Form 10-10176 Environmental Hazards Registry (EHR) Worksheet for Veter

OMB Control Number: 2900-XXXX
Estimated Burden: 60 minutes
Expiration Date: 07/31/2023

ENVIRONMENTAL HAZARD REGISTRY (EHR) WORKSHEET
(WORKING TEMPLATE)
The Paperwork Reduction Act of 1995 requires us to notify you that this information collection is in accordance with the clearance requirements of Section 3507 of
the Paperwork Reduction Act of 1995. 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 by all individuals who must complete this form will average 60 minutes. This includes the time it will take to
read instructions, gather the necessary facts and fill out the form.
Privacy Act Statement: The authority for collection of the requested information is found in 38 U.S.C. 527 and 1116 (Ionizing Radiation Registry and Agent
Orange Registry) and 38 U.S.C. 1117 (Gulf War Registry). The data from the Environmental Hazards Registry examination is used to collect information on health
issues that may be affecting Veterans who were deployed to various conflicts. Providing the requested information during a registry examination is voluntary;
however, if not provided, VA will be unable to enter the Veteran into the registry. Failure to furnish any or all registry information will have no effect on other
benefits to which the Veteran may be entitled. VA will not disclose your personal information to third parties without your consent, except for routine uses made in
accordance with the Privacy Act of 1974 and the applicable VA System of Records Notice (SORN): National Patient Databases-VA (121VA19); Ionizing
Radiation Registry (69VA131); Agent Orange Registry (105VA131); and Gulf War Registry (93VA131).

Demographics

Ionizing Radiation, Agent Orange, Gulf War, Other (Specify)

Last Name

First Name

Social Security Number

Middle Name
Date of Birth

Address
City

State

Zip Code

Plus 4

County
Birth Sex:

Self-Identified Gender Identity:

F-M = Transmale/Transman/Female to Male
O = Other
M = Male
M = Male
I = Individual chooses not to answer
M-F = Transfemale/Transwoman/Male to Female
F = Female
F = Female
Marital Status: 1 = Married 2 = Divorced 3 = Separated 4 = Widowed 5 = Single, Never Married
Race
Enter all races below (One entry per row)
Race Code
Collection Method
1 = Native American or Alaskan Native
5 = White/Caucasian
1 = Observer
2 = Asian
6 = Biracial
2 = Proxy
3 = Black or African American
7 = Declined to answer
3 = Self-Identification
4 = Native Hawaiian or Other Pacific Islander
4 = Unknown

Enter all ethnicities that apply. One entry per row.
Ethnicity Code
1 = Hispanic or Latina/o
2 = Not Hispanic or Latina/o
3 = Declined to answer
4 = Unknown by patient

Ethnicity
Collection Method
1 = Observer
2 = Proxy
3 = Self-Identification
4 = Unknown

Periods of Service
Enter all periods of service that apply. One entry per row.
Branch: 1 = Army
2 = Air Force
3 = Navy
4 = Marines
5 = Coast Guard
6 = Other
Branch of
Start Date
End Date
Remarks/Deployed to:
Service
(mm/dd/yyyy)
(mm/dd/yyyy)

VA FORM
MAY 2020

10-10176

Supersedes VA Form 10-9009, June 2005
VA Form 10-9009A, March 2010 / VA Form 10-0020A, June 2005

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Military Related Exposures
Enter exposure for which you are seeking a registry evaluation.
1 = Agent Orange 2 = Gulf War 3 = Ionizing Radiation 4 = Depleted Uranium (DU) 5 =Toxic Embedded Fragments (TEF)
6 = Airborne Hazards and Open Burn Pits - AHOBP (See Separate CPRS Worksheet)
Exposure
Start Date
End Date
Service Location
Military Occupational Specialty (MOS)
Code
(mm/dd/yyyy)
(mm/dd/yyyy)

Remarks: (Document location unit if known)

Social History
Physical Activity
Do you routinely participate in any physical activities or exercises? Y = Yes N = No
Which physical activities or exercises do you routinely participate? (ex., walking, running, calisthenics, sports)

How often to do you participate in this physical activity or exercise?
1 = 1x/Week 2 = 2x/Week 3 = 3x/Week 4 = More than 3x week
How long do you usually participate in this physical activity or exercise?
Do you currently smoke?
Y= Yes N= No

Hrs

Tobacco Use
How many cigarettes do you smoke How old were you when you began smoking?
each day?

Have you ever smoked cigarettes even occasionally?
When did you last stop?

Min

Y = Yes N = No

Year

Do you use any other forms of tobacco? Y = Yes N = No
If so, which ones?
Do you live in a household where someone else smokes (second-hand smoke exposure)? Y = Yes N = No
Alcohol Use
Do you ever drink alcohol (including beer and wine)? Y = Yes N = No

Average number of drinks per week?

Illicit or Recreational Substance Use
Do you currently use any substance, illegal or prescription that is not prescribed by your medical doctor (i.e.,
marijuana, opioids, prescription medications)? Y = Yes N = No
Remarks

Birth Data
Have any of the Veteran’s children
Please specify (i.e., spina bifida)
showed signs of birth defects?
1 = Yes 2 = No
If yes, in what year was this child born?
Was this child born pre or post deployment?
Number of children

Maternal age

Paternal age

VA FORM 10-10176, MAY 2020

Remarks

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Agent Orange Exposures

Y = Yes

History
N = No NA = Not Applicable

1 = Yes 2 = No 3 = Not Sure

Handled or sprayed Agent Orange
Not directly sprayed, but was in area recently sprayed
Exposure to other herbicides other than Agent Orange (if yes, please specify)
Direct contact with Agent Orange
Ate food or drink that could have been sprayed with Agent Orange
Gulf War Exposures
Y = Yes N = No NA = Not Applicable
Smoke from oil fires
Smoke fumes from tent heaters, diesel, or petrochemical substances
Exposure to burning trash/feces
Skin exposure to diesel or other petrochemical substances
CARC (Chemical Agent Resistance Compound) paints
Depleted Uranium (Burning or Shrapnel)
Shrapnel injuries with retained fragments
Microwave radiation from radar
Personal pesticide use, including creams, sprays, or flea collars
Nerve gas or other nerve agents
Drug (pyridostigmine) used to protect against nerve agents
Mustard gas or other gas agents
Ate food contaminated with smoke, oil, or other chemicals
Ate food other than what was provided by the armed forces
Bathed in or drank water contaminated with smoke, oil, or other chemicals
Bathed in or drank water other than what was provided by the armed forces
Immunization against anthrax
Other Immunizations (for example, botulism). If yes, please specify.
Stationed at Qarmat Ali (If yes, please complete Sodium Dichromate Exposure
worksheet)
***Sodium Dichromate Exposure is assessed during an Airborne Hazards and Open Burn Pits Registry Exam***
Ionizing Radiation
Y = Yes N = No NA = Not Applicable
Were you exposed to radiation during military service?
Received nasopharyngeal radium treatments during service?
Diagnosed with any possibly radiogenic-related diseases (If yes, please list in remarks section)
Remarks:

VA FORM 10-10176, MAY 2020

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Self-Assessment of Health
1= Excellent; 2= Very Good; 3= Good; 4= Fair; 5= Poor; 6 = Very Poor
Which best describes the Veteran’s health?
Chief Complaint/Exposure(s) of most concern and related to this registry exam:

Current Diagnoses

Past Medical and Surgical Histories

Head, Eyes, Ear, Nose, and Throat

Review of Systems

Dental/Oral
Heart
Chest/Pulmonary
Gastrointestinal
Reproductive/Urologic
Musculoskeletal
Skin
Blood/Bruising
Infectious Disease History
Neurologic
Behavioral Health
Exposures/Other
Physical Exam

VA FORM 10-10176, MAY 2020

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Agent Orange Presumptive List

Gulf War Presumptive List

AL Amyloidosis
Chronic B-cell Leukemias
Chloracne (or similar acneform disease)*
Diabetes Mellitus Type 2
Hodgkin's Disease
Ischemic Heart Disease
Multiple Myeloma
Non-Hodgkin's Lymphoma
Parkinson's Disease
Peripheral Neuropathy, Early-Onset*
Porphyria Cutanea Tarda*
Prostate Cancer
Respiratory Cancers (includes lung cancer)
Soft Tissue Sarcomas (other than
osteosarcoma, chondrosarcoma, Kaposi's
sarcoma, or mesothelioma)
*Must be at least 10 percent disabling within one
year of exposure to herbicides.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

***Ionizing Radiation Presumptive List- please visit
our website at:
https://www.publichealth.va.gov/exposures/
radiation/index.asp
***Additional information on updates and changes
can be found by visiting our website at
https://www.publichealth.va.gov/index.asp
Additional Tests Ordered as Indicated

• Chest X-ray (Chest X-ray or Chest CT for Qarmat
Ali evaluations)

BP:

P:

Resp:

1. Chronic Fatigue Syndrome
2. Fibromyalgia
3. Functional GI disorders (e.g., irritable
bowel syndrome (IBS), functional
dyspepsia, and functional abdominal pain
syndrome)
4. Undiagnosed Illnesses (e.g., abnormal
weight loss, fatigue, cardiovascular
disease, muscle and joint pain,
headache, menstrual disorders,
neurological and psychological problems,
skin conditions, respiratory disorders,
and sleep disturbances
Certain presumptive diseases, which will be
considered to have been incurred in or aggravated
by service even if there is no evidence of such
disease during active service. With three exceptions
(see asterisks), one of the following must have
become manifest to a degree of 10 percent or more
within 1 year of the date of separation from a
qualifying period of active service:
• Burcellosis
• Campylobacter jejuni
• Coxiella burnetii (Q fever)
• Malaria* (if not 10 percent or more within
one year of separation, may be 10 percent
or more at a time when standard or
accepted treatises indicate that the
incubation period commenced during
qualifying period of service)
• Mycobacterium tuberculosis* (no time limit)
• Nontyphoid Salmonella
• Shigella
• Visceral leishmaniasis* (no time limit)
• West Nile Virus

Temp:

Eyes (e.g., conjunctivitis)

Pain:

HT:

WT:
N= Normal
A= Abnormal (Please explain)

Ear, Nose, and Throat (e.g., nasal mucosa,/septum, oropharynx)
Dental/Oral
Heart (e.g., heart sounds/borders/position, pulses, edema)
Chest/Pulmonary (e.g., lung sounds, cyanosis, clubbing, habitus)
Abdominal
Reproductive/Urologic/Rectal
Musculoskeletal/Back/Extremities
Skin
VA FORM 10-10176, MAY 2020

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Behavioral Health
Neurologic
Remarks/Additional Workups
What consults have you received in the past? Mark all that apply. Y = Yes N = No
Ear, nose, and throat
Cardiology
Pulmonary

Nephrology

Urology

Orthopedic

Rheumatology

Neurology

Behavioral Health

Dermatology

NONE

Disposition: Exam completed.
Additional referrals/consults for this visit:

Y = Yes N = No
Referral to Non-VA Primary Care Physician?
Referral to VA Primary Care Physician?
Hospitalized at VAMC for additional tests/treatment?
Tests Ordered
Complete Blood Count with Differential
Comprehensive Metabolic Panel (i.e., glucose, calcium, albumin, total protein,
sodium, potassium, CO2, Chloride, BUN, Creatinine, LFT)
Urinalysis
Additional Tests Ordered as Indicated
Arterial Blood Gas/Pulse Oximetry
Chest X-ray
Computed Tomography (CT) Chest
Echocardiogram
EKG
Hepatitis C
Hemoglobin A1C
Prostate-specific antigen (PSA)
Spirometry/ Pulmonary Function Tests (PFTs)
Thyroid Testing
Other Tests:
Remarks:

VA FORM 10-10176, MAY 2020

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Diagnoses

Diagnoses/Symptoms/Complaints for this Registry Exam
Currently
Date of Onset
Duration
Present
(mm/dd/yyyy)
(months)
Y = Yes N = No

Facility Number
Examiner Name

Examiner Information
Facility Suffix

ICD Code

Date of Exam

Examiner Title

Examiner Signature (Sign in ink)
Remarks

VA FORM 10-10176, MAY 2020

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