Vietnam-Era Veterans Follow-up Survey

OMB Control Number: 2900-XXXX
Estimated Burden: 45 minutes
Expiration Date: 07/31/2022

Vietnam-Era Veterans Follow-Up Study
This booklet contains questions about your current health and well-being. The purpose of this follow-up study is to better
understand changes in Veterans’ health status over time. With the information we obtain from this study, we can better
understand factors that influence changes in health and well-being over time.
Paperwork Reduction Act Statement: This information is being collected in accordance with section 3507 of the
Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor, and you are not required to respond to, a
collection of information unless it displays a valid OMB number. We anticipate that the time expended to complete this
survey will average 45 minutes. This includes the time needed to follow instructions, gather the necessary facts, and
respond to the questions. This information is being collected to better understand civilian and military factors that can
affect health and well-being over time. The results of this survey will help inform general knowledge about changes in
Veterans’ health status and treatment. Participation in this survey is voluntary, and failure to respond will not have any
impact on your entitlement to benefits.
Privacy Act Statement: Information gathered will be kept private to the extent provided by law. Data collected will be
aggregated, and no information will be attributable to you as an individual. Disclosure of information will involve release of
statistical data and other non-identifying data for improving the quality of service delivery by providing additional
background information about the participants to better serve them. Participation in this survey is voluntary, and failure to
respond will not have any impact on your entitlement to benefits.
Thank you in advance for completing this survey. If you have any questions or suggestions to decrease the burden, you
may contact our helpdesk at 877-776-5187.
Questionnaire Instructions
Please answer all the questions on the following pages as completely as possible. We are interested in your opinions.
Please remember that you are free to skip any question that makes you feel uncomfortable without any penalty or
prejudice.
Information you provide in this questionnaire will be considered privileged and held in confidence; you will not be identified
in any presentation of the results. Only your unique study identification number will appear on these questionnaire pages.
- Fill in only one box for each question unless it tells you
to "Mark all that apply."
- Please mark an "X" in the box as shown in the box to
the right:

Return your survey in the postage-paid envelope to receive $20 cash.
If you do not have the envelope, please send to:
VIETNAM VET STUDY
C/0 ALTARUM
3520 GREEN CT. STE 300
ANN ARBOR, MI 48105

Page:1

Activity

A1 Which one of the following best describes
your usual daily activities related to moving
around? Do not include exercise, sports,
or physically active hobbies done in your
leisure time.
Sit during most of the day

A6 On days when you do vigorous activities for at
least 10 minutes at a time, how much total
time per day do you spend doing these
activities?
Hours per day:

Stand during most of the day
Walk around most of the day

A2

During the past seven days, did you walk
for at least 10 minutes at a time for fun,
relaxation, exercise or to get somewhere?
Yes

No

OR Minutes per day:

A7 In a usual week, do you do light or
moderate activities for at least 10 minutes
at a time that cause only light sweating or
a slight to moderate increase in breathing
or heart rate (such as brisk walking,
bicycling, vacuuming, gardening, etc.)?
Yes

No à Go To A10

A8 How many days per week do you do these
A3

During the past 12 months, have you
increased your physical activity or
exercise?
Yes

No

light to moderate activities for at least 10
minutes?
Number of days:

A9 On days when you do light to moderate
A4 In a usual week, do you do vigorous
activities for at least 10 minutes at a time
that cause heavy sweating or large
increases in breathing or heart rate (such
as running, aerobics, heavy yard
work, etc.)?
Yes

No à Go to A7

activities for at least 10 minutes at a time, how
much total time per day do you spend doing
these activities?
Hours per day:

OR Minutes per day:

The following questions are about your use
of tobacco and alcohol.
A5 How many days per week do you do these
vigorous activities for at least 10 minutes
at a time?
Number of days

A10 In your lifetime, have you smoked a total
of at least 100 cigarettes, cigars, or pipes?
Yes

No

à Go To A14

Page:2

A11 Have you ever smoked daily or almost
every day for at least 1 year?
Yes

No

A17 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

A12 Do you smoke now?
Yes, daily

Monthly

Yes, occasionaly

Weekly

Not at all

Daily or almost daily

A13 What tobacco products do you use?
Cigarette

Pipe

Cigar

Smokeless
(e.g.,dip, snuff)

A18 Please select the statement below which
best describes you at present.
Former drinker
Occasional drinker
Light drinker

For the following questions, a drink is a 12
oz beer, a 5 oz glass of wine, or 1.5 oz of
liquor
A14 During your entire life, have you had at
least 12 drinks of any type of alcoholic
beverage?
Yes

Moderate drinker
Heavy drinker
Teetotaler (I never drank)
Other (please specify)

No à Go To A18

A15 In the past 6 months, how often did you
have a drink containing alcohol?

The following question is about your sleep
habits.

Never
Monthly
2-4 times per month

A19 On average, how many hours do you
sleep per night?

2-4 times or less a week

Less than 2 hours

4 or more times a week

2 or more hours but less than 4 hours
4 or more hours but less than 6 hours

A16 In the past 6 months, how many drinks of
alcohol did you have on a typical day
when you were drinking?
1 or 2

6 or more hours but less than 8 hours
8 or more hours but less than 10 hours
10 hours or more

3 or 4
5 or 6
7, 8, or 9
10 or more
Not applicable
Page:3

The following questions are about your ability to perform various activities involved in daily
living.
B1 In general, would you say your health is:
Excellent
Very good

B4 The following items are about activities
you might do during a typical day. Does
your health limit you in these activities? If
so, how much?
Yes,
Yes, No, not
limited a limited a limited
lot
little
at all

Good
Fair
Poor

B2 In the past week, how much assistance did
you require in the following activities due
to a health condition?

a. Moderate activities,
such as moving a table,
pushing a vacuum cleaner,
bowling, or playing golf.
b. Climbing several flights
of stairs

I am
completely
I can do
I can do dependent
without any with some
on
I do not do
assistance assistance assistance this activity

a. Bathing

B5 During the past 4 weeks, have you had
any of the following problems with your
work or other regular daily activities as a
result of your physical health?

b. Eating
c. Transferring
from bed or a
chair
d. Using the toilet
e. Walking around
your home

No,
none
of the
time

f.Dressing
g. Preparing
meals
h. Managing your
money
i. Doing household
chores
j. Using the
telephone
k. Taking
medications
properly

Yes,
some
of the
time

Yes,
most
of the
time

Yes,
all of
the
time

a. Accomplished less
than you would like
b. Didn’t do work or
other activities as
carefully as usual

B3 The following questions ask you to
compare your health one year ago to your
health now.
Some About Some
Much -what the -what Much
better better same worse worse

a. Compared to one year
ago, how would you rate
your physical health in
general now
b. Compared to one year
ago, how would you rate
your emotional health in
general now

Yes, a
little
bit of
the
time

B6 During the past 4 weeks, 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)?
Yes, a
No, little Yes, Yes, Yes,
none bit of some most all of
of the the of the of the the
time time time time time

a. Accomplished less
than you would like
b. Didn’t do work or
other activities as
carefully as usual
Page:4

B7

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

B8

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 best 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

Good bit of Some of the A little of the None of the
the time
time
time
time

a. Have you felt calm and peaceful?
b. Did you have a lot of energy?
c. Have you felt downhearted and blue?
d. How much of the time has your
physical health or emotional problems
interfered with your social activities (like
visiting with friends, relatives, etc.)?

B9

In the past 30 days, how much difficulty did you have in ….
None

Mild

Extreme/
Moderate Severe cannot do

a. Standing for long periods, such as 30 minutes?
b. Taking care of your household responsibilities?
c. Learning a new task, for example, learning how to get to a new
place?
d. Joining community activities (for example, festivities, religious or
other activities) in the same way as anyone can?
e. How much have you been emotionally affected by your health
problems?
f. Concentrating on doing something for ten minutes?
g. Walking a long distance such as a kilometer (or equivalent)?
h. Washing your whole body?
i. Getting dressed?
j. Dealing with people you do not know?
k. Maintaining a friendship?
l. Your day-to-day work?

Page:5

The following questions are about specific health conditions and your history with these
conditions.
C1 Have you ever been told by a doctor or other health professional that you had any of the
following Circulatory System conditions? Select all that apply.
Yes

I currently take medication
and/or receive treatment for
this condition

a. High blood pressure (hypertension)
b. Stroke
c. Transient ischemic attack (TIA)
d. Heart disease
e. Heart attack
f. Coronary artery/ coronary heart disease (includes angina)
g. Peripheral vascular disease
h. High cholesterol
i. Congestive heart failure
j. Anemia

C1.1 If applicable, please tell us the year that you were diagnosed with the following conditions.

C2

a. Stroke

Year Diagnosed:

b. Transient ischemic attack (TIA)

Year Diagnosed:

c. Heart attack

Year Diagnosed:

Have you ever been told by a doctor or other health professional that you had any of the
following Mental Health conditions? Select all that apply.
Yes

I currently take medication and/or
receive treatment for this
condition

a. Panic disorder
b. Generalized anxiety disorder (GAD)
c. Social Phobia
d. Other anxiety disorder
e. Attention deficit hyperactivity disorder
f. Bipolar disorder
g. Depressive disorder
h. Posttraumatic stress disorder (PTSD)
i. Eating disorder
j. Personality disorder
k. Schizophrenia
Page:6

C3 Have you ever been told by a doctor or other health professional that you had any of the
following types of Cancer? Select all that apply.
Yes

I currently take medication and/or
receive treatment for this
condition

a. Breast cancer
b. Prostate cancer
c. Testicular cancer
d. Colon cancer/ Rectal cancer
e. Lung cancer
f. Skin cancer
g. Brain cancer
h. Liver cancer
i. Pancreatic cancer
j. Respiratory cancers (e.g., lung, larynx, throat, tonsil)
k. Urinary bladder cancer
l. Soft tissue sarcoma
m. Thyroid cancer
n. Other cancer:

C3.1 If applicable, please tell us the year that you were diagnosed with the following conditions.
a. Breast cancer

Year Diagnosed:

b. Prostate cancer

Year Diagnosed:

c. Colon/rectal cancer

Year Diagnosed:

d. Lung cancer

Year Diagnosed:

e. Brain cancer

Year Diagnosed:

f. Liver cancer

Year Diagnosed:

g. Pancreatic cancer

Year Diagnosed:

h. Respiratory cancers

Year Diagnosed:

Page:7

C4 Have you ever been told by a doctor or other health professional that you had any of the
following types of Nervous System conditions? Select all that apply.
Yes

I currently take medication
and/or receive treatment for this
condition

a. Migraine headaches
b. Memory loss or impairment
c. Dementia (includes Alzheimer’s, vascular, etc.)
d. Concussion or loss of consciousness
e. Traumatic brain injury
f. Spinal cord injury or impairment
g. Epilepsy/seizure
h. Parkinson’s disease
i. Amyotrophic lateral sclerosis ALS or Lou Gehrig’s
disease
j. Multiple sclerosis

C4.1 If applicable, please tell us the year that you were diagnosed with the following conditions.

a. Dementia

Year Diagnosed:

b. Parkinson’s disease

Year Diagnosed:

c. Amyotrophic lateral sclerosis

Year Diagnosed:

d. Multiple sclerosis

Year Diagnosed:

Page:8

C5 Have you ever been told by a doctor or other health professional that you had any of the
following Health conditions? Select all that apply.
Yes

I currently take medication
and/or receive treatment for
this condition

a. Enlarged prostate (benign prostatic hyperplasia)
b. Asthma
c. Chronic lung disease (COPD, emphysema, or bronchitis)
d. Diabetes/”sugar”
e. Liver condition (e.g., cirrhosis)
f. Skin condition (e.g., eczema, psoriasis)
g. Sleep apnea
h. Thyroid problems
i. Fibromyalgia
j. Hepatitis B
k. Lupus
l. Lyme disease
m. Cataracts
n. Glaucoma
o. Macular degeneration
p. Blindness, all causes
q. Tinnitus or ringing in the ears
r. Severe hearing loss or partial deafness in one or both
ears
s. Tuberculosis
t. Hepatitis C
u. HIV/AIDS
v. Kidney disease without dialysis
w. Kidney disease with dialysis
x. Acute kidney disease with no current dialysis
y. Irritable bowel syndrome (IBS)
z. Ulcerative colitis
aa. Crohn’s disease
bb. Celiac disease / Sprue
cc. Osteoarthritis
dd. Rheumatoid arthritis
ee. Osteoporosis

C5.1 If applicable, please tell us the year that you were diagnosed with the following conditions.
a. Chronic lung disease

Year Diagnosis:

b. Diabetes/”sugar”

Year Diagnosis:

Page:9

The following questions are for women only. Select all that apply.
C6 Women's Health Conditions
No

Yes

Not
Sure

a. Have you had a hysterectomy?
b. Have you had both of your ovaries removed?
c. Have you ever taken female hormones (other than birth control pills or fertility drugs) for any
reason? (Female hormones include estrogens or progestins, hormone patches or creams,
hormone injections, or postmenopausal hormones).
d. During and after menopause, women are sometimes prescribed estrogen (Examples
include “Estrogen”, “Conjugated Estrogen”, “Premarin”, “Estrogen Patch”, “Combined
Estrogen/Progestin”). Have you ever taken menopausal estrogens?
e. During and after menopause, women are sometimes prescribed progestin (Examples
include “Provera, Medroxyprogesterone”, etc.) Have you ever taken menopausal progestins?

These next few questions ask about your experience with benefits provided by the
Department of Veterans Affairs. This does not include tuition assistance (TA) you may have
received while on active duty.
D1

Have you used any VA education or
training benefits, excluding VA
vocational rehabilitation?
Yes

D2

D4

Yes, I received services at VA, or they
were paid for by VA (including the
Mission Act)
No, I received services, but not from
VA and were not paid for by VA
No, I did not receive any health care
services

No

Have you ever been enrolled in VA
health care?
Yes

In the last 6 months, did you use any VA
health care services, or did you have
any of your health care paid for by VA?

Don’t know/don’t remember

D5

No
Don’t know

Where do you go to get health care?
Select all that apply.
VA hospital or clinic that is part of VA
Hospital that is not part of VA
(emergency room)
Urgent care facility
Community health center

D3

Have you ever used any VA health care
services?
Yes

Do not get health care

D6

No

à Go to D5

Don't know

à Go to D5

Do you have a VA service-connected
disability rating?
Yes

No à Go to D10

Page:10

D7

What is your current VA service-connected
disability rating?

D9

For what conditions?
Physical/medical conditions

%

D8

Mental health conditions
Both physical and mental health
conditions

When did you get this rating?
In the past year
2 – 5 years ago

D10

6 - 10 years ago

Do you receive a non-service-connected
disability pension from the VA?

More than 10 years ago

Yes

No

D11 During the past year, how important was the disability payment benefit you received from VA in
helping you meet your financial needs?
Extremely important
Very important
Moderately important
Slightly important
Not at all important
Don’t know

D12 Indicate whether you have used any of the following types of health care services in the past 6
months. If so, please indicate if you received this care at a VA facility.
Received this care
(past 6 months)?

Did you receive this care
at a VA facility?

a. Overnight stay in a hospital for medical or surgical care
b. Outpatient care for doctor visits, urgent care, routine exams,
medical tests, or shots
c. Overnight stay in a hospital for mental health or substance abuse
treatment
d. Prescription medications
e. Over the counter medications
f. In-home health care for yourself
g. Care for any prosthetics or medical equipment, including home
oxygen
h. Care for hearing aids or eye glasses
i. Overnight stay in a rehabilitation hospital or nursing care facility
j. Dental care
k. Emergency room
l. Other types of medical treatments

Page:11

D13 How much do you agree or disagree with the following statements?
Completely Somewhat
agree
agree

Neither
agree nor
disagree

Somewhat Completely
disagree
disagree

N/A

a. If the cost of health care to me increases, I
will use VA more
b. I would only use VA if I did not have access
to any other sources of health care
c. I have a doctor outside VA who I really like
and trust
d. Veterans who can afford to use other
sources of health care should leave the VA to
those who really need it
e. Veterans like me who use VA are satisfied
with the health care they receive
f. VA health care providers explain
treatment/diagnoses in a way that patients can
understand
g. There is a VA provider in my area that offers
all of the health care services that Veterans like
me need
h. I have one particular health care provider
who is in charge of my care

D14

If you needed long-term Nursing Home Care, would you …
Definitely go to the VA?
Maybe go to the VA?
Definitely go somewhere else?

D15

What are the ways you plan to use VA health care in the future? Select all that apply.
As a primary source of health care
Backup to non-VA care for specialized services
A “safety net” to use only if needed
For prescriptions
For specialized care
Some other way
No plans to use VA for health care

Page:12

D16

Are you currently covered by any of the following types of health insurance or health coverage
plans? Select all that apply.
Not covered by any health insurance or health plan
Insurance through a current or former employer or union (of yours or another family member)
Insurance purchased directly from an insurance company (by you or another family member)
Medicare, for people 65 and older, or people with certain disabilities
Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low
incomes or a disability
VA
TRICARE, TRICARE For Life, CHAMPVA, CHAMPUS or other military health care
Indian Health Services
Any other type of health insurance or health coverage plan (please specify)

In this section we are going to make a series of statements about the VA. For each question,
select the one answer that best reflects how true or correct the statement is for you.
D17

How long does it take to travel from your
home to the VA facility nearest your
home?

D20

Do you use the VA Outpatient Facility as
your primary source for medical care?
Yes

No

Less than 1 hour
Between 1 and 2 hours
Between 2 and 4 hours
More than 4 hours

D18

Have you ever sought treatment at a VA
Hospital or Outpatient Facility?
Yes

No

à Go to D23

D21 About how many times have you used the
VA Hospital or Outpatient Facility in the
past 3 years?
1 - 2 times
3 - 5 times

D19

When was the last time you used the VA
Outpatient Facility?

6 - 10 times
11 or more

Past 3 months
Past 6 months
Past 1 year
Past 3 years
Past 5 years

Page:13

D22 If you have been treated at a VA facility, how correct or true are the following statements about
your actual experiences with the VA healthcare system the last time you used it?
Not true

Slightly true Moderately true

Very true

a. I was given an appointment within a reasonable time
b. The medical staff of the VA has a positive attitude
toward Vietnam veterans
c. Vietnam veterans are treated the same as veterans of
other wars
d. The medical staff is competent
e. The staff of the VA is well aware of special Vietnam
veteran needs like Agent Orange
f. I was asked about the possibility of exposure to Agent
Orange
g. There is an adequate staff at the VA to meet patient
needs
h. When I tell the doctor something, I am confident it was
completely understood
i. The doctor is able to communicate effectively and
clearly to me
j. The VA service is well organized and smoothly running
k. There is a lot of paperwork and “red tape” involved in
using the VA
l. The staff at the VA is courteous to patients
m. The staff at the VA is helpful to me in filling out the
required paperwork
n. The facilities available for doing the paperwork are
private
o. I have always been fully informed about the
examinations and tests I have undergone at the VA
p. Taken all in all, the service at the VA is as good as
most other health care facilities I have dealt with
q. I am confident the VA will always “be there” for me in
the future

Page:14

D23 Have you ever seen anyone for advice and help with emotional, nervous or mental problems?
Yes

No à Go to next page

D24 When did you first seek this help? (enter year)

D25 Have you seen anyone during the past six months for an emotional, nervous or mental
problem?
Yes

No

D26 Did you ever go to a VA facility for help with an emotional, nervous or mental problem?
Yes

No à Go to E1

D27 When did you first go? (enter year)

D28 During your examination at the VA, were you asked…
Yes

No

a. Whether you were ever in a life-threatening situation?
b. Whether you were ever in combat?
c, Whether bad memories from the service come back to you?
d, Whether you have nightmares about the service?
e. Whether you avoid situations that remind you of the service?
f. Whether you ever experienced military sexual trauma?

Page:15

SOUTHEAST ASIA MILITARY SERVICE
In this section we are going to ask a series of questions about your service experiences in
Southeast Asia. If you did not serve in that area of the world, check the box below and go to
question E4.
I did not serve in Southeast Asia àGo to E4

We are interested in finding out what you remember about whether you were exposed to
defoliating herbicides, such as Agent Orange, which were used to kill jungle cover in
Southeast Asia. If you believe you were exposed to such a chemical agent, either directly
loading it, spraying it, or entering a freshly sprayed area, we would like you to describe how
you were exposed, for how long and whether you felt any immediate effects.
If you don’t remember being directly exposed to herbicides check the box below and go to
question E4.
I don't remember being directly exposed to herbicides àGo to E4

E1

Exposure situations. Listed below are some ways in which servicemen may have been
exposed to herbicides. Check all the ways in which these situations apply to you.
Did you
hold this job?
No

Yes

Did you experience
immediate effects?
No

Yes

What were these effects?
Skin
Coughing irritation

Nausea

Other

a. Sprayer on airplane (C-123)
b. Sprayer on helicopter
c. Sprayer on boat
d. Loader/handler of spray for a
plane, helicopter or boat
e. Job involving clearing vegetation
and/or patrolling around camp,
roads or clearing fire free zones
f. Slept in/walked through sprayed
areas. Exposed to herbicides used
near camp or on roads you traveled
on
g. Other jobs or situations involving
exposure (please specify below)

E2

Estimate the total number of weeks you were exposed to herbicides.
Weeks

E3

Did you participate in Operation Ranch Hand?
Yes

No

Page:16

For the next two questions, think back to your service during the Vietnam War era (1961-1975).
E4

Did you have any injury(ies) from any of the following? Please only include injuries from your
military service during the Vietnam War era (1961-1975). Select all that apply.
Fragment or shrapnel
Bullet
Vehicular (any type of vehicle, including airplane)
Fall
Blast (Booby trap, RPG, Land mine, Grenade, etc.)
Other (please specify)

E5

Did you have a concussion or head injury during your service?
No à Go to E8

Yes

E6

E7

Approximately how many times did this occur?

Did you experience any of the following symptoms? Select all that apply.
No problems at the time
of the injury
Did not remember what
happened immediately
before the event
Headaches

Ringing in the ears

Memory problems

Nausea

Sleep problems

Dizziness

Balance problems

Irritability

Confusion

Double-vision

For the next question, please include any injury, whether or not it was related to your military
service. Do not include any injuries you reported in questions E4 and E5.
E8

Have you ever had concussions or brain injuries from any of the following? Select all that
apply.
Military training

Accidents (vehicular, falls, etc.)

Playing sports

Violence (non-military)

Page:17

Life experiences often have some mixture of the desirable and undesirable. The following are
experiences that some individuals feel resulted from their military service. From the two lists
of desirable and undesirable experiences, please indicate to what extent you experienced
each one by selecting the appropriate box to the right of each statement.
F1

Desirable Experiences
Not at all

A little

Somewhat

A lot

Not at all

A little

Somewhat

A lot

a. Lifelong friends
b. A broader perspective on things
c. Learned to cope with adversity
d. Greater self-discipline, dependability
e. Became more independent
f. Improved life chances through education
g. Value life more
h. Positive feelings about self
i. Became proud to be an American
j. Clearer direction and purpose in life
k. Better job skills and options
l. Rewarding memories
m. Learned cooperation, teamwork
n. Appreciate peace more

F2

Undesirable Experiences
a. Economic problems for me or my family
b. Disrupted my life
c. Lonely for my family
d. Delayed career, put me behind age mates
e. Combat anxieties, apprehensions
f. Hurt my marriage
g. Waste of time, boredom
h. Misery, discomfort
i. Loss of friends
j. Lost my good health
k. Separation from loved ones
l. Drinking problem
m. Bad memories or nightmares
n. Death and destruction

Page:18

F3

Please think about your military experience, and what was the most distressing or disturbing
event that occurred during that time. Below is a list of problems that people sometimes have in
response to a very stressful experience. Please read each problem carefully and then mark one
of the boxes to the right to indicate how much you have been bothered by that problem in the
past month.
Not at all

A little bit Moderately Quite a bit Extremely

a. Repeated, disturbing, and unwanted memories of the
stressful experience?
b. Repeated, disturbing dreams of the stressful experience?
c. Suddenly feeling or acting as if the stressful experience were
actually happening again (as if you were actually back there
reliving it)?
d. Feeling very upset when something reminded you of the
stressful experience?
e. Having strong physical reactions when something reminded
you of the stressful experience (for example, heart pounding,
trouble breathing, sweating)?
f. Avoiding memories, thoughts, or feelings related to the
stressful experience?
g. Avoiding external reminders of the stressful experience (for
example, people, places, conversations, activities, objects, or
situations)?
h. Trouble remembering important parts of the stressful
experience?
i. Having strong negative beliefs about yourself, other people, or
the world (for example, having thoughts such as: I am bad,
there is something seriously wrong with me, no one can be
trusted, the world is completely dangerous)?
j. Blaming yourself or someone else for the stressful experience
or what happened after it?
k. Having strong negative feelings such as fear, horror, anger,
guilt, or shame?
l. Loss of interest in activities that you used to enjoy?
m. Feeling distant or cut off from other people?
n. Trouble experiencing positive feelings (for example, being
unable to feel happiness or have loving feelings for people
close to you)?
o. Irritable behavior, angry outbursts, or acting aggressively?
p. Taking too many risks or doing things that could cause you
harm?
q. Being “superalert” or watchful or on guard?
r. Feeling jumpy or easily startled?
s. Having diffculty concentrating?
t. Trouble falling or staying asleep?

Page:19

F4

The following statements ask about your attitudes, experiences, and thoughts about your
military service, and how these may have changed compared to when you were younger.
Please read each item carefully and mark the choice that best applies. When responding to
these statements, think about the war(s) in which you served.
Neither
Strongly
disagree
disagree Disagree or agree

Strongly
agree

Agree

a. I think about the war more than I used to
b. Everyday things have started reminding me of the war
c. As I get older, I get more upset when talking about the war than I
used to
d. My family and friends tell me that I have recently been speaking
more emotionally about the war
e. I dream about the war more now than when I was younger
f. These days, I become more emotional around certain days or
anniversaries that remind me of the war
g. Lately, my thoughts about the war bother me more
h. I need to talk about the war more now than when I was younger
i. These days, I think more about my role in the war
j. When I am faced with stressful events, I find myself thinking
about the war
k. Lately, I think more about friends I lost during the war

It is possible for the same experience to be both positive and negative.
F5

Worst

1

Best

2

3

4

5

6

7

8

9

2

3

4

5

6

7

8

9

10

Considering the very best periods of your
life, where would you place military
service, on a scale from 1-10, with 1
being the worst and 10 being the best?

F6

Worst

1

Best

10

Considering the very worst periods of
your life, where would you place military
service, on a scale from 1-10, with 1
being the worst and 10 being the best?
Definite
disadvantage

F7

1

Definite
advantage

2

3

4

5

6

7

8

9

10

Overall, would you say that the
experience of military service has turned
out to be more of a disadvantage or
advantage in life, on a scale from 1-10,
with 1 being a definite disadvantage and
10 being a definite advantage?

Page:20

Least
influential

F8

1

Most
influential

2

3

4

5

6

7

8

9

10

Considering the most influential events in
your life, where would you place military
service as an influence on the person you
are now, on a scale from 1-10, with 1
being least influential and 10 being most
influential?

G1

Below are several statements with which you may agree or disagree. Indicate your agreement
with each item by selecting the appropriate response.
Neither
Strongly
Slightly agree nor
Disagree Disagree Disagree disagree

Slightly
agree

Agree

Strongly
agree

a. In most ways my life is close to ideal
b. The conditions of my life are excellent
c. I am satisfied with my life
d. So far I have gotten the important things I
want in life
e. If I could live my life over, I would change
almost nothing

G2

When you were a child, younger than 18, did you experience the following? Select all that
apply.
No

Yes

a. Death of mother
b. Death of father
c. Permanent separation from mother
d. Permanent separation from father
e. Have a parent that had problems with drugs or alcohol and/or emotional difficulties
f. Sexual abuse by someone in charge of your care
g. Physical abuse by someone in charge of your care

G3

Since you were an adult, 18 or older, did you experience the following ever or while in the
military? Select all that apply.
Yes, ever

Yes, in the military?

a. Sudden unexpected death (due to suicide, murder, or sudden illness) of
someone you were very close to
b. Sexual activity against your will because of force or threat of force
c. Separation from your child due to loss of custody
d. Death of a child
e. Physical assault (e.g., beat up) by someone with whom you had a
sustained relationship (e.g., boyfriend)
f. Witness someone else being physically assaulted
g. Serious natural or man-made disaster (e.g., hurricane, earthquake, fire)
h. Combat (e.g., incoming fire, physical threat)
i. During any of the above-mentioned events, in childhood or adulthood,
did you expect that you would be killed?

Page:21

Thinking about the events reported above, indicate the degree to which the listed changes
occurred in your life as a result of the event.
G4

As a result of this event,
Did not Very small
experience degree

Small
degree

Moderate
degree

Great
degree

Very great
degree

a. I changed my priorities about what is important in life
b. I have a greater appreciation for the value of my own life
c. I developed new interests
d. I have a greater feeling of self-reliance
e. I have a better understanding of spiritual matters
f. I more clearly see that I can count on people in times of
trouble
g. I established a new path for my life
h. I have a greater sense of closeness with others
i. I am more willing to express my emotions
j. I know better than I can handle difficulties
k. I am able to do better things with my life
l. I am better able to accept the way things work out
m. I can better appreciate each day
n. New opportunities are available which wouldn’t have been
otherwise
o. I have more compassion for others
p. I put more effort into my relationships
q. I am more likely to try to change things which need
changing
r. I have a stronger religious faith
s. I discovered that I’m stronger than I thought I was
t. I learned a great deal about how wonderful people are

Page:22

The following questions are about your health and well-being.
Your Well-Being
H1

Thinking about only the past 7 days …
Not at all

A little bit

Somewhat

Quite a bit

Very much

a. I have been able to concentrate
b. I have been able to bring to mind words that I wanted to use
while talking to someone
c. I have been able to remember things, like where I left my
keys or wallet
d. I have been able to remember to do things, like take
medicine or buy something I needed
e. I am able to pay attention and keep track of what I am doing
without extra effort
f. My mind is as sharp as it has always been
g. I am able to shift back and forth between two activities that
require thinking
h. My memory is as good as it has always been
i. I am able to keep track of what I am doing, even if I am
interrupted

H2

In the past 7 days …
Never

Rarely

Sometimes

Often

Always

a. I felt worthless
b. I felt that I had nothing to look forward to
c. I felt helpless
d. I felt sad
e. I felt like a failure
f. I felt depressed
g. I felt unhappy
h. I felt hopeless

Page:23

H3

In the past 7 days …
Never

Rarely

Sometimes

Often

Always

a. I felt fearful
b. I found it hard to focus on anything other than my
anxiety
c. My worries overwhelmed me
d. I felt uneasy
e. I felt nervous
f. I felt like I needed help for my anxiety
g. I felt anxious
h. I felt tense

H4

How much of the time during the past 4 weeks did you …
All of the
time

Most of the
time

Good bit of Some of the A little of the None of the
the time
time
time
time

a. Have difficulty reasoning and solving
problems? For example, making plans, making
decisions, and/or learning new things?
b. Have difficulty doing activities involving
concentration and thinking?
c. Become confused and start several actions at
a time?
d. Forget, for example, things that happened
recently, where you put things, and/or
appointments?
e. Have trouble keeping your attention on any
activity for very long?
f. React slowly to things that were said or done?

Page:24

Recent Life Issues
Please read each item below. Indicate if you experienced it during the past year or ever in your
lifetime. Check both if apply.
I1

Have you experienced …
Yes, in past year

Yes, in my lifetime

a. Deterioration of memory?
b. Death of spouse?
c. Institutionalization of spouse?
d. Death of son or daughter?
e. Death of a parent?
f. Death of other close family member?
g. Major personal injury or illness?
h. Retirement?
i. Divorce?
j. Major deterioration in financial state?
k. Marital separation?
l. Marriage?
m. Death of a friend?
n. Major deterioration in health or behavior of a family member?
o. Major decrease in activities that you really enjoyed?
p. Child’s divorce or marital separation?
q. Decrease in responsibilities or hours at work or where you
volunteer?
r. Increase in responsibilities or hours at work or where you
volunteer?
s. Move to a less desirable residence?
t. Change to a less desirable line of work?
u. Spouse retired?
v. Deterioration in living conditions?
w. Troubles with the boss or coworkers?
x. Worsening relationship with a child?
y. Worsening relationship with your spouse or partner?
z. Assuming major responsibility for a parent?
aa. Institutionalization of parent?
bb. Loss of a very close friend due to a move or break in friendship?
cc. Being burglarized or robbed?
dd. Loss of prized possessions due to move?

Page:25

Your Social Support
People sometimes look to others for companionship, assistance, or other types of support.
How often is each of the following kinds of support available to you if you need it?
J1

How often is the following support available to you?
None of A little of Some of Most of All of the
the time the time the time the time time

a, Someone to help you if you were confined to bed
b. Someone you can count on to listen to you when you need to talk
c. Someone to give you good advice about a crisis
d. Someone to take you to the doctor if you needed it
e. Someone who shows you love and affection
f. Someone to have a good time with
g. Someone to give you information to help you understand a situation
h. Someone to confide in or talk to about yourself or your problems
i. Someone who hugs you
j. Someone to get together with for relaxation
k. Someone to prepare your meals if you were unable to do it yourself
l. Someone whose advice you really want
m. Someone to do things with to help get your mind off things
n. Someone to help with daily chores if you were sick
o. Someone to share your most private worries and fears with
p. Someone to turn to for suggestions about how to deal with a personal
problem
q. Someone to do something enjoyable with
r. Someone who understands your problems
s. Someone to love and make you feel wanted

About You
K1

What is your current relationship status?
Married
Divorced

K2

Is there someone for whom you are the
primary caregiver?
Yes

No

à Go to K4

Separated
Widowed
Single/never married
In a romantic relationship and living as a
couple
In a romantic relationship but not living
as a couple

Page:26

K3

What is their relationship to you? Select
all that apply.

K6

What was your family annual income
(before taxes) last year?

Spouse/partner

Under $25,000

Parent

$25,000 - $49,999

Child

$50,000 - $99,999

Sibling

$100,000 or higher

Grandparent
Grandchild
Other (please describe)

K7

About how tall are you without shoes?
Feet
Inches

K4

What is your current employment
situation? Select all that apply.
Working for pay full-time (30 hours or
more per week)
Working for pay part-time (less than 30
hours per week)

K8

About how much do you weigh without
clothes or shoes?
lbs

Working at more than one job
Working as a volunteer (no pay)
Not working but actively looking for work
Not working and not looking for work

K9

How do you describe your race/ethnicity?
Select all that apply.

Disabled

Native American or Alaska Native

Homemaker

Black or African American

Retired

Asian

Other (please describe)

Filipino
West Asian/Middle Eastern/North
African
Hispanic/Latino

K5

Which of these best describes your
present situation?
I really can’t make ends meet with the
income I now have
I just about manage to get by with the
income I now have
I have enough to get by and even a little
extra
I can buy pretty much anything I want
with the income I now have

Native Hawaiian
Other Pacific Islander (please specify in
first box below)
White/European
Other race /ethnicity (please specify in
second box below)
Other Pacific Islander
Other race/ethnicity:

Page:27

If you are feeling any distress after completing this survey, please call the anonymous
VA Crisis Line at 1-800-273-TALK (8255). The Crisis Line can help you find out about
additional help in your area, or you can just talk about any concerns. The people who
answer the phone are professionals who are trained and experienced in talking with
others about various problems and situations. You can all anytime, 24 hours a day, 7
days a week. This free service has no connection with this study.
Thank you for taking the time to complete this survey. You will be mailed $20 in cash once the
survey is received. Please remember that all the information you have provided is confidential.
Someone may be contacting you in a few weeks to invite you to participate in a telephone
interview that is a continuation of this study. You will receive an additional $20 after
completing the telephone interview.
The best phone number(s) to reach you:

-

-

-

-

Home
Cell
Work

Home
Cell
Work

Please indicate the most convenient times to reach you.Select all that apply.
Days
Evenings
Weekends

What time zone do you live in?
Alaskan Standard Time (AKST)
Atlantic Standard Time (AST)
Central Standard Time (CST)
Eastern Standard Time (EST)
Hawaii-Aleutian Standard Time (HST)
Mountaint Standard Time (MST)
Pacific Standard Time (PST)

Page:28