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Appendix H Persian Gulf Registry Code Sheet 123
9. RACE/ETHNiCITY (Enb~ orKe code st rtoht) 1 ~en InO.stn or Al~ban Nat~e' 3~eck, Not d Hi~c Or~rt ~ Ht~sente 2~.n or P - k l~r 4 Wnitet, Net of Hl~c Oript "Unb~own 124 ADEQUACYOFTHE VA PERSIAN GULFREGISTRY AND UCAP PERSIAN GULF REGISTRY CODE SHEET ~ ~ ~_ Ule IDIOnn~OO the vekrut ·upplie~t r~ety be di~tclo~od outside the VA to Fedaal, St k and h~l pVCaDmCDt egonc~t etDd N.tioDal Health Oreg~n;~rioo~t to a4ut r~ tht devdoprnertt o, p f rtue~ch pU~pOBUt u~d r~her WClt Jlt ~tatod in tbe 'Notice of Sy~tt~ ~ of VA Record~t- pctblishod ID the Fodenl Register Ut ~r~Ce V~;tD t~ Priv~ Act of 1974 t or INSTRUCTIONS: Ple~e p~tt. Uee or~ly oDe htkr or sumber per blocL lf poutibh usc bistcic bellporDt or fat-tip p~ Sh~d ueae for VA use or~ly. (DO NOT US8 BLU8 INX) 2. LAST NAME (1-33) 1111111111111111111111111 3. FIRST NAt~E (34~8) 1 1 1 1 1 1 1 1 1 6. SOCIAL SECURITY NUMBER (00~) (60) i. MIDDLE NAbtE (49.S8) 1 r~ 1 1 1 1 7. D.O.B. (C4~tt..c bl~t) MO (70 71) DAY (72~73 ) YR (74-75) III ................ cl. ADDRESS (St~cet Ne~e rtitC Ap~rtt Number, I' a - ~tt) 70~101 1111111111111111 b~ CtTY OR TOWN (102~127) 1 1 1 1 1 1 1 1 1 1 1 8D. LEAVE BLANK (133) (134) (13S) (136) _ 10. t`ARITAL STATUS (Enta, or~e code at rigM) 1 ~nbd 3~petrreted 5~s', N~r ~htrrbd 2~d 4 Widowd 8B. COUNTY STATE 1 1 ~ 1 8C. DP CODE (12B-132) . 142 . 145 . ~.. 143 . 146 147 F 1 MO(1S6~1S7)| YR(1~1S9) 1 ~MO(100~101)| YR(1i 12~103) B. NEXT TO W M | l l | | O | l l l 11.SEX(Ertit~ronee | 144 | 12.cuRRENTSTATUS(Entercnecoodettretrbi~t) oodee at rigl~t) I ~ 1 · topatbat 3. tacaert er~d 5-Active D~ty llepetiert) l 1 2 · OtApathent 4 -Active O~,y [Outpatient) 13 BRA - >t OF 8ERVICE {# more ttYen crue, er~r t~et P - _, OUII 8e~e) 1.Anny 3~.v,y 5-Coacat Owd 2-Alr Fo~s' 4~ Corpe ~r . . 14. OID VETERAN HAVE MILITARY SERVICE IN PERSIAN OULF MEA? Y.Y - . (n 'Ye~e', llcet b~ thee datace d v~ntr.'s laet tvect p~'d ~t ~tt)N - k, (' ·No', Pw' au# v~, nr~t "gbice 1Or POR ~orn. 1 F 1 MO (14~143) 1 YR (1S0 151) A. LAST PERtOO I R I l l l 1 164 l 1 1 MO(152-153)| YR(154~1SCi) 1 1 1 1 1 | 1SB. IF OTHER SERVICE OR ~DONT KNOvr | (Enter epprop~tt~tt codcc h bbd' 104) 1 4 · Other (Speel~y I.e. Alr Foreet, | Orourd or Alr Crttw. e le.) I S - Dortl Knr.'w 154. IN WHAT AREAS DID VETERAN SERVE7 (Enter e - ,oroDrktt ood~' h bb" 104) 1 - Ccml~tht ZO~c 2 · Oth" Larte k~e 3 - SKC Duty 108 UST t~tLITARY OCCUPATIONAL SPECIALTY (MOS) 1 OD. IF YES, UST HERE AND IN CONSOUDATED HEALTH RECORD . 165 | 16. MIUTMY UNITS ANOMOS 1 16^ UST MILITARY UNITS iN WHICH VETERAN SERVED. | PLEASE SPECIFY COMPUETE UNA88REV1ATEO T~ ITLE. {Co~. h`~ ~} 10C, WERE ACTUAL DUTIES DIFFERENT FRCM tUC)S? ENTER EITHER O, THE FOLLOWING COOKS tN BLOCK 166 Y=Yes N.No . 1 6E. ENTER THE NAME OF THE UNIT IN WHICH VETERAN HAD THE LONGEST AND NEXT TO LONGEST PERIOD OF SERVICE WHIUE IN THE PERSIAN GULF NOTeA&e: Thcse units could be dittoreot from the onc to which ~hc vetor~tn. Wlt' ~ si~ned ir veterans was on detected duty. 17. ENTER THE DATES OF THE LAST TWO PERIODS OF 8ERVtCE (11 dll~nt born cbove) I F I MO (167168) 1 YR (109~170) A. LAST PERIOD I R I V~ FORM 1 0~9009a(RS) MO(171-172)1 YR (173-174) 1 1 F I MO (175-176)1 YR (177-170) 1 LMO (179-160)LYR (161-162) l l l 1 8.NEXTTO LAST | O | l l | | O | l l l
APPENDIX H limit: SSN: | 18. Vt I ERANS EXPOSURE TO ENVIRONMENTAL FACTORS (ENTER APPROPRIATE CODES) l 125 1 8A. ARE YOU CURRENTLY SMOKING CIGARS I I ES? ENTER ONE OF THE FOLLOWING CODES IN BLOCK 183. IF NO, GO TO tTEM 18D. Y-YES N-NO (1 83) 18B. IF YES, HOW MANY YEARS HAVE YOU BEEN SMOKING CIGARS ~ ~ ES? ENTER THE NUMBER OF YEARS IN BLOCK 184 AND 185. ~ - ~ ~ ~: . :. . . ~. ... ~ 18~. tom ~E~AVEF~t3E ~ MANY PACKS ARE YOt-1 SMOKING PER DAY? ENTER THE NUMBER OF i PACKS IN BLOCKS 188 AND 1= :-- 18D. HAVE YOU SMOKED CIGARE ~ ~ AS INTHE PAST? ENTER ONCE FOIL~JI=~SINEtL 188. IF NO, GO TO ITEM 18G. Y-YES N-NO 18E. IF YES, HOW MANY YEARS HAD YOU SMOKED? ENTER NUMBER OF YEARS IN BLOCKS 189 AND ago (184) stem _ (185) (187) . . alas) (189)1(190) (191) 1(192)1 | 18F. ONTHEAVERAGE, HOW MANY PACKS DIDYOU SMOKE PER DAY? ENTERTHENUMBEROF PACKS IN BLOCKS 191 AND 192 18G-Z1.WHILE IN THE PERSIAN GULF DO YOU BELIEVE YOU WERE EXPOSED TO ANY OF THE FOLLOW- ING: 18G. SMOKE FROM OIL FIRES? ENTER ONE OF THE FOLLOWING CODES IN BLOCK 193. Y-YES N-NO U-UNKNOWN 18H. SMOKE OR FUMES FROM TENT HEATERS? ENTER ONE OF THE FOLLOWING CODES IN BLOCK Y~YES N-NO 194. U-UNKNOWN 181. CIGARS ~ I t SMOKE (PASSIVE) FROM OTHERS? ENTER ONE OFTHE FOLLOWING CODES IN BLOCK Y-YES NERO 195. U-UNKNOWN . . 18J. DIESEL AND/OR OTHER PETROCHEMICAL FUMES? ENTER ONE OF THE FOLLOWING CODES IN ysyEs N-NO BLOCK 196. U-UNKNOWN 18K. EXPOSURE TO BURNING TRASHtPECES? ENTER ONE OF THE FOLL~= AS IN BLOCK Y-YES N-NO ~ 97 U-UNKNOWN 18L. SKIN EXPOSURE TO DIESEL OR OTHER PETROCHEMICAL FUEL? ENTER ONE OF THE FOLLOW- Y YES N-NO ING CODES IN BLOCK 1` U-UNKNOWN 18M. CARC (CHEMICALAGENTRESISTANTCOMPOUND)? ENTER ONE OF THE FOLLOWING COCsE~1tV AYES N-NO BLOCK 199. U-lJNKNOWN _ ~ 1~. OTHER PAl NTS AND/OR SOLVENTSAND/Ofl PETROCH£1ultCAL SU BSTANCES? ENTER ONE OF THE Y-YES N-NO FOLLOWING CODES IN BLOCK _00. U UNKNOWN | ~ 8a. DEPLETED URANIUM? ENTER ONE OF THE FOLt t~NG C~ IN BL=K em. 1 8P. MICROWAVES? ENTER ONE OF THE FOLLOWING Ct)OF~ IN Rl ASK 5n5 (193) (194) 1 (196) | (197) (1 98) . . 1 (arty Y-YES N-NO U~UNKNOWN !- Y-YES N-NO U-UNKNOWN (201) 1 .m_l 20z) 1 ,. . I i 18Q. PERSONAL it: USE, iNCkt~tOING OPtEAMS, SPRAYS OR fLEA COLLARS? ENTER ONE OF Y-YES N-NO ~( ) i I THE FOLLOWING CODES IN BLOCK 203. U-UNKNOWN l l r ~- | 18R. NERVE GAS OR OTHER NERVE AGENTS? ENTER ONE OF THE FOLLOWING CODES IN BLOC Y~YES N=NO ~) 204. U-UNKNOWN I I 1 | 18S. DRUG (PYRIDOSTIGMINE) USED TO PROTECT AGAINST NERVE AGENTS? ENTER ONE OF THE I FOLLOWING CODES IN BLOCK 205. | JOT. MUSTARD GAS OR OTHER AGENTS? EASTER ONE OF THE FOLLOw'nn confer I~ R! OCK AYES N=NO U-UNKNOWN Y-YES N-NO U~UNKNOWN ~. . ; | 18U. ATE OR DRANK FOOD CONTAMINATED WITH SMOKE, OILOR OTHER CHEMICAL? ENTER ONE OF Y - YES N=NO l | THE FOLLOWING CODES IN BLOCK 207. UNKNOWN l - 1 (205) 1 ~' (206) 1 1
Y.YES N.NO 18Z. IMMUNIZA;llON A - INST BOTULISM? ENTER ONE OF THE FOLLOWING CODES IN BLOCK 212. U.UNKNOWN 1 BY. IMMUNeAnON AGAINST ANTHRAX? ENTER ONE OF THE FOLLOWING CODES IN BLOCK 211. Y.YES N.NO Id - uNKNoWN 126 ADEQUACY OF THE VA PERSIAN GULF REGISTRY AND UCAP NAME: SSN: 1 BY. ATE FOOD OTHER THAN PROVIDE BY ARMED FORCES? ENTER ONE OF THE FOLLOWING CODES Y.YES N-NO IN BLOCK 208. U.UNKNOWN , (208) 1 {209) 1 _ 18W. BATHED IN OR DRANK WATER CONTAMINATED WITH SMOKE OR OTHER CHEMICAL? ENTER ONE Y-YES N.NO OF THE FOLLOWING CODES IN BLOCK 209. U~NOUlN i8X. "~7 EN WA7~0THER WAN PRIDED F~ ~o~ - OWL ' Y.YES'''N~ IN() CODES IN BLOCK 210. U UNKNOWN 'FULL ~ (212) j 1 8Z1. OTHER EXPOSURES? ENTER HERE AND IN CHR ONLY. 19. DID VETERAN HAVE ANY OF THE FOLLOWING EXPERIENCES WHILE lN THE PERSIAN GULF? ENTER APPROPRIATE CODE. (213) (214) (215) , ~I (216) (217) (218) =i 19A. DID YOU EVER GO ON COMBAT PATROLS OR HAVE OTHER VERY DANGEROUS DUTY? ENTER ONE OF THE FOLLOWING CODES IN BLOCK 213. 1~ 2.1-aX `4-12X 4~13~5DX 5~51+TIMES 1BB. WERE YOU EVER UNDER ENEMY FIRE (INCLUDING ·SCUDS.)? ENTER ONE OF nHE FOLLOWING CODES IN BLOCK 214. 1 _ NEVER 2 = 1 DAY 3 =< 1 WEEK 4 = 1-< 4WEEKS 5 = 4 WEEKS OR MORE 19C. WHAT PERCENTAGE OF PEOPLE IN YOUR UNIT WERE KILLED (KIA), WOUNDED OR MISSING IN AC TION (MIA), ENTER ONE OF THE FOLLOWING CODES IN BLOCK 215. TENONS 2-1-25% 3~50% 4~51-75# 5.76# OR MORE * 19D. OFTEN told TOW SEE ~1~ ~BY #tat ~ fit ~ ~ - £ THE FOLLOWING CODES IN BLOCK 216. 1.NEVER 2.1-2X W12X 413-50X 5~51 OR ha. ORE TIMES . 1gE. HOW OFTEN WERE YOU IN DANGER OF BEING INJURED OR KILLED (I.E. PINNED DOWN, OVERRUN, AMBUSHED, NEAR MISS, ETC.)? ENTER ONE OF nHE FOLLOWING CODES IN BLOCK 217. 1.~Jr-VFR 2.1-2Y 12X d_1.~~Y F_~1 OR~ORFTIUF~ 19F. DID YOU WITNESS CHEMICAL ALARMS? ENTER ONE OF THE FOLLOWING CODES IN BLOCK 21R 20. VETERANS HEALTH (Vt I IRAN'S EVALUATION) 20A. WHICH BEST DESCRIBES Vt I ERAN'S HFAL:T1H OF I ER PERSION GUM SERVICED ENTER ONE OF THE FOLLOWING CODES IN BLOCK 219. 1 . Very Good 2 . Good 3. Falr 4. Poor 5 . Very Poor . .. .. i,, , . 21. VETERAN'S FUNCTIONAL IIVIPAIR~ENT Y.YES N.NO U.UNKNOWN 21A. WHICH BEST DESCRIBES VETERAN'S OWN ASSESSMENT OF FUNCTIONAL IMPAIRMENT? ENTER, ONE OF THE FOLLOWING CODES IN BLOCK 220. 1.NO IMPAIRMENT 2-SLIGHT IMPAIRMENT 3-MODERATE IMPAIRMENT 4-SEVERE IMPAIRMENT (219) (220) 21B. HOW MANY WORKDAYS WERE LOST BY VETERAN DUE TO ILLNESS IN THE PAST 90 DAYS? ENTER (221) (222) NUMBER OF DAYS LOST IN BLOCKS 221-222. 22. EVIDENCE OF BIRTH DEFECTS AND INFANT DEATH(S) AIVIONG VE I ERAN'S CHILDREN AND PROB LE" wrrH PREGNANCY AND INFERTILITY. 22A. HOW MANY CHILDREN DOES VETERAN HAVE? ENTER NUMBER IN BLOCKS 223 AND 224. (I.E. 05). IF NONE, LEAVE BLANK AND GO TO ITEM 22C. (223)1(224) 1
APPENDIX 127 NAME: SSN: 22B. HOW MANY OF THESE CHILDREN WERE BORN WITH BIRTH Dc~tCTS? (BIRTH DEFECTS ARE _ ANY STRUCTURAL FUNCTIONAL OR BlOCHEbilCAL ABNOR - LITY AT BIRTH WHETHER GE NETICAULY DE I "IVIINED OR INDUCED DURING GESTATION THAT IS NOT DUE TO INJURIES SUF FERED DURING BIRTH.) ENTER NUMBER IN BLOCKS 225 AND 226. IF NONE, 430 TO ITEM 22C. = 22B1. HOW MANY OF THESE CHILDREN WERE CONCEIVED BEFORE GUN SERVICE? ENTER THE NUM. (I BER OF CHILDREN IN BLOCKS Z7 AND 228. IF NONE, LEAVE BLANK AND GO TO ITEM 22B2. ,1 ,1 wax = 22B1 (a) STATE MATERNAL AGE AT CONCEPTION OF FIRST CHILD CONCEIVED BEFORE GULF SERVICE? ENTER AGE IN BLOCKS 229 AND 230, 22B2. HOW MANY OF THESE CHILDREN WERE CONCEIVED DURING AND AFTER GULF SERVICE? EN TER NUMBER IN BLOCK 231 AND 232. IF NONE, LEAVE BLANK AND GO TO ITEM 22C. 22B2(a) STATE MATERNAL AGE AT CONCEPTION OF FIRST CHILD CONCEIVED DURING AND AFTER GULF SERVICE? ENTER AGE IN BLOCKS 229 AND 230. (231) . (233) _ 22C1. HAS Vt I ERAN OR SPOUSE HAD INFERTILITY BEFORE GUM SERVICE? ENTER ONE OF THE FOL LOWIN<3 CODES IN BLOCK 236. IF NO, GO TO ITEM 22C2. Y.YES N.NO | 22C1 (a). STATE MATERNAL AGE DURING FIRST ATTEMPTS TO CONCEIVE. ENTER AGE IN BLOCKS 237 AND 238. 22C2. HAS VETERAN OR SPOUSE HAD INFERTILITYAFTER RETURN FROM GULF SERVICE? ENTER ONE OF THE FOLLOWING CODES IN BLOCK 239. IF NO, GO TO ITEM 22D. Y-YES N-NO 22C2(a). STATE MATERNAL AGE DURING FIRST ATTEMPTS TO CONCEIVE. ENTER AGE IN BLOCKS 240 AND 241. 22D. HAS Ve I BRAN OR SPOUSE HAD blISCARRIAGE(S) (NOTE: MISCARRIAGES ARE SPONTANEOUS EXPLOSION OF THE PRODUCTS OF CONCEPTION BEFORE 20 WEEKS OF ¢ESTA;rlON - SPONTA NEOUS ABORTION) ENTER ONE OF THE FOLLOWING CODES IN BLOCK 242. IF NO, GO TO ITEbl ~ = 22D1. HAS Vt I FRAN Ok ISPOt~;E~BC~eS~P£Fl~l GULF? ENTER ONE OF THE FOLLOWING CODES IN BLOCK 243. IF NO GO TO ITEM 22D2. ~ ~ 22D1 (a). STATE MATERNAL AGE AT CONCEPTION. ENTER AGE IN BLOCKS 244 AND 245. 22D2. HAS VETERAN OR SPOUSE HAD MISCARRIAGES AFTER PERSIAN GULF? ENTER ONE OF THE FOLLOWING CODES IN BLOCK 248. IF NO, GO TO ITEM 22E. Y_YES N,NO 22D2(a). STATE MATERNAL AGE AT CONCEPTION, ENTER AGE IN BLOCKS 247 AND 248. 22E. HAS Via I BRAN OR SPOUSE HAD STILL BlRTIH(S)? (NOTE: STILL BIRTH IS BIRTH AFTER 20 WEEKS OF GESTATION OF AN INFANT WHO SHOWED NO EVIDENCE OF LIFE AN I ER BIRTH.) ENTER ONE OF THE FOLLOWING CODES IN BLOCK 2~. IF NO, GO TO ITEUI 22F. Y.YES N-NO 22E1. HAS VETERAN OR SPOUSE HAD STILL BIRTH(S) BEFORE GULF SERVICE? ENTER ONE OF THE FOLLOWING CODES IN BLOCK 250. IF NO, GO TO ITEM 22E2. 4232) I) 22C. HAN VETERAN OR SPOUSE HAD INFERTILITY PROBLEMS? tlN~eR I IUITY MOel~ OF VETERAN OR SPOUSE BECOMING PRESENT. NOTE: INFERTILITY - RELATNE STERILITY DEFINED ~ US ABILITY TO CONCEIVE AFTER 12 OR MORE MONTltS OF INTERCOURSE WITHOUT USE OF CON- TRACEPl1ON AND WHEN NEI - ER tWOUSE IS SURGICALLY STEIN.) ENTER ONE OF THE FOLLOWS CODElt IN BLOCK 236. IF NO, GO TO ITEM 22D. Y-YES N-NO (236) t237)14238)1 _ (239)1 3 (242) (243) Y - YES N - NO L (2-44 (249) Y_YF~ Need | 22E1 (a). STATE MATERNAL AGE AT CONCEPTION. ENTER AGE IN BLOCKS 251 AND 252. 22E2. HAS VETERAN OR SPOUSE HAD STILL BIRTH(S) AFTER RETURN FROM GULF SERVICE? ENTER ONE OF THE FOLLOWING CODES IN BLOCK 253. IF NO, GO TO ITEM 22F. (250) (253) | 22E2(a). STATE MATERNAL AGE AT CONCEPTION. ENTER AGE IN BLOCKS 254 AND 255. Y.YES N.NO 22F. HAS VETERAN OR SPOUSE HAD INFANT DEATH(S). (NOTE: DEATH THAT OCCURRED WITHIN ONE I YEAR OF BIRTH AMONG BABIES BORN ALIVE.) ENTER ONE OF THE FOLLOWING COOKS IN BLOCK 256. IF NO, GO TO ITEM 22G. Y-YES N.NO 1 22F1. HAS VETERAN OR SPOUSE HAD INFANT DEATH(S) BEFORE GULF SERVICE? ENTER ONE OF THE I FOLLOWING CODES IN BLOCK 257. IF MO, GO TO ITEM 22F2. Y=YES N-NO - 1 (256) 1 Hi I 22F1 (a). STATE MATERNAL AGE AT CONCEPTION. ENTER AGE IN BLOCKS 258 AND 259. | 22~. NAG VETERAN OR SPOUSE HAD INFANT DEATH(S) AFTER GULF SERVICE ENTER ONE OF THE I FOLLOWING CODES IN BLOCK 260. IF MO, GO TO ITEM 22G. 4 = Y.YES N.NO (260)
1 ~ ~ 1~0 ]~y ~ ~ ~ _\ O~F ~ ~P NATE: SSN: . ~ MEW ME VERNAL AGE ~ ONCE:. ENTER AGE ~ ~ "1 AD ma. IF ^ W-^N VE 1 EM REAMS SHE ~ PREGAME IN PeRSl~ Gum RECORD ME OF OHIO 8#_ AD ~P#~ OF e#~ ~_~__~--~_ Dam Of B#R~ ~N -/ ~/- P^RT ~ ~ BE COMPLIED ~ EMOTING PHYSIC go. SOFT - ~I ~ I YEAR 2~- 1 _~) 1 (at 1 1 1 1 1 1 1 ad, ~ NO. ~ ~71-~ V_ =~P~#_. = ~&~IN~ __&_ ___ (1 ) DESCRIBE SY~P= OAR 1VE ^ C (2) ICD-g<ODES ~ GO. & YR ~ ~(4) DU_ON BOW YEAR (SO S) (2~-~) (at) (2~ 2~ 1 1 I i 1 (art) 1 1 1 1 1 1-~ (2~-2~) ~ ~ ~ ~ (~-~) (2~ at) At) (2~) ~ ~ ~ ~ ~ (~1-~) ~ ~ ~ ~ ~ ~ (~-~) (awn ~ ~ ~ ~ At) ~ ~ ~ ~ ~ {~1-~) _ _ . p@~) . ~ ~ ~ ~ ~ ~ (act ~ ~ ~ ~ ~ ~ ~ (apt) ~ ~ ~ ~ ~ (-370) ~ ~ ~ ~ ~ ~ (at) p13-31~ (~1-~ (3~) (31~) ~ ~ ~ ~ ~ (3~) ~ ~ ~ ~ ~ ~ (~1~) __ _ _ ___ __ 7 R~ PRESET N-NO ~12) . -) Ha) Ha) Ha) Ha) H10) (411) 1 1 ~ I = ~ 1 ~ I = 1 25K.U=~=S~ERE~.~S-~F~I~.~ICHV ~SiDERS~E-~ERE I-E- ~ ~!~! CHIEF CO~P~lN~. E_R ICED CODE IN At. go. Dl~NO~C CONSUL. EVER WE MUNG ODES ~ B~KS 4~_. 1~ OUR ~ USUAL ~E. ~RKu~SU~ ~E. D~1S EMBED. 2~0RKu~SU~lON ~E. UNLINED 1L~E" ~ORKu~NSu~ ~NE. ~ D~GN=IS. ^LLERG~i~UNOLOGY BOCK 418 B. AUDIOLOGY BOCK 419 I C. CARDIOLOGY BLOCK 420 I D. DENTISTRY BOCK 421 1 E. DER~LOGY BLOCK 4= I F. EAR, NOSE AND THROW 423 I G. ENDOCRINOLOGY BLOCK 424 T ~ G^STROENTEROLOGY BLOCK 425 FI I I Be) age) Ad. ~1) Ha) Ha) ~4) Ha) 5
APPENDIX H 129 NAME: SSN: I. HEMATOLOGYtONCOLOGY. BLOCK 426 (ma) J. INFECTIOUS DISEASES/PARASITOLOGY. BLOCK 427 (427) K. NEPHROLOGY. BLOCK 428 (42B) L. NEUROLOGY.BLOCK429 (429) M. OCCUPATIONAL MEDICINE. BLOCK 430 (430) N. PULMONARY. BLOCK 431 (431) O. PSYCHIATRY. BLOCK 432 (432) P. PSYCHOLOGY/PSYCHOMETRIC TESTING. BLOCK 433 (433) Q. RHEUMATOLOGY. BLOCK 434 (434) . _ R. OTHER, ENTER FOLLOWING CODES IN BLOCK 435 Y=YES | (435) N=NO _ . S. ADDITIONAL WORKUPS/CONSULTATIONS PERFORMED WHICH WERE NOT LISTED IN ITEMS 26A~. LIST HERE AND IN CHR.
130 ADEQUACY OF THE VA PERSIAN GULF REGISTRYANDUCAP N^lvit: SSN: Z7. DIAGNOSE USTUPTO 10~10RDEFINITEMEaCA`LDl~ONLINESZ7A~l.UST PRIMARY DIAGNOSIS ON UNEA. BLOCKS43e~86 FOR=_ ICD4bCt4 CODES. LEAVE BLANK IF NO Do - NOSE 18 ~ HAS CODERS: USE .~ o GM CODES #I FIRST FIVE NUT BLOCKS OF EACH DOW 27A. DESCRIBE DIAGNOSIS (Narradve) A. (PRIMARY) B. C. _. D. E. F. . ~ G. _ t471\ . H. 1. J. NOTE: CODERS: DO NOT REPEAT OR LIST SYMPTOM CODE ALREADY UsTED UNDER ITEM 25A-J. 28. BLOCK486 IFNO DIAGNOSIS IS MADE, ENTER.1. IN BLOcKATRIGHT, OTHERWISE, EVE BLANK THIS ITEM MUSTBECONSIDERED IN CONJUNCTION WITH ITEM 27 ·DI4GNOSIS - 28 DISPOSITION (Enter code Y-Yes or N-No) 2 - EXA - NATION COMPLETED? 4e7 298 HOSPITALIZED AT VAA.C FOR FURTHER 408 yet" N Fb Y-Y" N-No 200 REFERRED FOR oLrTpAnENT CARE? ME REFERRED TO PRIVATE PHYSICIAN NON VA 491 CuNIC OR NON-VA HosP TAL? yet" N~b y.y" N - b _ X AFTER co.4pLEnoN OF PHASE I EXAM (REFER To PAR s). THE PHYSIC AN HAS 483 31. HAS PHASE II EXAM (REFER To CH 3) BEEN INITIATED? DErERhuNED THE VETERAN HAs UNEXPLAINED ILLNE8S? Y Y" New Y Y.8 N-No 32 uTeLeE THIs sEcTIoN FOR Ar=T ONAL INFO~AT ON (E a PAR 1.07 - - 10, PT ll0. 33. NAIVE OF r~uNER. (PRINT FULL NAME) J4 TALE OF EXA~iNER. (FULL TrTLE OF EXAMINER) 35. 8 ONATURE OF EXAUINER 36A. SIGNATURE OF VRP (VETERANS REGISTRY PHYSICS (m) Em_ (441) t4461 `4sn ill- , l ICD - CM (Cotbs) _ (4J~ (4 - (4 - (4471 t44el (448) . === __ MEL . . == = = . mu ~ ~ . . 14 - 1411BI ~ t4U1~: . === . . 077) . _== = . ~ ~4e2~ ~ ~ . i44e - - ( 7q 29C. HOSPITALIZED AT VAMC FOR TREATMENT? y,y" N No 2BF. BIOPSY? Y Yet to 7
APPENDIX H 131 NAME: SSN: PART 111 PHASE 11- UNIFORM CASE ASSESSMENT (UCA) 1. WERE THE FOLLOWING TESTS PERFORMED? Enter ~e following codsa In bloclo 1-24. Y ~ YES N . NO 2. BLOOD TESTS. BLOCKS 1-18: OTHER - BLOCKS 1~24. , (2) 1 C. C-REACTIVE PROTEIN . (5) (GLUTA~IC ~F. SOOT ~? o~nc 1 ~w~' ~ CBC (CO~PLETE BLOOD COUNT) _ B. SED RATE? (SKIN ERETI~IA DOSE) (4) E. FLUORESCENT ANA1 ~R ANTI-BODY) H. LDH (UCTIC ACID HY0ft0GENASE) . (1m K HEPATIT19 B SURFACE ANTIaODY? . (13) N. V'TAIdtN~12 . (18) O. T4 (THFt0XINE TOTAL SERUU)? (19)4. TB 8KN TEST (PPD)? (TUBERCULOSIS SKIN TEST PURIFIED PROTEIN DERIVATIVE) (22)SCID FOR OS - IIbR (STRWrURED CU - CAL IN~VIEW FOR DUONOS18) _ ~ ~: _ (12) 41~ _ _ = ~ ~4) _ D. RHE4ATOID FACTOR? (TIW~NASE O. 8OPT ~T) GLUTA - C PYRWATE) _ _ _ _ ~ _ _~ l _ (14) _ (1~ _ _ _ 20) _ __ _ el) _ 1. AUCAUNE PHOSPHATASE J. CPK? CREATINE PHOSPHOKINASE) L HEPATIT18 B CORE ANTKlEN? (VENEREAL M. VDRL? DISEASE RESEARCH LABORATORY) (HU~AN 114 - WO. DEFICIENCY) R. TSH (.THYROID STI~ATING HOR~? 3. URINALYSIS 5. CHEST XRAY O. P8YCHIATRIC EVALUATK)N? 6B. CAPS PTSD SC4LE (CIJNICAL AClINS~D PO l,T TRAUMATIC STRES8 DISORDE~ 7. LIST DIAGNO ES: bL iS CODERS: ENTER ICD-9-CM CODE IN BLOI ,KS 25 39. IF NONE, LEAYE BLANK. _ 30) _ p5) 1311 t381 . ~ . 32r ~ . , (33) &~. UST DdAGNOSE9. MAS CODERS: ENTER ICD~ CODES IN BLOCltS 41~6 i. IF NO ~ LEA' E BUN K _ DESCRIBE DUONOSES ~) | ~N~ (46) (55) 9A~ UST DUGNOSE5. MA9 CODERS: ENTER ICD-9 Cld CODE'S IN BLOCKS 570. IF NONE. LEAVE BEANK ICD - CODE8 P~ 2. 8. mCH0LOGY~ROPSYCH0~TE8T? I (40) E - r code h bloat 40) Y-Yca N - b | 1 10. DENTAL EXAA1? (En~r ood. h bbdt ~n Y-Yce .1 '10 I ~eCODES .. - 1(41)1(42)1 1 1 1 2. 1~4~ 1~4 3 1~61)lt52, (46) 1 (44) 1 B. INFECT~S DISEASE - SCREENING EX - ? | (66) , (En~r oode h block 66) 1_ DESCRIBE DI0NO8E5 (Nanall_) I Y-Y" N - b 1 1 (67) (62) 2. 1 1 1 1 10~ UST O - NOSES. MAO CODERS: ENTER W9~ COOKS IN BLOCKS 66-77. U: NONE, LEAVE BLANK DESCRIIBE DlAONOSES (Nul~) l 1 ,, 1~08)1 1-'1 (00) (66) K D - CODE5 r l ~4) 8 ~T~) (76) 1 P6) l r~ 1 1 ~)
,2 ADEQUACY OF THE VA PERSIAN GULF REGISTRY AND UCAP 1 _ . - P4) ~, P4) Po 11 B. UBT D~GNOSE8. MAO CODERB: ENTER ~ CODE8 IN BLOCK8 ?~. If NONE. lEAVE eLANK. DES~E DLAON05E8 (Nu~) _ ~1) . . . . pl) . _ P~ ~7 __ 12. HEADACHE AND/OR MEMORY LOSS 12A. NEuRoLoGyco~uLr, (EI_ oode h ~ 93) Y.Yos N-No Z- 128. UST DU~. MAS COD6RB: f~NTER ~ CODES ~ 8BOCKS 100~100.1f NadE, Lf~VE BLANK Df~E D1AGNOSE8 (Nui~) 1= (100} . (10~ ~OODE8 (101) (10 l _ ' {1023 . (1on . _ . (1~) 13. MUSCLE ACHES AND/OR NUMBNESS 138. U8T DIAONO~. - 8 OOW~: f~NTER ~ CODE8 IN BLOCK8 111~120.1F NONE, LEAVE WK ICD4~00QEB (11~ 1. t~ NEUaOLOOYOO - ULn | 110 | (Er~ code h ~110) 1 1 Y.Y" N-No | - Df~BE DI~ES (N_~) 1 (114) 14. CHRONIC FATIGUE 14B. U8T D - N08£~. "U COD6~: ENTER ~ CODES IN BLOCKS 122~131. ~F NONE, I£AVE ~ ~E D~NOSES ~) 1 - (124) (12~ 1 l 14A. cHRoNtcfAnGuE? 1 121 (E~ code h b - * 121) 1 Y.Y" N-No | 1 1" R~iEU - TOLOGY co~uLr? 1 132 1 {f~ code h Olodr 1:= ~I Y-Y" N-No I 1 1" P=~y c°~n I 143 | ~oodehbh*1a) y-Yes N-No I | 1 1 1 17^ DERIuToLoor co~uLr7 1 154 (Er~r code h bbde 154) Y-Yas N-No | 1eA. AUDIOLOGY? 1 105 (En - 04de h b~ 1 - Y.Yse N-No 1 1 (12~ 1 "='1 r~ r~ 1 15. JOINT PAIN sB. UST DUONOSE8. MAS CODER8: ENTER ~ CODES #d BLOCX5 133~142. IF NONE, WEAVE BLA - C oEaameDueNosEs(N~) ~ ~ ~: L L(~1 ~ ~lJe)' :: (13~ 16. CHRONIC COUGH AND/OR SHORTNESS OF BREATH l e8. U8T D~NOBE8. - 8 CODEnS. fNTER ~_ ~VE 8WaC DESC~ D~08-~) 1 ~DES (14c (151) L 1' 1 1 2 (144) 1 (146) (160 1 (l4~ 17. SKIN RASH 17B U8T DU`ONOBE8. - 8 COD6RB: ENTER ~A CODE8 IN BLOCKS 15~1e4. IF NONE, LEAVE BUNK. DE.8CRIBE DIAON08E8 (Nu~) I= (1Ug K D+OOOE8 (15 (le r(l~ - 18. VERTIGO AND/OR TINNITUS 1Sa. U8T DU~N08E8. uA8 CODERS: ENTER iCD~ CODE8 IN BLOCK8 1~175. rF Na~ uEAVE 8W.K DEscRlaE D - N08E8 tNeii~) l 1 - - 1 9 - (1en (1= (175)
APPENDIXH NAME: SSN: 133 19. CHEST PAIN AND/OR PALPITATIONS _ 19A. CARDIOLOGY CONSULT (Enter code In beck 176) Y.YES N.NO 176 1-L-T Off. UREAS CODERS ITCH ~ ~ ~ AS · ~. ~ Ned ~ ~ _ _ MOOED (l77) (178~ (1791 (162) (183' (184) ~o_aA~_ . 2. i . ~ . ~ : ~'a') (186) 20. REPRODUCTIVE CONCERNS 187 1~e Llsr DIACHOSES. HAS CODERS ENTER ICO-~-CH CODES IN BLOCKS 188. all. ~ NONE. LIA" B~. offal_ aims pi_ lagoon 188 (189) 1 (1 90)| (1 91 ) I (192) 2. (184) (195) (1~) (19n = 21. FINAL DIAGNOSES: PHASES lI = = = = 21 A. DIAGNOSES. LIST UP TO 10 MAJOR DEFINITE MEDICAL DIAGNOSES ON U NES 20A~J. UST PRIMARY DIAGNOSIS ON UNE A. BLOCKS 10248 OR CORRESPONDING ICD-~CM CODES. LEAVE BLANK IF NO DIAGNOSIS IS MADE. HAS CODERS: USE ICD-K:M CODES IN FIRST FIVE NUMBERED BLOCKS OF EACH DIAGNOSIS 20A. MALES - UROLOGY CONSULT? (enter code h beck 187) Y-YES N-NO 20B. FEI"LES - GYN CONSULT? (Enter code h block 188) AYES N-NO (193) (198) r~scr~ie~;Q~S INu~) A. (PRIMARY WOES (1~) (200) (201) (204) (205) (206) _ (209) (210) (211) (214) (215] (216) ~ ~ west (224) (225 (226) (229) (230) (231) (234) (235 (238) (239) (240] (241) (244) c (202) (207) (212) (217) (222) (227) (232) (237) (242) (203) l (208) (213) (218) (223> . 228) . 4233) (238) (243) l (248) B. C. D. E. G. H. 1. J. 22. AFTER COMPLETING PHASE II, UNIFORM CASE ASSESSMENT PROTOCOL, THE PHYSICIAN FEELS THAT THE VETE RAW "S ~ N UNEXPLAINED ILLNF~c? (Enter cotb In bbctt 248) Y-YES N-NO 10
