MILITARY HISTORY & EXPOSURE RISK SCREENING

MILITARY HISTORY & EXPOSURE RISK SCREENING
Thank you for your service! As a veteran, you may have been exposed to a range of chemical, physical, and environmental hazards during military service. These exposures may play an important role in your current, or future health. These exposure risks may have caused or contributed to your current condition(s This information may be helpful in providing the best quality of care. Any information you are willing, or able to provide, may be helpful. This information is confidential and used to help provide you the best quality care possible.
Name

First NameLast Name
Date of Birth

MonthDayYear
Branch
Dates of service

MonthDayYear
MOS and Job(s)
Where and when you served, your duties, and what you were exposed to, may play an important role in your current health. Your military history may provide important clues to help us better understanding your unique symptoms and conditions.

According to the DoD, “Comprehensive medical surveillance by healthcare providers involves the identification of veterans at risk, recognition and assessment of hazardous exposures during their military career, and the determination of protective measures, and monitoring of related health conditions.”

We take this duty seriously at East Lake Acupuncture and strive to always provide you with top quality care. Answer only what you are willing and able to answer.

Exposure risk information is voluntary, but extremely helpful and may help reveal previously overlooked conditions or symptoms that are important.
MILITARY EXPOSURE RISKS

Where you served and what you were exposed to, may play a role in your current condition. The more familiar we are with your history, the better we can help you.
Deployment History

Served in direct combat operations in any theater, campaign, or conflictOperations Destert Storm/Desert Shield (ODS)Operation New Dawn (OND)Operation Iraqi Freedom (OIF)Operation Enduring Freedom (EOF)Operation Desert SabreOperation Joint Endeavor, Bosnia, and HerzegovinaOperation Allied Force/Joint Guardian, KosovoDeployment to countries in the Southwest Asia theater of operations any time after August2, 1990 this includes, but is not limited to Iraq, and Saudi Arabia.Deployment to Afghanistan or Djibouti after September 11, 2001Contaminated water exposure at Camp Lejeune or MCAS New River water contamination (for at least 30 days from August 1953 through December 1987 while on active duty, or in the National Guard or Reserves)Project 112/Project Shipboard Hazard and Defense(SHAD) from 1962 to 1974Kandahar Air Field "Poo Pond" (Afghanistan)Uzbekistan/Karshi-Khanabadas (K2)Vietnam WarKorean WarWWIIOther
Exposures. Check all that apply

Exposure to sand, dust and particlesNoise (weapons, machinery, etc.)Vibration (weapons, machinery, rough terrain, etc.)Toxic, embedded fragments shrapnel, etcTBI (Traumatic Brain Injury)Asbestos Working in old buildings and ships and shipyards, jobs in mining, milling, construction, carpentry, demolition, etc.Sarin exposureFuels (JP8, diesel, etc.)Paints/solvents (lead paint, heavy metals)CARC (paint used to coat vehicles to resist corrosion)PCBS from coolant & insulating fluidDepleted uranium (coating on tanks and some ammunition)PesticidesHeavy metalsAirborne particulate matter OR burn pits in Iraq, Afghanistan, and DjiboutiExposure to the sulfur fire at Mishraq State sulfur mine near Mosul (Al Mishraq, Iraq)Airborne polluntants from teh waste incinerator near the Naval Air Facility at Atsugi, JapanHexavelent chromium contamination from the Qamat Ali water treatment plant in Basra, Iraq (2003)Exposure to mustard or nerve agents from demolishing or handling explosive ordinances in Iraq.Participated in testing at: Finschhafen, New Guinea or Porton Down, England.Other
Medically unexplained illnesses related to VIETNAM or GULF WAR service (“Gulf War Syndrome”) - A cluster of medically unexplained chronic symptoms that can include fatigue, headaches, joint pain, indigestion, insomnia, dizziness, respiratory disorders, and memory problems.

Chronic multisymptomatic illness aka "Gulf War Syndrome"Presumptive illness(s) from the Gulf War eraPresumptive illness(s) from the Vietnam Era
Vietnam War

Vietnam (combat operations and occupational hazards)Agent Orange ExposureNapalm ExposureC-123 airplanes Vietnam Korean DZ 1967-1971 Thailand bases 1962-1975 Herbicide tests and storage outside Vietnam Possible exposure due to Department of Defense herbicide tests and storage at military installations in the United States and at locations in other countriesRadiation exposureOther
Radiation Exposure

Dental techniciansNuclear weaponsRoutine exposure to radiationRadiation cleanup of Enewatak AtolNasopharyngeal (nose & throat) radium irradiation treatmentsRadiation Therapy used to treat disease (cancer)Plutonium cleanup, Palmoares, SpainFukushima nuclear accidentMcMurdo Station (1964-1973)"Atomic Veterans” Hiroshima and NagasakiLORAN radiation (1942 to 2010 – Coast Guard)Other
Mustard gas or lewisite exposure if you were in the ARMY or NAVY and serviced in any of the below locations:

Bari, ItalyBushnell, FLCamp Lejeune, NCCamp Sibert, ALDugway Proving Ground, UTEdgewood Arsenal, MDNaval Research Lab, Washington, DCOndal, IndiaRocky Mountain Arsenal, COSan Jose Island, Panama Canal ZoneCharleston, SCGreat Lakes Naval Training Center, ILHart's Island, NYNaval Training Center, Bainbridge, MDNaval Research Laboratory, VANaval Research Laboratory, Washington, DCParticipated in testing at: Finschhafen, New Guinea or Porton Down, EnglandUSS Eagle Boat 58
Vietnam ( combat activities and occupational hazards)

Dental techniciansPlutonium cleanup, Palmoares, SpainNuclear weapons techniciansFuushima nuclear accidentRoutine exposure to radiationMcMurdo Station (1964-1973)Radiation cleanup of Enewatak AtolNasopharyngeal (nose & throat) radium irradiation treatments“Atomic Veterans” Hiroshima and NagasakiRadiation Therapy used to treat disease (cancer)LORAN radiation (1942 to 2010 – Coast Guard)I don’t know what all I had
Vaccinations and preventative medications

Anthrax vaccineSmallpox vaccineRabies preventativeRabies treatmentPyridostigmine bromide(to protect against nerve agent attacks in Iraq – ODS)Botulinum toxidStandard inoculations against infectious disease including Hepatitis, Yellow Fever, Typhoid,Cholera, Meningitis, Whoop Cough, Polio, Tetanus, etc.Mefloquine/Lariam (round white pill used to prevent malaria)I don't know what all I had
Infectious Diseases

MalariaRabiesHepatitisMeningitisParasitesOther
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MILITARY HISTORY & EXPOSURE RISK SCREENING

MILITARY EXPOSURE RISKS