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Gulf War Illness Study


	Screening Questions Name : Address : City : State : Zip : Phone : Email : 1. Were you deployed to the Persian Gulf Theater of Operations between August 1990 and July 1991? Yes No Now, a few quick questions about your health… Over the last six months, have you had an ongoing or persistent problem with any of the following symptoms? 2. Fatigue? Yes No 3. Pain in your muscles? Yes No 4. Pain in your joints? Yes No 5. Joint stiffness? Yes No 6. Difficulty Sleeping? Yes No 7. Difficulty concentrating or remembering things? Yes No 8. Trouble finding words when speaking? Yes No 9. Feeling moody? Yes No 10. Feeling anxious? Yes No 11. Feeling depressed? Yes No And finally some questions about medical conditions a doctor may have diagnosed... Have you ever been diagnosed by a physician for any of the following conditions? 12. Diabetes? Yes No 13. Heart Disease (other than high blood pressure)? Yes No 14. Parkinson’s Disease? Yes No 15. Stroke? Yes No 16. ALS, or Lou Gehrig’s Disease? Yes No 17. Lupus? Yes No 18. Multiple sclerosis? Yes No 19. Cancer (other than skin cancer)? Yes No 20. Melanoma? Yes No 21. Liver disease? Yes No 22. Alcohol or drug dependence? Yes Have you been hospitalized for this condition in the past 2 years? Yes No Have you taken or been prescribed medication for this condition in the past 6 months? Yes No No 23. Depression? Yes Have you been hospitalized for this condition in the past 2 years? Yes No Have you taken or been prescribed medication for this condition in the past 6 months? Yes No No 24. Post traumatic stress disorder? Yes Have you been hospitalized for this condition in the past 2 years? Yes No Have you taken or been prescribed medication for this condition in the past 6 months? Yes No No 25. Schizophrenia? Yes No 26. Bipolar disorder or manic depression? Yes No