Form VA Form 10-0488 VA Form 10-0488 Follow-Up Study of a National Cohort of Gulf War and Gul

Follow-Up Study
of a National Cohort of Gulf War
and Gulf Era Veterans

QUESTIONNAIRE

Sponsored by the Department of Veterans Affairs

OMB Number: 2900-XXXX

Estimated Burden: 30 minutes

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 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.

Follow-Up Study of a National Cohort of Gulf War and Gulf Era Veterans

1a. Have you served in the U.S. Armed Forces in the Persian Gulf area?

___ No ___ Yes

I F YES, 1b. Period of Persian Gulf service:

From ____/____/____ to ____/____/____

Month Day Year Month Day Year

1c. Have you served in the U.S. Armed Forces since the Persian Gulf War ended in 1991?

___ No ___ Yes

IF YES,

1d. In what component(s) did you serve with since 1991? (Mark all that apply)

__ Active Duty __ Reserve __ National Guard

1e. Have you been deployed to Operation Enduring Freedom (OEF) and/or Operation Iraqi
Freedom (OIF)?

___ No ___ Yes

2. What were you doing most of the past 12 months? (Please mark one.)

__ Working outside the home __ Going to school

__ Keeping house __ On active duty

__ Child care __ Working from home

__ Keeping house and child care __ Something else

(Please specify: _________________________)

3a. Thinking back over the past 2 weeks, did you stay in bed or at home all or part of any day
because you did not feel well or as a result of illness or injury?

___ No ___ Yes IF YES, 3b. How many days did you stay in bed or at home more

than half of the day because of illness or injury during

the past 2 weeks?

_________ days

4a. Are you limited in your employment or the kind of work you can do around the house because of
any impairment or health problem?

__ No___ Yes IF YES, 4b. What kind of health problem(s) do
you have?

_____________________________________________

_____________________________________________

_____________________________________________

5a. During the past 12 months how many clinic or doctor visits have you made because you were sick?

(exclude routine visits for vaccinations, physical examinations, etc.)

___ None No. of visits 5b. Please explain reasons for visits or diagnosis.

1. _ ________________________________________

2. _________________________________________

3. _________________________________________

4. _________________________________________

6a. During the past 12 months how many times have you been hospitalized overnight or longer?

___ None No. of 6b. Please explain reasons for hospitalizations or diagnosis.

Hospitalizations

1. ________________________________________

_________ 2. ________________________________________

3. ________________________________________

4. ________________________________________

7a. About how tall are you without shoes? ______ ______

(feet) (inches)

7b. About how much do you weigh without shoes? ______

(pounds)

(*If currently pregnant, please give your usual weight before becoming pregnant)

7c. In general, would you say your health is:

Excellent	Very good	Good	Fair	Poor

8a. Has your doctor ever told you that you have any of the following conditions? NO YES	8b. Has this condition been present in the past 4 weeks? NO YES
1. Arthritis of any kind (including rheumatoid or osteoarthritis)
2. Fibromyalgia
3. Skin cancer
4. Any other cancer
5. Dermatitis or any other skin trouble
6. Cirrhosis of the liver
7. Hepatitis

	Has your doctor ever told you that you have any of the following conditions? NO YES		Has this condition been present in the past 4 weeks? NO YES
	8. Chronic Fatigue Syndrome
	9. Gastritis (irritation of the stomach)
	10. Irritable bowel syndrome
	11. Diabetes
	12. Other endocrine disorder (including thyroid problems)
	13. Repeated seizures, convulsions, or blackouts
	14. Depression
	15. Neuralgia or neuritis (nerve inflammation)
	16. Any disease of the genital organs
	17. Coronary heart disease
	18. Hypertension (high blood pressure)
	19. Stroke or cerebral-vascular accident
	20. Tachycardia or rapid heart
21. Asthma
22. Emphysema or chronic bronchitis (or chronic obstructive pulmonary disease)
23. Repeated bladder infections

AMYOTROPHIC LATERAL SCLEROSIS (ALS) QUESTIONS

9a. Were you ever told by a health professional that you have ALS or Lou Gehrig’s disease?

• Yes-Go to 9b

• No-Go to 9c

• DK -Go to 9c

9b. Were you clinically diagnosed with ALS?

• Yes

• No-Go to 9c

9c. Is there another current diagnosis given by a health professional?

• Yes-Go to 9d

• No

9d. What was the diagnosis (check all that apply)?

• Possibly ALS (not yet determined/diagnosed)

• Primary lateral sclerosis

• Progressive bulbar palsy

• Progressive muscular atrophy

9e. Have you had progression in muscle weakness?

• Yes

• No

IRRITABLE BOWEL SYNDROME (IBS) QUESTIONS

10a. In the last 3 months, how often did you have discomfort or pain anywhere in your abdomen?

• Never-skip remaining questions

• Less than one day a month

• One day a month

• Two to three days a month

• One day a week

• More than one day a week

• Every day

10b. For women: Did this discomfort or pain occur only during your menstrual bleeding and not at other times?

• No

• Yes

• Does not apply because I have had the change in life (menopause) or I am a male

10c. Have you had this discomfort or pain 6 months or longer?

• No

• Yes

10d. How often did this discomfort or pain get better or stop after you had a bowel movement?

• Never or rarely

• Sometimes

• Often

• Most of the time

• Always

10e. When this discomfort or pain started, did you have more frequent bowel movements?

• Never or rarely

• Sometimes

• Often

• Most of the time

• Always

10f. When this discomfort or pain started, did you have less frequent bowel movements?

• Never or rarely

• Sometimes

• Often

• Most of the time

• Always

10g. When this discomfort or pain started, were your stools (bowel movements) looser?

• Never or rarely

• Sometimes

• Often

• Most of the time

• Always

10h. When this discomfort or pain started, how often did you have harder stools?

• Never or rarely

• Sometimes

• Often

• Most of the time

• Always

10i. In the last 3 months, how often did you have hard or lumpy stools?

• Never or rarely

• Sometimes

• Often

• Most of the time

• Always

10j. In the last 3 months, how often did you have loose mushy or watery stools?

• Never or rarely

• Sometimes

• Often

• Most of the time

• Always

Functional dyspepsia questions

11a. In the last 3 months, how often did you have pain or discomfort in the middle of your chest (not related to heart problems)?

• Never

• Less than one day a month

• One day a month

• Two to three days a month

• One day a week

• More than one day a week

• Every day

11b. In the last 3 months, how often did you have heartburn (a burning discomfort or burning pain in your chest)?

• Never

• Less than one day a month

• One day a month

• Two to three days a month

• One day a week

• More than one day a week

• Every day

11c. In the last 3 months, how often did you feel uncomfortably full after a regular sized meal?

• Never-skip to question #

• Less than one day a month

• One day a month

• Two to three days a month

• One day a week

• More than one day a week

• Every day

11d. Have you had this uncomfortable fullness after meals 6 months or longer?

• No

• Yes

11e. In the last 3 months, how often were you unable to finish a regular size meal?

• Never-skip to question 7

• Less than one day a month

• One day a month

• Two to three days a month

• One day a week

• More than one day a week

• Every day

11f. Have you had this inability to finish regular size meals 6 months or longer?

• No

• Yes

11g. In the last 3 months, how often did you have pain or burning in the middle of your abdomen, above your belly button but not in your chest?

• Never-skip remaining questions

• Less than one day a month

• One day a month

• Two to three days a month

• One day a week

• More than one day a week

• Every day

11h. Have you had this pain or burning 6 months or longer?

• No

• Yes

11i. Did this pain or burning occur and then completely disappear during the same day?

• Never or rarely

• Sometimes

• Often

• Most of the time

• Always

11j. Usually, how severe was the pain or burning in the middle of your abdomen, above your
belly button?

• Very mild

• Mild

• Moderate

• Severe

• Very severe

11k. Was this pain or burning relieved by taking antacids?

• Never or rarely

• Sometimes

• Often

• Most of the time

• Always

11l. Did this pain or burning usually get better or stop after a bowel movement or passing gas?

• Never or rarely

• Sometimes

• Often

• Most of the time

• Always

11m. How often was this pain or discomfort relieved by moving or changing positions?

• Never or rarely

• Sometimes

• Often

• Most of the time

• Always

12a. In the past 12 months, have any of the following life events happened to you? NO YES	12b. IF YES, in what month and year did this FIRST happen? MONTH/YEAR
A pplied for unemployment benefits	/
A pplied for a job	/
A pplied for disability payment	/
M ajor financial problems (such as bankruptcy)	/
L ost medical insurance	/
Y ou were divorced or separated	/
7. Death or serious accident/illness of a family member or close friend	/
8. Lost a job	/
9. Started a new job or got promoted or returned to school	/
1 0. Formed a new sexual relationship	/
1 1. Got married	/
1 2. Had a child	/
1 3. Moved to another house or apartment	/
1 4. Personally experienced a serious injury from a motor vehicle accident	/

13a. Have you smoked cigarettes in the past 12 months?

 No  Yes IF YES, 13b. How many cigarettes do you smoke per day? _______

13c. How old were you when you first

started smoking? ________

(AGE)

IF NO, 13d. Have you ever smoked cigarettes even occasionally?

 No  Yes IF YES, 13e. When did you last stop? ________

(YEAR)

13f. During the past 12 months, have you been treated for a sexually transmitted disease or
venereal disease (e.g., gonorrhea, syphilis, herpes, Chlamydia)?

 No  Yes

13g. During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?”

 No  Yes

14a. Have you experienced any of the following symptoms during the past 12 months? For the purpose of the study the severity of symptoms is defined as follows:

mild: just aware but not slowed down by symptoms, or sufficient to take non- prescription drugs

to relieve the symptoms (aspirin, tums, etc.).

severe: sufficient to seek medical advice, take prescription drugs, lose work or limit routine

activities.

14b. In the past 12 months have you had persistent or recurring problems with … ? NO YES	IF YES, PLEASE MARK ONE MILD SEVERE	14c. Has this symptom been present more than 6 months? NO YES
1. Any headaches
2. A sore throat, hoarse voice or other throat problems
3. Generalized muscle aching or cramps
4. Joint aching or pain
5 . Problems with fatigue lasting more than 24 hours after exertion
6 . Awaken feeling tired and worn out after a full night of sleep
7 . Had difficulty in concentrating, reasoning or memory loss
8 . Tender lymph nodes

15. 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.

15a. In the past 4 weeks, have you had … ?

A

NOT LITTLE QUITE

AT ALL BIT MODERATELY A BIT EXTREMELY

1. Repeated, disturbing memories of stressful

experiences from the past.

2. Repeated, disturbing dreams of stressful

experiences from the past.

3. Suddenly acting or feeling as if stressful

experiences were happening again.

4. Feeling very upset when something

happened that reminds you of stressful

experiences from the past.

5. Trouble remembering important parts of

stressful experiences from the past.

6. Loss of interest in activities that you

used to enjoy.

7. Feeling distant or cut off from other people.

8 . Feeling emotionally numb, or being unable to

have loving feelings for those close to you.

9. Feeling as if your future will somehow

be cut short.

1 0. Trouble falling asleep or staying asleep.

1 1. Feeling irritable or having angry outbursts.

1 2. Having difficulty concentrating.

1 3. Being “super-alert,” or watchful or on guard.

1 4. Feeling jumpy or easily startled.

1 5. Having physical reactions when something

reminds you of stressful experiences from

the past

1 6. Avoid thinking about your stressful

experiences from the past, or avoid

having feelings about them.

1 7. Avoid activities or situations because they

remind you of stressful experiences

from the past.

16. 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

17. 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

18. 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

19. During the past 4 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

19. 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?

19. 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.)?

All of the time	Most of the time	Some of the time	A little of the time	None of the time

19. During the past 4 weeks, how much have you been Not Bothered Bothered

bothered by any of the following problems? Bothered a little a lot

1. S tomach pain……………………………………………

2. B ack pain………………………………………………..

3. P ain in your arms, legs, or joints (knees, hips, etc.)..

4. M enstrual cramps or other problems with your

periods…………………………………………………..

5. P ain or problems during sexual intercourse…………

6. H eadaches………………………………………………

7. C hest pain……………………………………………….

8. D izziness………………………………………………...

9. F ainting spells…………………………………………...

10. F eeling your hearth pound or race……………………

11. S hortness of breath…………………………………….

12. C onstipation, loose bowels, or diarrhea……………..

13. N ausea, gas, or indigestion…………………………..

n . Wheezing in your chest……..………………………..

o . Problems with Coughing…..…………………………..

p . A fever or chills……………..…………………………..

19. Over the past 2 weeks, how often have you been bothered More Nearly

by any of the following problems? Several than half every

Not at all days the days day

1. L ittle interest or pleasure in doing things……………….

2. F eeling down, depressed, or hopeless…………………

3. T rouble falling or staying asleep, or sleeping

too much …………………………………………………

4. F eeling tired or having little energy……………………..

5. P oor appetite or overeating………………………………

6. Feeling bad about yourself – or that you are a failure

o r have let yourself or your family down………………

7. Trouble concentrating on things, such as reading

the newspaper or watching television…………………

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

m ore than usual…………………………………………

9. Thoughts that you would be better off dead or of

h urting yourself in some way……………………………

QUESTIONS ABOUT ANXIETY

NO YES

24a. In the past 4 weeks, have you had an anxiety attack –

s uddenly feeling fear or panic?…………………………………

If you checked “NO” to question # 24(a), go to question #26.

b . Has this ever happened before?………………………………..

c. Do some of these attacks come suddenly out of the blue –

that is, in situations where you don’t expect to be nervous or

uncomfortable?……………………………………………………

4. Do these attacks bother you a lot or are you worried about

h aving another attack?…………………………………………..

25. Think about your last bad anxiety attack. NO YES

1. W ere you short of breath?………………………………………..

2. D id your heart race, pound, or skip?…………………………….

3. D id you have chest pain or pressure?…………………………..

4. D id you sweat?…………………………………………………….

5. D id you feel as if you were choking?…………………………….

f . Did you have hot flashes or chills?………………………………

7. Did you have nausea or an upset stomach, or the feeling that

y ou were going to have diarrhea?……………………………….

7. D id you feel dizzy, unsteady, or faint?…………………………..

8. D id you have tingling or numbness in parts of your body?….…

9. D id you tremble or shake?………………………………………..

k . Were you afraid you were dying?………………………………..

26. Over the past 4 weeks, how often have you been bothered by More than

any of the following problems? Several half the

Not at all days days

1. Feeling nervous, anxious, on edge, or worrying a lot

a bout different things………………………………………

If you checked “Not at all”, go to question #27.

2. F eeling restless so that it is hard to sit still………………

3. G etting tired very easily……………………………………

4. M uscle tension, aches, or soreness……………………..

5. T rouble falling asleep or staying asleep…………………

6. T rouble concentrating on things, such as reading a

book or watching TV……………………………………….

7. B ecoming easily annoyed or irritable……………………..

2 7. Do you ever drink alcohol (including beer or wine)?…………….. NO YES

IF NO GO TO QUESTION #28.

IF YES, 27a. Average # of drinks per week? 27b. How old were you when

__1-2 __ 9-10 __ 17-18

__ 3-4 __ 11-12 __ 19-20

__ 5-6 __ 13-14 __ more than 20

__ 7-8 __ 15-16

you first started drinking

fairly regularly?

_________

(AGE)

27c How often do you have 5 or more drinks on one occasion?

___ Never ___ Less than monthly ___ Once a month ___ Weekly ___ Daily ___ Almost daily

27d. Have any of the following happened to you more than once in the past 6 months?

NO YES

1. Y ou 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……………………………….

2. Y ou missed or were late for work, school, or other activities

because you were drinking or hung over………………………

27e. Have any of the following happened to you more than once in the past 6 months? NO YES

2. Y ou had a problem getting along with other people while you

were drinking……………………………………………………..

2. You drove a car after having several drinks or after drinking

too much………………………………………………………….

27f. If you checked off any problems on questions 22-27e, how difficult have these problems made it

for you to do your work, take care of things at home, or get along with other people?

Not difficult Somewhat Very Extremely

at all difficult difficult difficult

28. In the past 4 weeks, how much have you been bothered by any of the following problems?

Not Bothered Bothered

Bothered a little a lot

1. Worrying about your health…………………………………

2. Y our weight or how you look……………………………………

3. L ittle or no sexual desire or pleasure during sex……………..

4. D ifficulties with husband/wife, partner/lover or

boyfriend/girlfriend………………………………………………

5. The stress of taking care of children, parents, or other family

m embers………………………………………………………….

6. S tress at work outside of the home or at school………………

7. Financial problems or worries…………………………………..

8. H aving no one to turn to when you have a problem………….

9. S omething bad that happened recently……………………….

10. Thinking or dreaming about something terrible that

happened to you in the past – like your house being

destroyed, a severe accident, being hit or assaulted, or

being forced to commit a sexual act…………………………....

29. In the past 12 months, have you been hit, slapped, kicked or otherwise
physically hurt by someone, or has anyone forced you to have NO YES

an unwanted sexual act?

30. Are you taking any medicine for anxiety, depression, or stress? NO YES

GO TO THE NEXT QUESTION

31. FOR WOMEN ONLY: Questions about menstruation, pregnancy and childbirth.

1. Which best describes your menstrual periods?

____ Periods are regular or unchanged in pattern.

____ No periods because pregnant or recently gave birth.

____ Periods have become irregular or changed in frequency, duration or amount.

____ Having periods because taking hormone replacement (estrogen) therapy
or oral contraceptive

____ No period for over one year.

32. IF NO PERIOD FOR OVER ONE YEAR,

a. What is the reason that you have not had a period in the past 12 months?

_____ Pregnancy

_____ Breast feeding

_____ Menopause/hysterectomy

_____ Medical conditions/treatments

_____ Other

NO

b. During the week before your period starts, do you have a serious (or N/A) YES

problem with your mood – like depression, anxiety, irritability, anger

or mood swings?………………………………………………………….

3. I f YES: Do these problems go away by the end of your period?……

3. H ave you given birth within the last 6 months?……………………….

3. H ave you had a miscarriage within the last 6 months?………………

3. A re you having difficulty getting pregnant?……………………………

33a. Have you taken female hormone pills containing both estrogen and progestin

(like Prempro, Premphase)? {Do not include birth control pills}

YES………………………………… 1

NO……………………………………2

b. Are you taking pills containing both estrogen and progestin now?

YES……………….…………………1

NO……………………………………2

c Not counting any time when you stopped taking them, for how long altogether
{have you taken/did you take} pills containing both estrogen and progestin?

_____ Years _____ Months

The following questions ask about unexplained multisymptom illnesses, that is, having several different symptoms together that persist for 6 months or longer and are not adequately explained by conventional medical or psychiatric diagnoses.

Unexplained multisymptom illness might include things like fatigue, muscle or joint pain, headaches, memory problems, digestive problems, respiratory problems, skin problems, or any other unexplained symptoms. These problems are often not labeled at all, but may sometimes be diagnosed as chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, or multiple chemical sensitivity.

34. Since January 1991, have you ever experienced unexplained multisymptom illness that lasted
6 months or longer?

〇 No [If NO, skip to page 18] 〇 Yes

35. During what year did you first experience unexplained multisymptom illness?

______ (year) [If unsure, please estimate.]

36. What was the most recent year in which you experienced unexplained multisymptom illness?

______ (year) [If unsure, please estimate.]

37. During the past 12 months, how many alternative treatment visits have you made because you had

health problems? _____ None Number of visits_________

38. If alternative treatments were used in the past 12 months, please indicate all treatment(s), the reasons for the treatment(s), and whether treatment was used at VA or elsewhere.

(Mark all that apply)

Treatment Not used Used at VA Used Elsewhere Reason for treatment

a . Acupuncture ______________________

b. Biofeedback ______________________

c. Chiropractic care ______________________

d. Energy healing ______________________

e. Folk remedies ______________________

f. Herbal therapy ______________________

g . High dose/megavitamin therapy ______________________

h. Homeopathy ______________________

i. Hypnosis ______________________

j . Massage ______________________

k . Relaxation ______________________

l. Spiritual healing ______________________

This page will be kept separately from the rest of the pages to ensure confidentiality.

39. Name: _________________________________ _____________________ ________

Last First MI

40. SS#: _________ - ______ - __________

41. Date of Birth: _____ / _____ / _____

Month Day Year

42. Home Phone: (_________) __________--____________

43. Work Phone: ( ________ ) _________ -- ___________

44. Gender: Male Female

45. Current marital status

____ Married

____ Separated

____ Divorced

____ Widowed

____ Single, never married

____ Single, living with partner

46. What is the highest level of education that you have completed?

____ Did not finish high school or receive GED

____ High School degree / GED / or equivalent

____ Some college, no degree

____ Associate’s degree

____ Bachelor’s degree

____ Master’s, doctorate, or professional degree

47. Current annual household income before tax:

____ less than $20,000 ____ $50,000 - $74,999

____ $20,000 - $34,999 ____ $75,000 - $99,999

____ $35,000 – $49,999 ____ $100,000 or more

48. What is your race/ethnicity (Mark all that apply)

____ White

____ Black or African American

____ Asian

____ American Indian or Alaska Native

____ Native Hawaiian or other Pacific Islander

Hispanic or Latino Yes____ No____

49. e-mail address: ______________________________________________

P

VA FORM 10-0488
MAY 2010

age 20 of 18