4) Did you serve in Vietnam, Cambodia, Laos, or the contigueos waters Surrounding any of these countries ? Yes No 5) Did you serve in IndoChina in a non-military capacity, such as Red Cross or other civilian or Government agency ? NA Yes No 6) If you served in Indo-China in a non-military capacity, by whom were you Employed, and what did you do Employer Allied Government U.S. Government Civilian Company Air America Other Forign Gov. Church Red Cross Job Advisor Businesman Worker Pilot Diplomat Gov. Employee Dates of Service in S.E. Asia 7) Dates of Vietnam service (First Tour) From : Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 To : Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975
8) Dates of Vietnam service (Second Tour) From : Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 To : Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975
9) Dates of Vietnam service (Third Tour) From : Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 To : Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975
10) Please fill in the next boxes with the requested information... If you are not entering any info in thes boxes, PLEASE type NA to indicate Non Applicable. Please DO NOT leave any box blank. a) Enter the outfit who you spent most of your tour with in Vietnam b) If you were with more than one outfit, enter who you were also with, ( list just the outfit which you spent the next greatest amount of time with ) : c) If you had a second tour, enter the outfit who you spent most of your second tour with in Vietnam d) If you were in more than one outfit on your second tour, enter the outfit you were also with ( list just the outfit which you spent the next greatest amount of time with ) : e) If you had a third tour, enter the outfit who you spent most of your third tour with in Vietnam f) If you were in more than one outfit on your third tour, enter the outfit you were also with ( list just the outfit which you spent the next greatest amount of time with ) : 11) Enter your Primary MOS while on your first Tour (please type in a number or NA) : a) Now your Secondary MOS if Aplicable (please type in a number or NA) : b) If you served more than one tour, enter your Primary MOS while on your second Tour (please type in a number or NA) : c) Now your Secondary MOS if Aplicable (please type in a numberor NA) : d) Please do the same as above if you served a third tour. ( Enter your Primary MOS while on your third Tour, please type in a number) : e) Now your Secondary MOS if Aplicable (please type in a number or NA) : 12) In which Major Corp area did you operate, and when were you there ? : Use map if needed Click here for map of Vietnam If you were in these area's check the appropriate box I Corp : No Yes When were You there, From : Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 To : Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 II Corp : No Yes When were You there, From : Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 To : Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 III Corp : No Yes When were You there, From : Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 To : Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 IV Corp : No Yes When were You there, From : Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 To : Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 13) At which Airport, Port, or Location did you Enter Vietnam ? : (First Tour) : Arived DaNang Siagon Camron Bay (Second Tour) : Arived DaNang Siagon Camron Bay (Third Tour) : Arived DaNang Siagon Camron Bay 14) At which Airport, Port, or Location did you Leave Vietnam ? : (First Tour) : Departed DaNang Siagon Camron Bay (Second Tour) : Departed DaNang Siagon Camron Bay (Third Tour) : Departed DaNang Siagon Camron Bay 15) What was your Rank, Rate, or Grade when you Entered Vietnam : E1 E2 E3 E4 E5 E6 E7 E8 E9 WO1 WO2 WO3 O1 O2 O3 O4 O5 O6 16) What was your Rank, Rate, or Grade when you Left Vietnam : E1 E2 E3 E4 E5 E6 E7 E8 E9 WO1 WO2 WO3 O1 O2 O3 O4 O5 O6 17) Did you spend time in the Field ? : Yes No 18) How Much Total time did You spend in the Field ?... (Months) None 0-1 1-2 2-3 3-4 4-5 5-6 6-7 7-8 8-9 9-10 10-11 11-12 12-13 More 19) Did you ever drink water which came directly from the field, jungle, rice paddies, or wells ? Yes No 20) Did you bathe in streams, rivers, lakes, creeks, or any other body of water in Vietnam ? Yes No 21) Did you operate in an area or area's in which you actually saw Agent Orange being sprayed, dropped or used ? Yes No 22) Did you operate in an area or area's in which you observed the effects of jungle or undergrowth defoliation ? Yes No 23) Did you engage in field operations which required the crossing of streams, creeks, rivers, lakes, or other water areas ? Yes No 24) Did you eat food which was cooked in the field ? Yes No 25) Did you sleep in the Field ? Yes No 26) While in Vietnam, did you engage in any perimeter clearing operations ? Yes No 27) Were you wounded in Vietnam ? Yes No 28) If Yes, how many times were you wounded ? Never 1 2 3 4 29) Which area(s) of your body was wounded ? Click "Yes" to all that apply : Head / Face No Yes Eyes No Yes Ears No Yes Throat / Neck No Yes Chest No Yes Abdomen/Stomach No Yes Back No Yes Spine No Yes Genitals No Yes Left arm / Hand or Fingers No Yes Right Arm / Hand and or Fingers No Yes Left leg / Foot and or Toes No Yes Right leg / Foot and or Toes No Yes 30) If you were wounded in Vietnam, please select type : a) Not Wounded Small arms fire Shrapnel Explosive devices (non booby trap) Booby traps Mine Knife/Bayonet Aircraft crash/explosion Boat crash/explosion Other If wounded more than once select again here, if not leave NA : b) NA Small arms fire Shrapnel Explosive devices (non booby trap) Booby traps Mine Knife/Bayonet Aircraft crash/explosion Boat crash/explosion Other If wounded more than Twice select here, if not leave NA: c) NA Small arms fire Shrapnel Explosive devices (non booby trap) Booby traps Mine Knife/Bayonet Aircraft crash/explosion Boat crash/explosion Other 31) While in Vietnam, were you treated for any minor medical condition (exclude any mental or Dental treatment) such as illness or minor wounds which did NOT require hospitalization ? Yes No 32) While you were in Vietnam, were you treated for any mental emotional, or psychological condition ? Yes No 33) While in Vietnam, were you treated for any Dental problems (including any extractions or other treatment) ? Yes No 34) Were you hospitalized in Vietnam ? Yes No If yes, when, (chose) If not leave NA : NA Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec NA 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 Where ? : NA I Corp II Corp III Corp IV Corp Why ? : NA Enemy fire Booby trap Explotion Friendly fire 35) Did you recieve Blood tranfusion(s) in Vietnam ? Yes No 36) While in Vietnam, did you sustain any injury, illness or disease which required medical, dental or psychological treatment NOT associated with hostile action?Yes No 37) At the time of your arrival in Vietnam, your general health was : Chose Excellent Good Fair Poor 38) At the time you finally left Vietnam, Your general health was : Chose Excellent Good Fair Poor 39) What was your weight when you arrived in Vietnam (in pounds) : Weight 80-100 100-110 110-120 120-130 130-140 140-150 150-160 160-170 170-180 180-190 190-200 200-210 210-220 220-230 230-240 240-up 40) What was your weight when you left Vietnam (in pounds) : Weight 80-100 100-110 110-120 120-130 130-140 140-150 150-160 160-170 170-180 180-190 190-200 200-210 210-220 220-230 230-240 240-up 41) What is your present average weight (in pounds) : Weight 80-100 100-110 110-120 120-130 130-140 140-150 150-160 160-170 170-180 180-190 190-200 200-210 210-220 220-230 230-240 240-up 42) Have you gained or lost 40 pounds in any one year since your Vietnam service (Excluding amputations) :Yes No 43) If your answer to 42 is yes, indicate when you began to experiance weight change (in years AFTER returning) : NA 0 - 1 1 - 2 2 - 3 3 - 4 4 - 5 5 - 6 6 - 7 7 - 8 8 - 9 9 - 10 10 - 11 11 - 12 12 - 13 13 - 14 14 - 15 15 - UP 44) Did you gain or lose this weight : NA Gained Lost 45) During the first five years after your return from Vietnam, your general health was : Chose Excellent Good Fair Poor 46) During the first five years after your return from Vietnam, were you treated by any health professional for any medical condition (exclude any psychological or dental conditions) ? : Yes No 47) During the first five years after your return from Vietnam, did you receive any psychological treatment/counselling? : YesNo 48) During the first five years after your return from Vietnam, did you recieve any dental treatment ? : Yes No 49) During the first five years after your return from Vietnam, were you hospitalized for any reason ? : Yes No 50) During the period five years through ten years after your return from Vietnam, your general health was : Chose Excellent Good Fair Poor 51) During the period five years through ten years after your return from Vietnam, were you treated for any medical condition (exclude any psychological or dental care) ? : Yes No 52) During the period five years through ten years after your return from Vietnam, did you receive any psychological care ? : YesNo 53) During the period five years through ten years after your return from Vietnam, did you recieve any dental care ? : Yes No 54) During the period five years through ten years after your return from Vietnam, were you hospitalized for any reason ? : Yes No 55) Durring the last ten years, did you need medical, psychological or dental care which you did NOT receive ? Yes No Medical care : Yes No Psychological care Yes No Dental care Yes No 56) Durring the last ten years, were you advised by any health professional to seek medical care (exclude any psychological and dental care) but which you did NOT actually receive ?Yes No 57) Durring the last ten years, were you advised by any health professional to seek psychological care but which you did NOT actually receive ?Yes No 58) Durring the last ten years, were you advised by any health professional to seek dental care or treatment, but which you did NOT actually receive ?Yes No 59) Before you went to Vietnam, did you suffer from or experience any skin rashes, lesions, jungle rot or skin disorders, on any part(s) of your body ? :Yes No 60) During your tour in Vietnam, did you suffrer from or experience any skin rashes, lesions, jungle rot or skin disorders (including toes) ? :Yes No 61) After your return from Vietnam, did you ever, or do you now suffrer from or experience any skin rashes, lesions, jungle rot or skin disorders ? :Yes No 62) Did you ever have a blood test while in Vietnam ? :Yes No 63) Have you ever had a blood test since your return from Vietnam ? :Yes No 64) Have you ever been diagnosed as haveing any type of Cancer ? :Yes No 65) Have any members of your immediate family (parents, siblings, children, aunts or uncles) ever been diagnosed as haveing any type of Cancer ? :Yes No 66) Have you ever coughed, urinated or passed blood ? :Yes No 67) Do you NOW take any prescription medication ? :Yes No 68) Are you presently under the care of a physician or other health professional for the treatment of any medical problem or condition (exclude psychological or Dental) ? :Yes No 69) Are you presently under the care of a psychiatrist, psychologist, or mental health professional ? :Yes No 70) Are you presently under the care of a dentist ? :Yes No 71) Are you missing any teeth (including extractions) ? :Yes No If yes, how many teeth have you lost : 0 1 2-4 4-6 6-8 8-10 10-12 12-14 14-16 16-18 18-20 20-22 22-24 All If yes, how many have you lost since Vietnam NA 1 2-4 4-6 6-8 8-10 10-12 12-14 14-16 16-18 18-20 20-22 22-24 All 72) Have you had any surgery SINCE your return from Vietnam ? :Yes No 73) Please desribe your usual nature / disposition ( pick only the one that best decribes your personality, most of the time ) Please chose only one : Laid back Calm Depressed Humorous Angry Violent 74) At the present do you suffer from Depression ?Yes No a) Do you have moderate mood swings ? :Yes No b) Do you have severe mood swings ? :Yes No c) Do your mood swings often become violent ? :Yes No d) Have you been depressed in excess of one year ? :Yes No e) Have you been depressed in excess of five years ? :Yes No f) Did you suffer from depression before Vietnam ? :Yes No 75) Do you believe you were exposed to Agent Orange ? :Yes No 76) Do you believe that your health has suffered as a result of exposure to Agent Orange ? : Yes No 77) The total number of children that I have fathered ( or given birth to ) is : 0 1 2 3 4 5 6 7 8 9 10 11 12 78) The number of children that I have fathered ( or given birth to ) PRIOR to my tour of service in Vietnam is : 0 1 2 3 4 5 6 7 8 9 10 11 12 79) The number of children that I have fathered ( or given birth to ) SINCE my return from Vietnam is : 0 1 2 3 4 5 6 7 8 9 10 11 12 80) Did you Father ( or did you carry any child) who was conceived after your Vietnam service that was stillborn ? :Yes No a) If yes, is there any past history of stillborn deliveries in your family background ? : NA Yes No b) If yes, is the history in your family or your spouses family ? : NA Mine Spouse 81) Did you father ( or did you have ) a pregnancy, conceived after your return from Vietnam, that ended in miscarriage ? : Yes No 82) Did you father ( or give birth to ) any child, conceived after your Vietnam service, that has had any type of physical or mental disability, including learning disabilities ? :Yes No 83) Have you fathered ( or given birth to ) any child, conceived after your Vietnam service, who has died as a result of an illness or disease ? :Yes No a) If yes .. What was the age of that child : NA 0-1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 84) Was there more than one child that has died as a result of illness or disease ? : NA Yes No a) If yes, what was the age of that child : NA 0-1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 85) Have you fathered ( or given birth to ) any child, conceived after your Vietnam service, that has required medical or surgical treatment ? :Yes No 86) Did you father ( or give birth to ) any child, conceived after your Vietnam service, who is not in good physical or mental health today ? :Yes No 87) Do you believe that your children are or may be effected as a result of your exposure to Agent Orange ? : Yes No 88) Have you ever filed a claim or request with the VA for : a) Medical Treatment : Yes No b) Psycological Care / Counseling : Yes No c) Dental Treatment : Yes No d) Agent Orange Compensation : Yes No e) Service Connected Disability : Yes No f) Education Benefits : Yes No 89) Have you ever filed a claim or request for benefits or treatment with the VA which was denied : Yes No 90) If your claim or request was denied by the VA, please indicate the reason given by the VA for the denial : Chose what best applies : Reason Incomplete fileing Insuficiant evidence Negative test results Failure to file in time 91) Have you ever filed an appeal with the VA ? Yes No 92) If you filed an appeal, were you successful ? Yes No 93) Have you ever recieved VA disability payments ? Yes No 94) Do you now recieve VA disability payments ? Yes No 95) If you previously recieve, or are currently receiving VA disability payments, indicate the percentage of disability : NA 10 20 30 40 50 60 70 80 90 100 a)Reason for award : NA Agent Orange Combat Related Wounds PTSD Service conected Other 96) Have you ever received care / treatment from the VA for the following : a) Medical Treatment : Yes No b) Psycological Care / Counseling : Yes No c) Dental Treatment : Yes No d) Any Agent Orange related problems : Yes No e) Any Service Connected Disability : Yes No 97) Have you ever attempted to receive medical, psycological or dental care or treatment from the VA and been denied such care or treatment : Yes No 98) If you have previously received care or treatment by the VA, please rate the quality of care : Quality Excellent Good Fair Poor 99) How far do you live from the nearest VA outpatient clinic ( Miles )? : Miles 1-10 10-15 15-20 20-25 25-30 30-35 35-40 40-45 45-50 50-55 55-60 60-65 65-70 70-75 75-80 80-UP 100) How far do you live from the nearest VA Hospital ( Miles ) ? : Miles 1-10 10-15 15-20 20-25 25-30 30-35 35-40 40-45 45-50 50-55 55-60 60-65 65-70 70-75 75-80 80-85 85-90 90-95 95-100 Over 100 101) Does Public transportation exist between your home and the VA Outpatient Clinic ? : Yes No 102) Does Public transportation exist between your home and the VA Hospital ? : Yes No 103 ) The reduced travel allowance payments for Veterans to travel to and from VA medical treatment facilities has had the following effect upon my ability to receive medical care. Chose one and be guided by the decriptions below : No effect, Minimum effect, still being treated by VA facility. Some effect, still treated but more difficult to get there. Serious, Still recieve treatment but not as often as necessary for my medical needs. Critical, I am unable to afford any transportation to the VA facility and am deprived of needed care. Effect No effect Minimum effect Some effect Serious Critical 104) The department of Veterans Affairs spends large sums of money to print and distribute notices, bulletins and other information to veterans and their families concerning Agent Orange. Kindly indicate the effectiveness of this information upon yourself and your family Chose the one that fits best and be guided by the decriptions below : I believe that the VA has kept me well informed about Agent Orange. I believe that the VA has kept me adequately informed, but could do a little better job. I believe that the VA has Not kept me well informed about Agent Orange. I believe that the VA has done a poor job of keeping me informed about Agent Orange. Informed Well informed Adequately informed Not kept me well informed Poor job keeping me informed 105) Do you believe that the VA has provided you with sufficiant information to take advantage of the various government benefits available to veterans ? Chose the one that fits best and be guided by the decriptions below : The VA has provided me with adequate information. The VA has provided me with less than adequate information. The VA has not provided me with sufficiant information. The VA has failed to provided me with information necessary to take advantage of various government benefits. Information Adequate Less than adequate Not provided Failed 106) Do you believe that the VA is NOW providing adequate care, treatment and or compensation to the victims of Agent Orange exposure ? Chose the one that fits best and be guided by the decriptions below : Yes, the VA is providing sufficiant care, treatment and / or compensation for Agent Orange. YES, the VA is providing all necessary care, treatment and / or compensation for Agent Orange. NO, the VA has not provided sufficiant care, treatment and / or compensation for Agent Orange. NO, the VA has failed in its resposibility to provided care, treatment and / or compensation for Agent Orange. Care Sufficiant Is providing Not provided sufficiant Failed 107) Please utalize the space below to elaborate in brief on any particular numered question you felt did not cover your situation compleately or as close as it should have. When you do please referance the question number and add what you feel was missed. Please keep this brief as we do not have a large staff.