Form 10-0048 Former POW Medical History

OMB No. 2900-0427
Average Burden: 90 Minutes
Exp. Date: XX/XX/XXXX

Former POW Medical History
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of section 3507 of the Paperwork Reduction
Act of 1995. The public reporting burden for this collection of information is estimated to average 90 minutes per response, including the time for reviewing instructions, searching existing data
sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Respondents should be aware that not withstanding any other provision of law,
no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control number. This is intended to provide your
physician with a detailed history and physical for use during a physical examination. Failure to provide the data will have no adverse effect on benefits to which you might otherwise be entitled.
PRIVACY ACT INFORMATION: The information requested on this form is solicited under the authority of Title 38, U.S.C., Part I, Chapter 5, Section 527 that authorizes the collection of
data that will allow measurement and evaluation of the Department of Veterans Affairs Programs. The purpose(s) for collecting the information is in response to Public Law 97-37, the "Former
Prisoner of War Benefits Act of 1981," that liberalizes eligibility requirements and extends the existing benefits. Your obligation to respond is voluntary. Information from the data collection
will become part of a system of records that complies with the Privacy Act of 1974. This system is identified as "Patient Medical Record -VA (24VA19)" as set forth in the Compilation of
Privacy Act Issuances via online GPO access at http://www.gpoaccess.gov/privacyact/index.html.

PLEASE TYPE OR PRINT YOUR ANSWERS IN INK. DO NOT COMPLETE SHADED AREAS. WHEN YOU NEED MORE SPACE, CONTINUE
YOUR REMARKS ON A BLANK SHEET OF PAPER.
SECTION A. IDENTIFYING DATA
(This is a mandatory field.)

1. NAME (Last, First, Middle)

2. SOCIAL SECURITY NO. (mandatory)

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

3. VA CLAIM NUMBER

4. AGE
B. ON CAPTURE

A. PRESENT

C. ON REPATRIATION D. ON DISCHARGE

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

AIR FORCE

COAST GUARD

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

7. DATE OF MILITARY DISCHARGE

8. SPECIFY TYPE OF MILITARY
DISCHARGE

9. LAST MILITARY IDENTIFICATION NUMBER

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

RANK/GRADE

BRANCH OF SERVICE

11. MARITAL STATUS

A. AT TIME OF
INDUCTION

(Check appropriate categories)

B. AT TIME OF
CAPTURE

A. AT TIME OF INDUCTION

C. AT TIME OF
REPATRIATION

B. AT TIME OF CAPTURE

D. AT TIME OF
MILITARY DISCHARGE

C. AT TIME OF REPATRIATION

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

VIETNAM
OTHER (Specify)

Married

Divorced

Separated

Widowed

D. AT PRESENT

13. PRISONER OF WAR CATEGORY (Check all that apply)
WWII (Pacific)
WWI
WWII (Europe)
KOREAN

Single

14. THEATER(S) IN WHICH YOU PARTICIPATED (Check all that apply)
KOREA
EUROPE
PACIFIC
SOUTHEAST ASIA

SOUTHWEST ASIA

SOUTHWEST ASIA

CHINA, BURMA, INDIA

OTHER (Specify)

SECTION B. HISTORY OF CAPTIVITY
17B. IF SO, HOW LARGE WAS THE GROUP

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

16. WERE YOU CAPTURED ALONE
YES
NO

17A. WERE YOU CAPTURED IN A
GROUP
YES
NO

17C. DID THE GROUP REMAIN
INTACT DURING CAPTIVITY

17D. HOW MANY OF YOUR ORIGINAL
GROUP SURVIVED CAPTIVITY

18. CIRCUMSTANCES OF CAPTURE (Check all that apply)
DURING ISOLATION
DURING ISOLATION OF
IN A BATTLE
FROM YOUR UNIT
YOUR UNIT
DURING AN
AIRCRAFT WAS SHOT DOWN
DURING A RETREAT
ADVANCE

YES

NO

19A. WERE YOU INJURED DURING CAPTURE
(If yes, described how you were injured)
YES

ORDERED TO
SURRENDER BY
A HIGHER US OR
ALLIED AUTHORITY

NO

SHIP WAS CAPTURED/SUNK

OTHER (Specify)

19B. DESCRIBE YOUR INJURY(IES) (If you do not have enough space, continue in item 62.)

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

FARM

CONSTRUCTION

MINE

DOCK

FACTORY

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

VA FORM
AUG 2009

10-0048

21A. DID YOU PARTICIPATE IN A
PLAN TO ESCAPE
NO
YES

21B. DID YOU MAKE AN ACTIVE ATTEMPT TO
ESCAPE

21C. IF SO, WERE YOU SUCCESSFUL

22. LENGTH OF CAPTIVITY IN MONTHS

YES

YES

NO

NO

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

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25. EXPERIENCES DURING
CAPTURE

YES

NO. OF
TIMES

NO

NO. OF
DAYS

A. INTIMIDATION

YES

26. ISOLATION IN CLOSE QUARTERS

NO

NO. OF
TIMES

NO. OF
DAYS

A. PRISON SHIPS

B. BEATlNGS

IF YOU WERE ON A PRISON SHIP, WAS
IT ATTACKED

C. WITNESSED BEATINGS
B. RAILROAD CARS
D. PHYSICAL TORTURE
IF YOU WERE HELD IN A RAILROAD
CAR, WAS IT ATTACKED

E. WITNESSED PHYSICAL
TORTURE
F. PSYCHOLOGICAL TORTURE
(Brain Washing)

C. SOLITARY CONFINEMENT

G. SEXUAL ABUSE

D. OTHER (Specify)

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

29.WOUNDS AND INJURIES DURING CAPTIVITY (Check all that apply)
NONE
HEAD
CHEST

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

NO

NO

YES

30A. DID YOU EXPERIENCE

YES

NO

A. PROLONGED PERIODS OF FEAR AND ANXIETY

ABDOMEN

BACK

LEGS

OTHER (Specify)

30B. DID YOU EXPERIENCE

YES

ARMS

NO

NO. OF
TIMES

NO. OF
DAYS

A. FORCED MARCHES
WERE YOUR FORCED MARCHES ATTACKED

B. PROLONGED PERIODS OF DEPRESSION
C. PROLONGED PERIODS OF FEELINGS OF
HELPLESSNESS

B. OTHER (Specify)

D. LONELINESS AND ISOLATION FROM OTHER
POW'S

32. EXPOSURE TO
HEAT
(Check those you
experienced.)

E. PERIODS OF NIGHTMARES, CONFUSION,
OR DELIRIUM DURING CAPTIVITY
F. THOUGHTS OF SUICIDE
G. ATTEMPTS AT SUICIDE
31. RADIATION EXPOSURE (Explain specifically)

BEFORE
IN
CAPTURE CAPTIVITY

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

A. NONE

A. NONE

B. HEAT
EXHAUSTION

B. FROSTBITE

C. LOSS OF
CONSCIOUSNESS

C. TRENCHFOOT
D. IMMERSION FOOT
OR HAND

INDICATE NO. OF
TIMES PER DAY
D. OTHER (Specify):

E. IMMERSION IN
COLD WATER
F. OTHER (Specify):

34. COMMUNICATIONS

CHECK ONE

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

35. DIETARY HISTORY Estimate weight in pounds
NO
RARELY

ON ENTERING
SERVICE

WEIGHT AT TIME OF
CAPTURE

LOWEST WEIGHT IN
CAPTIVITY

PRESENT

NO

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

VA FORM
AUG 2009

10-0048

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

NONE

INADEQUATE

ADEQUATE

NONE

AVERAGE DAILY DIET

A. WATER

H. DAIRY PRODUCTS

B. BROTH

I. MEAT

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

J. NUTS

D. BREAD

K. FISH

E. LEGUMES (Peas/Beans)

L. FRUITS

F. RICE

M. VEGETABLES

G. POTATOES

N. MILLET (Small seeded cereals and
grasses)

INADEQUATE

ADEQUATE

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

YES

NO

DISEASE

YES

NO

DISEASE

YES

NO

DISEASE

DYSENTERY

TUBERCULOSIS

SKIN DISEASE

BERIBERI

MALARIA

WORMS

VITAMIN DEFICIENCY

DIPHTHERIA

PNEUMONIA

SCABIES

PELLAGRA

YES

NO

YES

NO

OTHER (Specify)

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

NO

YES

NO

YES

NO

CHEST PAINS

CAVITIES

SUNBURN

FEVER

RAPID HEART BEATS

TOOTH ABSCESS

SKIN ULCERS

FREQUENT URINATION

SKIPPED OR MISSED
HEART BEATS

LOSS OF TEETH

BOILS

BLOODY URINE

IMPAIRED VISION

SORES AT THE ANGLES
OF THE MOUTH

PALE SKIN

KIDNEY STONE

POOR NIGHT VISION

SORE TONGUE

BREAST LUMPS

UNSTEADY GAIT

PARTIAL BLINDNESS

EXCESSIVE THIRST

NAUSEA

SWELLING IN THE
JOINTS

EYE ULCERS

SWOLLEN GLANDS

VOMITING

SWELLING OF THE
LEGS AND/OR FEET

HEARING DISORDER

SKIN RASHES

DIARRHEA

SWELLING OF THE
MUSCLES

BLEEDING GUMS

BLISTERS

EPISODE(S) OF JAUNDICE

BROKEN BONES

TOOTHACHE

DRY SCALY SKIN

CHILLS

BURNS

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

NUMBNESS OR WEAKNESS
IN THE ARMS OR LEGS

ACHES OR PAINS IN THE
MUSCLES AND/OR JOINTS

PSYCHOLOGICAL OR
EMOTIONAL
PROBLEMS

40. AVAILABILITY OF MEDICAL TREATMENT
DURING CAPTIVITY

YES

(lF YES, QUALITY) 41. OPERATIONS PERFORMED DURING YOUR PERIOD OF CAPTIVITY
NO GOOD FAIR POOR
AMPUTATIONS ONLY (Specify)
NONE

A. MEDICAL TREATMENT WAS ADEQUATE
B. SURGICAL TREATMENT WAS ADEQUATE

OTHER (Specify)

C. DENTAL TREATMENT WAS ADEQUATE
42A. TYPE OF MEDICAL TREATMENT RECEIVED DURING CAPTIVITY

VA FORM
AUG 2009

10-0048

42B. HOSPITALIZATIONS (number of times and reasons for hospitilizations)

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

44. APPROXIMATE DATE
YOU WERE RETURNED TO
FRIENDLY CONTROL

45. BRIEFLY DESCRIBE THE CONDITIONS OF YOUR RELEASE AND RESCUE

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

49B. IF YES, WHAT WAS
THE PERCENTAGE

49C. WHAT WAS THE DISABILITY

50A. DID YOU EVER APPLY TO THE VA FOR DENTAL
CARE BENEFITS BASED ON YOUR FORMER POW STATUS
NO

YES

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

50C. WHAT WAS THE RATING

NO

51. DO YOU FEEL THAT YOU WERE PROMOTED TO THE RANK YOU WOULD HAVE
BEEN/ SHOULD HAVE BEEN IF YOU HAD NOT BEEN CAPTURED
NO

YES

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

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

NO

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

54A. DID YOU PERFORM
RESERVE DUTY
YES

NO

54B. IF YES, HOW MANY YEARS DID YOU
SERVE

NO

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

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

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

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

NO

YES

YES

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

NO

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

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

NO

60B. BRIEFLY DESCRIBE CURRENT MEDICAL AND/OR PSYCHOLOGICAL
CONDITIONS

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

GOOD

FAIR

POOR

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

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

YES

NO

(If yes, please explain)

63. PLEASE ADD ANY ADDITIONAL COMMENTS YOU WISH TO MAKE

64. SIGNATURE

65. DATE
(mm/dd/yyyy)

VA FORM
AUG 2009

10-0048

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