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National Health Study for a
New Generation of
U.S. Veterans
Questionnaire
Sponsored by
3/8” spine perf
U.S. Department of Veterans Affairs
6 DIGIT BARCODE
PRIVACY ACT STATEMENT
The information requested on this questionnaire is solicited under authority of 38 U.S.C. Section 7303. It is being collected to assist VA in learning
more about the health of recent veterans and will help VA to provide better medical care. The information you supply will be confidential and protected
by the provisions of the Privacy Act of 1974 (5 U.S.C. 552a) and specifically the VA system of records entitled 34VA12, “Veteran, Patient, Employee
and Volunteer Research and Development Project Records - VA.” Releases of the information may only be made with your consent or as identified in a
“routine use” of the system of records. Routine uses include releases of statistical data and non-identifying data for research and associated
administrative purposes. Disclosure is voluntary; failure to furnish the requested information will have no adverse effect on any VA benefit to which
you may be entitled.
PAPERWORK REDUCTION ACT INFORMATION: This information is collected in accordance with the clearance requirements of section 3507
of the Paperwork Reduction Act of 1995. Accordingly, VA may not conduct or sponsor, and you are not required to respond to, a collection of
information unless it displays a valid OMB control number. VA anticipates that the time expended by all individuals who complete this questionnaire
will average 30-45 minutes. This includes the time it will take to read instructions, gather the necessary facts, and fill out the questionnaire.
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ALL RIGHTS RESERVED.
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GENERAL INSTRUCTIONS
To participate in this important project, please follow these instructions:
1.
2.
3.
4.
5.
Read and complete questions 1 through 72.
Follow instructions for questions that apply to you.
Read the VA Research Consent Form included with this questionnaire package.
Return this booklet and the signed Consent Form in the postage-paid addressed envelope enclosed in the package.
Keep the cover letter and the extra Consent Form for your records.
If you have any questions please feel free to contact:
National Health Study for a New Generation of U.S. Veterans
Hours: Monday - Friday, 8:00 A.M. - 5:00 P.M. (EST)
Telephone: 1-877-VET-0088
Email: vetwellness@hmstech.com
MARKING INSTRUCTIONS
•
•
•
•
•
While you can use a pen, please use a PENCIL in case you want to change an answer.
Please do NOT use felt tip pens.
Correct Incorrect
Make solid, heavy “X” marks in the box.
Mark
Mark
Please erase cleanly or white-out any mark you wish to change.
✓ ✗
Please do not make any stray marks on this form.
Erasure
Mark
✗
3/8” spine perf
(This page will be kept separately from the rest of the pages to ensure your confidentiality.)
PLEASE PRINT
NAME:
First
Middle
Last
Suffix
(Jr., III, etc.)
Address
City
Apt/Unit Number
State
Zip Code
Best telephone numbers to reach you at:
Cellular
Home (
)
Work
Area Code
Cellular
Home (
)
Work
Area Code
-
E-mail address:
Birthdate:
m m
@
d d
y
y
y
y
Last 4 digits of your social security number:
-
PLEASE START HERE
1 In what component(s) have you served? (Mark all that apply)
Active Duty
Reserve
National Guard
2 What branch(es) did you serve with? (Mark all that apply)
Air Force
Army
Coast Guard
Marine Corps
Navy
3a During military service, what was your last principal duty?
3b During military service, what was your last occupation code (MOS, NEC or AFSC)?
4a Have you been deployed to Operation Enduring Freedom (OEF) and/or Operation Iraqi Freedom (OIF)?
No
Yes
4b IF YES, what was your period of last deployment:
From
m m
d d
y
y
y
y
To
m m
d d
y
y
y
y
5 Since 2001, please mark all locations of operations you served in:
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Afghanistan
Iraq
Kuwait
Other (Please specify)
Qatar
Turkey
Bosnia/Kosovo
Europe
Africa
North America
Central America
South America
On a ship
6 Since 2001, how many times were you deployed to the following operations?
Total Deployments
0
1
2
3
4
5+
OEF
OIF
Other
7a Have you used VA health care services since you were separated from active duty?
No (Skip to question 7d)
Yes
7b What are the main reasons you enrolled in VA
health care services? (Mark all that apply)
7c All things considered, how satisfied are you
with your health care in the VA?
To obtain regular or routine health care
To obtain specialist health care
To obtain dental care
To obtain prescription medications, eye glasses,
hearing aids, or other devices
To obtain mental health care
To obtain special emphasis care such as for a spinal
cord injury, traumatic brain injury, blind
rehabilitation, prosthetics
To receive nursing home care
To obtain home health care
Other
Completely satisfied
Very satisfied
Somewhat satisfied
Neither satisfied nor dissatisfied
Somewhat dissatisfied
Very dissatisfied
Completely dissatisfied
}
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1
Skip to
question 8
7d If you have never used VA services, why not? (Mark all that apply)
I prefer to use other health care coverage
I do not wish to use VA health care services
because of concerns about quality of care
I do not know if I am eligible
VA health care services are not in a convenient location for me
Other (Please specify)
8 What health care coverage do you have? (Mark all that apply)
Private or self-purchased insurance
Employer-based insurance
Department of Defense's TRICARE
Veterans Affairs
Medicare
Medicaid
Other
None
9 Since separation from active duty, have you received a letter from the VA Secretary informing you of programs and
benefits that you may be entitled to through the VA?
No
Yes
Don't remember
10 Do you belong to a Veterans group(s) such as Veterans of Foreign Wars of the United States (VFW) or American Legion?
No
Yes (Please specify all)
11 Has a doctor ever told you that you have any of the following conditions? (Please mark after each condition)
Condition
No
Yes
Year First Told Condition
No
Yes
Year First Told
y
y
y
n. Sinusitis
y
y
y
y
y
o. Bronchitis
y
y
y
y
y
y
p. Asthma
y
y
y
y
y
y
y
q. Frequent bladder infections
y
y
y
y
y
y
y
y
r. Significant hearing loss
y
y
y
y
g. Irritable bowel syndrome or
colitis (irritation of the colon)
y
y
y
y
s. Multiple sclerosis
y
y
y
y
h. Diabetes
y
y
y
y
t. Chronic fatigue syndrome
y
y
y
y
i. Repeated seizures,
convulsions, or blackouts
y
y
y
y
u. Posttraumatic stress
disorder
y
y
y
y
j. Migraines
y
y
y
y
v. Depression
y
y
y
y
k. Coronary heart disease or
artery disease
y
y
y
y
w. Sleep apnea
y
y
y
y
l. Hypertension
y
y
y
y
x. Traumatic brain injury
y
y
y
y
y
y
y
y
b. Skin cancer
y
y
y
y
y
y
y
d. Cirrhosis of the liver
y
y
e. Hepatitis
y
f. Any other liver trouble
m. Stroke
c. Any other cancer (Please specify)
2
3/8” spine perf
y
a. Arthritis of any kind
12 Not including blood donations, in what month and year was
your last HIV test?
m m
y
13 During the past 12 months, have you been treated for a sexually transmitted
disease or venereal disease (e.g., gonorrhea, syphilis, herpes, chlamydia)?
y
y
Don't know
Never tested
y
No
Yes
14a During the past 12 months, how many clinic or doctor visits have you made because you had a health problem?
(exclude routine visits for vaccinations, physical examinations, etc.)
None
14b Please explain reasons for visit(s) or diagnoses:
4.
5.
6.
1.
2.
3.
Number of visits
15a During the past 12 months, how many times have you been hospitalized overnight or longer?
None
15b Please explain reasons for visit(s) or diagnoses:
1.
2.
3.
Number of times
4.
5.
6.
16a During the past 12 months, have you taken any prescribed medications?
No
16b IF YES, please specify name(s) of medication(s):
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Yes
1.
2.
3.
4.
5.
6.
17 During the past 12 months, how many alternative treatment
visits have you made because you had health problems?
None
Number of visits
18 If alternative treatments were used in the past 12 months, please indicate all treatment(s), the reasons
for the treatment(s), and whether treatment was used at VA or elsewhere. (Mark all that apply)
Treatment
Not used
Used at VA Used elsewhere
Reason for treatment
a. Acupuncture
b. Biofeedback
c. Chiropractic care
d. Energy healing
e. Folk remedies
f. Herbal therapy
g. High dose/megavitamin therapy
h. Homeopathy
i. Hypnosis
j. Massage
k. Relaxation
l. Spiritual healing
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3
No
19
Yes
a. Has a doctor or other health professional ever told you that you had a
head injury?
If NO, skip to question 20.
b. Have you received treatment from a doctor or other health professional
for a head injury?
If NO, skip to question 20.
c. Was this treatment helpful?
d. Were you prescribed medication(s)?
No
20
Yes
a. Has a doctor or other health professional ever told you that you have
posttraumatic stress disorder (PTSD)?
If NO, skip to question 21.
b. Have you received treatment from a doctor or other health professional
for PTSD?
If NO, skip to question 21.
c. Was this treatment helpful?
d. Were you prescribed medication(s)?
21 In general, would you say your health is:
Very good
Excellent
Good
Fair
Poor
22 The following questions are about activities you might do during a typical day. Does your health now limit you
in these activities? If so, how much?
Yes, limited a little
No, not limited at all
a. Moderate activities, such as moving a table,
pushing a vacuum cleaner, bowling, or playing golf
b. Climbing several flights of stairs
23 During the past 4 weeks, how much of the time have you had any of the following problems with your work or
other regular daily activities as a result of your physical health?
All of
the time
Most of
the time
Some of
the time
A little of
the time
None of
the time
a. Accomplished less than you would like
b. Were limited in the kind of work or other activities
24 During the past 4 weeks, how much of the time 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)?
All of
the time
Most of
the time
Some of
the time
A little of
the time
None of
the time
a. Accomplished less than you would like
b. Did work or other activities less carefully than usual
25 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
4
Extremely
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Yes, limited a lot
26 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 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
Some of
the time
A little of
the time
None of
the time
a. Have you felt calm and peaceful?
b. Did you have a lot of energy?
c. Have you felt downhearted and depressed?
27 During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with
your social activities (like visiting friends, relatives, etc.)?
All of the time
Most of the time
Some of the time
A little of the time
None of the time
28 This question contains a list of comments made by people after stressful life events. Please read each item and
mark how frequently these comments were true for you during the past 4 weeks. If it did not occur during the
past 4 weeks, please mark the 'Not at all' column.
Not
at all
3/8” spine perf
In the past 4 weeks, have you had…?
A little
bit
Moderately
Quite
a bit
a. Repeated, disturbing memories of stressful experiences from
the past
b. Repeated, disturbing dreams of stressful experiences from
the past
c. Suddenly acting or feeling as if stressful experiences were
happening again
d. Feeling very upset when something happened that reminds
you of stressful experiences from the past
e. Trouble remembering important parts of stressful
experiences from the past
f. Loss of interest in activities that you used to enjoy
g. Feeling distant or cut off from other people
h. Feeling emotionally numb, or being unable to have loving
feelings for those close to you
i. Feeling as if your future will somehow be cut short
j. Trouble falling asleep or staying asleep
k. Feeling irritable or having angry outbursts
l. Having difficulty concentrating
m. Being “super-alert,” or watchful or on guard
n. Feeling jumpy or easily startled
o. Having physical reactions when something reminds you of
stressful experiences from the past
p. Avoid thinking about your stressful experiences from the
past, or avoid having feelings about them
q. Avoid activities or situations because they remind you of
stressful experiences from the past
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5
Extremely
29 If you experienced any of the symptoms described in question 28, were these stressful experiences related to:
Military service only
Other traumatic life events only
Both military and other life events
Don't know/not applicable
30 Over the last 2 weeks, how often have you been bothered by any of the following problems?
Not
at all
Several
days
More than
half the days
Nearly
every day
a. Little interest or pleasure in doing things
b. Feeling down, depressed, or hopeless
c. Trouble falling or staying asleep, or sleeping too much
d. Feeling tired or having little energy
e. Poor appetite or overeating
f. Feeling bad about yourself or that you are a failure or have let
yourself or your family down
g. Trouble concentrating on things, such as reading the newspaper or
watching television
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h. Moving or speaking so slowly that other people could have noticed.
Or the opposite - being so fidgety or restless that you have been
moving around a lot more than usual
i. Thoughts that you would be better off dead or of hurting
yourself in some way
★
If you are experiencing emotional distress and need to talk to a trained VA professional, you may call
1-800-273-TALK (8255), 24 hours a day, 7 days a week.
31 Over the last 4 weeks, how often have you been bothered by any of the following problems?
Not
at all
a. Feeling nervous, anxious, on edge, or worrying a lot about different things
b. Feeling restless so that it is hard to sit still
c. Getting tired very easily
d. Muscle tension, aches, or soreness
e. Trouble falling asleep or staying asleep
f. Trouble concentrating on things, such as reading a book or watching TV
g. Becoming easily annoyed or irritable
6
Several
days
More than
half the days
32a During military service, did you experience any of the following events? (Mark all that apply)
No
Yes
Estimated
Number of Times
a. Blast or explosion (IED, RPG, land mine, grenade, etc.)
b. Motor vehicle, aircraft, or water transportation accident
c. Fragment wound or bullet wound above the shoulders
d. Falls
e. Injury from sports/physical training
f. Other injury (Please specify)
If you marked NO for all events, skip to question 34.
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32b Did you have any of the following IMMEDIATELY after any of the events in question 32a? (Mark all that apply)
Losing consciousness/“knocked out” IF MARKED, about how long were you unconscious?
Being dazed, confused, or “seeing stars”
Not remembering the event
Concussion
Head injury
No, none of the above (Skip to question 34)
minutes
32c Did any of the following problems begin or get worse after any of the events in question 32a? (Mark all that apply)
Memory problems or lapses
Balance problems or dizziness
Sensitivity to bright light
Irritability
Headaches
Sleep problems
Trouble concentrating
Hearing problems
Other problems (Please specify)
No, none of the above (Skip to question 34 )
33 In the past week, have you had any of the following? (Mark all that apply)
Memory problems or lapses
Balance problems or dizziness
Sensitivity to bright light
Irritability
Headaches
Sleep problems
Trouble concentrating
Hearing problems
No, none of the above
7
34 During military service, were you exposed to or did you experience any of the following?
No
Yes
a. Dust and sand
No
Yes
i. Pesticide-treated uniforms
j. Depleted uranium (DU)
(e.g., handling DU munitions)
k. Ate local food other than provided by
Armed Forces
b. Burning trash/feces
c. Diesel, kerosene and/or other
petrochemical fumes
d. Skin exposure to JP8, diesel, or other
petrochemical fuel
l. Contact with Prisoners of War (POWs)
e. Smoke from oil fires
m. Exposure to loud noises
f. Solvents or degreasers
n. Radiation
g. Paint operations (vehicles or equipment)
o. Industrial pollution
h. Insect repellant (spray, lotion, or cream
applied to your skin)
p. Other exposure you consider harmful
(Please specify)
35 During military service, did you receive any of the following vaccinations?
a. Smallpox (leaves a scar on the arm)
b. Anthrax
c. Rabies
No
No
No
Yes
Yes
Yes
36a During military service, did you ever take medications to prevent malaria?
No
Yes
36b IF YES, please indicate which medicines you took. (Mark all that apply)
Doxycycline (Vibramycin®)
Primaquine
Other (Please specify)
37 When you were in the military…
No
a. Did you ever receive uninvited or unwanted sexual attention (e.g., touching,
cornering, pressure for sexual favors, inappropriate verbal remarks)?
b. Did anyone ever use force or the threat of force to have sex with
you against your will?
If NO, skip to question 38.
c. If yes, did you ever contract a sexually transmitted disease as a result?
During any of your deployments: (If no deployment, skip to question 43a)
Yes
No
38 Were you wounded or injured by hostile actions?
No
Yes
39 Did you ever feel that you were in great danger of being killed?
40 Did you see anyone wounded, killed, or dead? (Mark all that apply)
No
Yes, coalition
Yes, enemy
Yes, civilian
41 Were you engaged in direct combat where you discharged your weapon? (Mark all that apply)
No
Yes, land
Yes, sea
Yes, air
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Chloroquine (Aralen®)
Mefloquine (Lariam®)
Don't know
Yes
42 Since returning from your deployment, have you had serious conflicts with your spouse, family members, or close
friends that continue to cause you worry or concern?
No
Yes
43a During the past 12 months, have you smoked cigarettes?
No
Yes
43b IF YES, how many cigarettes do you smoke per day?
number of cigarettes per day
43c How old were you when you first started smoking?
age
(Skip to question 44)
43d IF NO, have you ever smoked cigarettes even occasionally?
No
Yes
43e IF YES, in what year did you last stop?
y
y
y
y
year
44 How often do you have a drink containing alcohol?
Once a month
or less
Never
(Skip to question 48)
2 to 3 times
a week
2 to 4 times
a month
4 or more times
a week
45 How many drinks containing alcohol do you have on a typical day when you are drinking?
1-2
3
4
5-6
7-9
10 or greater
46 How often do you have 5 or more drinks on one occasion?
3/8” spine perf
Never
Less than monthly
Once a month
Weekly
Daily or almost daily
47 Have any of the following happened to you more than once in the last 6 months?
No
Yes
a. You drank alcohol even though a doctor suggested that you stop drinking because of a
problem with your health
b. You drank alcohol, were high from alcohol, or hung over while you were working, going to
school, or taking care of children or other responsibilities
c. You missed or were late for work, school, or other activities because you were drinking or hung over
d. You had a problem getting along with other people while you were drinking
e. You drove a car after having several drinks or after drinking too much
48 How often do you use seat belts when you drive or ride in a car?
Always
Nearly always
Sometimes
Seldom
Never
Never drive or ride in a car
(Skip to question 50)
49 During the past 4 weeks, how many times did you ride with a driver who had perhaps too much to drink?
None
Don't know
number of times
50 Do you ride a motorcycle?
No
Yes, usually with a helmet
Yes, usually without a helmet
51 Do you usually drive… (Mark only one)
20 miles per hour or more over the speed limit
about 15 miles per hour over the speed limit
about 10 miles per hour over the speed limit
about 5 miles per hour over the speed limit
at or below the speed limit
never drive
9
52 During the past 3 years, have you:
No
Yes
a. Gotten a ticket for speeding?
b. Gotten a warning for speeding?
c. Gotten a ticket for any other moving violation (such as running a red light or stop sign)?
d. Been convicted of DWI or DUI?
e. Had your car insurance canceled or premiums increased as a result of claims or points?
53a Since 2001, have you been in a vehicle crash while in the United States?
No (Skip to question 54)
Yes
Yes
53b If so, were you: (Mark all that apply)
Number of
crashes
a. On a motorcycle wearing a helmet?
b. On a motorcycle not wearing a helmet?
c. In a vehicle as a driver?
3/8” spine perf
d. In a vehicle as a passenger?
e. Speeding over the limit?
f. Driving while intoxicated or under the influence?
g. Wearing a seatbelt?
53c Did any of these crashes occur: (Mark all that apply)
Yes
Number of
crashes
a. Before first deployment?
b. Between deployments?
c. Since last deployment?
d. Did not deploy
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10
54 During the past 12 months, how many people have you had sex with?
0
1
2
3
4
5+
55a During the past 12 months, have you had sex with someone who is not your main partner or whom you do not
consider to be your main partner?
No (Skip to question 56a)
Yes
55b IF YES, thinking back to the last time you had sex with that person, was a condom used?
No
Yes
56a Have you or your partner ever tried, for a period of 12 months or longer, to become pregnant?
No (Skip to question 57a)
Yes
56b IF YES, did you or your partner eventually get pregnant?
Stopped trying
Got pregnant
Still trying
56c Did you or your partner seek any medical help while trying to get pregnant?
No (Skip to question 57a)
Yes
56d Did the medical provider find any of the following reasons to explain why you or your partner were
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having difficulty getting pregnant?
Problems with ovulation
Blocked tubes
Endometriosis
Semen or sperm problems
No reason found
Other (Please specify)
57a If you are FEMALE: Have you ever been pregnant, regardless of whether there was a live birth outcome
from that pregnancy?
No (Skip to question 59)
Yes
number of pregnancies (Continue with question 58)
57b If you are MALE: Have you ever been the biological father in any pregnancy, regardless of whether there was a
live birth outcome from that pregnancy?
No (Skip to question 65)
Yes
number of pregnancies (Continue with question 58)
11
58 Please provide information on ALL of your pregnancies or pregnancies of your partner in which you are
the biological father. For multiple birth outcomes, make a separate entry for each (e.g., 2 entries for twins).
If you are uncertain about a detail, please provide your best estimate:
Pregnancy
1
2
4
5
Outcome
Live Birth
Currently Pregnant
Stillbirth
Miscarriage
Other:
Live Birth
Currently Pregnant
Stillbirth
Miscarriage
Other:
Live Birth
Currently Pregnant
Stillbirth
Miscarriage
Other:
Live Birth
Currently Pregnant
Stillbirth
Miscarriage
Other:
Live Birth
Currently Pregnant
Stillbirth
Miscarriage
Other:
Birth
weight Length of
(if live pregnancy
birth)
Birth defects
No
Yes
m m
y
y
lbs.
Months
or
oz.
Weeks
(please describe):
No
Yes
m m
y
y
lbs.
Months
or
oz.
Weeks
(please describe):
No
Yes
m m
y
y
lbs.
Months
or
oz.
Weeks
(please describe):
No
Yes
m m
y
y
lbs.
Months
or
oz.
Weeks
(please describe):
No
Yes
m m
y
y
lbs.
Months
or
oz.
Weeks
(please describe):
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Did partner
serve in:
OEF/OIF
Military
None
OEF/OIF
Military
None
OEF/OIF
Military
None
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3
Date of
pregnancy outcome
or due date
OEF/OIF
Military
None
OEF/OIF
Military
None
If you are FEMALE please continue to question 59. If you are MALE please skip to question 65.
59 What forms of contraception have you used before,
during, or after active duty? (Mark all that apply)
Before
active duty
On active duty
not deployed
On active
After separation
duty deployed from active duty
Before
active duty
On active duty
not deployed
On active
After separation
duty deployed from active duty
a. Birth control pills
b. Birth control ring
c. Birth control patch
d. Male condoms
e. Female condoms
f. Tubal ligation
g. Partner's vasectomy
h. Withdrawal
i. Injectable, e.g., Depo-Provera®, Lunelle®
j. Calendar/rhythm method or natural family planning
k. Diaphragm or cervical cap
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l. Intrauterine device (IUD), e.g., Mirena®, copper
m. Morning after pills/emergency contraception
n. Foam or jelly
o. Progestin implant, e.g., Norplant®
p. None
q. Not sexually active
r. Other: (Please specify)
60 Have you experienced any of the following?
a. Irregular periods
b. Painful periods
c. Abnormal Pap smear
d. Pelvic inflammatory disease
e. Chronic pelvic pain
f. Low sexual interest
g. Painful intercourse
h. Urinary tract infection
i. Hysterectomy
13
61 Are you currently using a hormonal method to stop or control your period?
No
Yes (Please specify)
Please answer questions 62-64 only if you were deployed. If not deployed, please skip to question 65.
62 While deployed, was it easy for you to get contraception?
No
Yes
Not desired
63a While deployed, did you use any hormonal methods to stop or control your period?
No
(Skip to question 64)
Yes (Please specify)
63b Were you offered a hormonal method to stop or control your period by a health care provider?
No
Yes (Skip to question 64)
63c Would you have preferred to have a hormonal method to stop or control your period?
No
Yes
64 While deployed, did you have access to sanitary supplies (e.g., pads, tampons)?
No
Yes
Not needed
65 During the past 12 months, what were you doing most of the time?
Employed for wages
Self-employed
On active duty
marital status:
Student
Retired
Other (Please specify)
Married or living with partner
Married but separated from partner
Single, never married
Divorced
67 Current annual household
Less than $35,000
$35,000–$49,999
income before taxes:
$50,000–$74,999
$75,000–$99,999
Widowed
$100,000–$149,999
$150,000 or more
68 What is the highest level of education that you have completed?
High school degree or equivalent/GED
Some college, no degree
Associate's degree
Bachelor's degree
Master's, doctorate, or professional degree
69 What is your race/ethnicity? (Mark all that apply)
White
Black or African American
70 About how tall are
feet
Male
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
71 About how much do you
and
you without shoes?
72 Gender:
Hispanic or Latino
Asian
weigh without shoes?
inches
pounds
*If currently pregnant, please give your usual weight before becoming pregnant.
Female
Thank you very much for taking the time to complete this questionnaire. Your assistance in providing this information is very much appreciated.
Please mail this completed questionnaire with the signed Consent Form in the postage-paid envelope as soon as possible. If you have any
questions, you may call us at 1-877-VET-0088 or e-mail us at vetwellness@hmstech.com.
National Health Study for a New Generation of U.S. Veterans, c/o HMS TECHNOLOGIES, INC., P.O. Box 708, Martinsburg, WV 25402
PLEASE DO NOT WRITE IN THIS AREA
SERIAL #
14
3/8” spine perf
66 Current
Looking for work or unemployed
On disability/unable to work
Homemaker/caring for family
| File Type | application/pdf |
| File Title | untitled |
| File Modified | 2011-11-06 |
| File Created | 2009-05-22 |