anticipating another deployment within the next year?

___ Yes ___ No

13b. How many times, in total, have you been deployed in support of OEF or OIF? ___ # of times

13c. How many times were you deployed before OEF/OIF? ___ # of times

14. During your most recent deployment, were you deployed from:

___ Active duty ___ National Guard ___ Reserves

15. What was your branch of the military when you were deployed?

____Marines ____ Army ____ Navy ____ Air Force ____Coast Guard

16. What was your military rank when you were deployed (e.g., E-5, O-6)? _____________

17. What was your primary military occupation (MOS, SSI, Rating or NEC, NOBC, or AFSC) when you were deployed? _____________

18. How would you describe your primary role during this deployment?

___ Combat arms ___ Combat-support ___ Service-support

19. Where were you stationed?

___________________________________________________________________________

20. If you are no longer in the military, did you receive an honorable discharge from the military?

___ Yes ___ No

21. Prior to your most recent deployment to Iraq or Afghanistan, did you ever serve in any of the following operations? (Mark all that apply)

___Vietnam ___Croatia-Bosnia (Provide Promise)

___Grenada ___Macedonia (Able Sentry)

___Lebanon ___Haiti (Restore Democracy)

___Panama (Operation Just Cause) ___Somalia (Restore Hope)

___Rwanda (Support Hope) ___Persian Gulf (Operation Desert Storm/Shield)

___Bosnia-Herzegovina (Operation Joint Endeavor/Guard)

22. We may be doing a follow-up study in the future. May we contact you again to ask if you would be interested in participating?

____Yes

____No

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