Va 10 9009A Form PDF Details

If you're looking for information on the VA 10 9009A form, you've come to the right place. This federal tax form is used to provide information and documentation needed by the U.S. Department of Veterans Affairs (VA) when determining benefit eligibility or amounts payable under certain government programs. Understanding how this important document works can help ensure that veterans get all the benefits they deserve. In this blog post, we will discuss what a VA 10 9009A form is, why it's required by the VA, and how to properly fill out one in order to maximize entitlements provided through various veteran’s services programs!

QuestionAnswer
Form NameVa 10 9009A Form
Form Length10 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 30 sec
Other namesva 10 9009a, va 9009a sheet pdf, va 10 9009a fillable, gulf war phase 1 worksheet

Form Preview Example

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TT

1. Use PTF

FACILITY NO.

 

SUFFIX

 

 

 

PERSIAN GULF REGISTRY CODE SHEET

 

#

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1

Number Only

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART 1 (PHASE I)

 

 

 

 

 

 

 

 

 

 

The information the veteran supplies may be disclosed outside the VA to Federal, State and local government agencies and National Health Organizations to assist in the development of programs for research purposes and other uses as stated in the "Notice of Systems of VA Records" published in the Federal Register in accordance with the Privacy Act of 1974

INSTRUCTIONS: Please print. Use only one letter or number per block. If possible use black ballpoint or felt-tip pen. Shaded areas for VA use only. (DO NOT USE BLUE INK)

2. LAST NAME (8-33)

3. FIRST NAME (34-48)

 

 

 

 

 

4. MIDDLE NAME (49-58)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. SOCIAL SECURITY NUMBER (60-69)

7. D.O.B. (Complete all blanks)

 

 

 

(60)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MO (70-71)

DAY (72-73 )

YR (74-75)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.ADDRESS (Street Name and Apartment Number, If applicable) 76-101

8A. CITY OR TOWN (102-127)

5.TYPE (59)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8B. COUNTY

 

 

 

 

 

 

 

 

STATE

 

8C. ZIP CODE (128-132)

8D. LEAVE BLANK

 

 

8E. COUNTY (137-139)

STATE (140-141)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(133)

 

 

(134)

 

(135)

 

(138)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. RACE/ETHNICITY (Enter one code at right)

 

 

 

 

 

 

 

 

 

 

 

 

142

10. MARITAL STATUS (Enter one code at right)

 

 

 

143

 

1=American Indian or Alaskan Native 3=Black, Not of Hispanic Origin

5=Hispanic

 

 

 

 

 

 

 

1=Married

 

3=Separated

5=Single, Never Married

 

 

2=Asian or Pacific Islander

 

4=White, Not of Hispanic Origin

6=Unknown

 

 

 

 

 

 

 

2=Divorced

 

4=Widowed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. SEX (Enter one

144

12. CURRENT STATUS (Enter one code at right)

 

 

 

 

 

 

 

145

13. BRANCH OF SERVICE (If more than one, enter latest Persian Gulf Service)

146

 

code at right

 

1= Inpatient

3=Incarcerated

 

 

5. Active Duty (Inpatient)

 

 

1=Army

 

3=Navy

5=Coast

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M=Male F=Female

 

 

 

 

 

 

 

 

 

 

 

 

2= Outpatient

4=Active Duty (Outpatient)

 

 

 

 

 

 

 

 

 

2=Air Force

4=Marine

6=Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. DID VETERAN HAVE MILITARY SERVICE IN PERSIAN GULF AREA?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

147

 

Y=Yes (If "Yes", list below the dates of veteran’s last two periods of service there)

N=No (If "No", Persian Gulf Veterans not eligible for PGR exam.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

MO(148-149)

YR (150-151)

 

 

MO(152-153)

YR (154-155)

 

 

 

 

F

 

 

MO(156-157)

 

YR (158-159)

 

MO(160-161)

YR (162-163)

 

A. LAST PERIOD

R

 

 

 

 

 

T

 

 

 

 

 

 

 

B. NEXT TO LAST

R

 

 

 

 

 

 

 

 

 

 

T

 

 

 

 

 

O

 

 

 

 

 

O

 

 

 

 

 

 

 

PERIOD

O

 

 

 

 

 

 

 

 

 

 

O

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15A. IN WHAT AREAS DID VETERAN SERVE?

 

164

15B. IF OTHER SERVICE OR "DON’T

 

 

16. MILITARY UNITS AND MOS

 

 

 

 

 

 

 

 

 

 

 

(Enter appropriate code in block 164)

 

KNOW"

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Enter appropriate code in block 164)

 

 

16A. LIST MILITARY UNITS IN WHICH VETERAN SERVED.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLEASE SPECIFY COMPLETE UNABBREVIATED TITLE. (Company, battalion, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1 = Combat Zone

 

 

 

 

 

4 = Other (Specify i.e. Air Force,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2 = Other Land Area

 

 

 

 

 

Ground or Air Crew, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3 = Sea Duty

 

 

 

 

 

 

5 = Don’t Know

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16B. LIST MILITARY OCCUPATIONAL SPECIALTY (MOS)

 

 

 

 

 

 

 

 

16C. WERE ACTUAL DUTIES DIFFERENT FROM MOS?

 

 

 

 

 

166

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ENTER EITHER OF THE FOLLOWING CODES IN BLOCK 166

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y =Yes

 

 

N =No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16D. IF YES, LIST HERE AND IN CONSOLIDATED HEALTH RECORD

16E. ENTER THE NAME OF THE UNIT IN WHICH VETERAN HAD THE LONGEST AND NEXT TO LONGEST PERIOD OF SERVICE WHILE IN THE PERSIAN GULF

NOTE A&E: These units could be different from the one to which the veterans was assigned if veterans was on detached duty.

17. ENTER THE DATES OF THE LAST TWO PERIODS OF SERVICE (If deferent from above)

F

MO(167-168)

YR (169-170)

MO(171-172)

YR (173-174)

F

MO(175-176)

YR (177-178)

MO(179-180)

YR(181-182)

A. LAST PERIOD

R O M

T O

B. NEXT TO LAST PERIOD

R O M

T O

VA Form JUL 1995

10-9009A(RS)JETFORM

 

 

 

-

-

NAME:

 

 

 

 

 

 

 

 

 

 

 

 

SSN:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18. VETERANS EXPOSURE TO ENVIRONMENTAL FACTORS (ENTER APPROPRIATE CODES)

 

 

 

 

 

 

 

 

 

 

 

 

18A. ARE YOU CURRENTLY SMOKING CIGARETTES? ENTER ONE OF THE FOLLOWING CODES IN BLOCK

 

(183)

 

 

 

 

 

 

 

183. IF NO, GO TO ITEM 18D.

Y=YES N=NO

 

 

 

 

 

 

 

 

 

 

18B. IF YES, HOW MANY YEARS HAVE YOU BEEN SMOKING CIGARETTES? ENTER THE NUMBER OF

 

(184)

(185)

 

 

 

 

 

 

YEARS IN BLOCK 184 AND 185.

 

 

 

 

 

 

 

 

 

 

 

 

18C. ON THE AVERAGE HOW MANY PACKS ARE YOU SMOKING PER DAY? ENTER THE NUMBER OF

 

(186)

(187)

 

 

 

 

 

 

 

PACKS IN BLOCKS 186 AND 187

 

 

 

 

 

 

 

 

 

 

 

 

18D. HAVE YOU SMOKED CIGARETTES IN THE PAST? ENTER ONE OF THE FOLLOWING CODES IN BLOCK

 

(188)

 

 

 

 

 

 

 

188. IF NO, GO TO ITEM 18G.

Y=YES N=NO

 

 

 

 

 

 

 

 

 

 

 

18E. IF YES, HOW MANY YEARS HAD YOU SMOKED? ENTER NUMBER OF YEARS IN BLOCKS 189 AND

 

(189)

(190)

 

 

 

 

 

 

 

190.

 

 

 

 

 

 

 

 

 

 

 

 

18F. ON THE AVERAGE, HOW MANY PACKS DID YOU SMOKE PER DAY? ENTER THE NUMBER OF PACKS

 

(191)

(192)

 

 

 

 

 

 

IN BLOCKS 191 AND 192.

 

 

 

 

 

 

 

 

 

 

 

18G-Z1.WHILE IN THE PERSIAN GULF DO YOU BELIEVE YOU WERE EXPOSED TO ANY OF THE FOLLOW-

 

 

 

 

 

ING.

 

 

 

 

 

 

 

 

 

 

 

18G. SMOKE FROM OIL FIRES? ENTER ONE OF THE FOLLOWING CODES IN BLOCK

Y=YES N=NO

(193)

 

 

 

 

 

 

193.

 

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

18H. SMOKE OR FUMES FROM TENT HEATERS? ENTER ONE OF THE FOLLOWING CODES IN BLOCK

Y=YES N=NO

(194)

 

 

 

 

 

 

194.

 

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

181. CIGARETTE SMOKE (PASSIVE) FROM OTHERS? ENTER ONE OF THE FOLLOWING CODES IN BLOCK

Y=YES N=NO

(195)

 

 

 

 

 

 

195.

 

 

 

 

 

 

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18J. DIESEL AND/OR OTHER PETROCHEMICAL FUMES? ENTER ONE OF THE FOLLOWING CODES IN

Y=YES N=NO

(196)

 

 

 

 

 

 

BLOCK 196.

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

18K. EXPOSURE TO BURNING TRASH/FECES? ENTER ONE OF THE FOLLOWING CODES IN BLOCK

Y=YES N=NO

(197)

 

 

 

 

 

 

197.

 

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

18L. SKIN EXPOSURE TO DIESEL OR OTHER PETROCHEMICAL FUEL? ENTER ONE OF THE

Y=YES N=NO

(198)

 

 

 

 

 

 

FOLLOW-

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18M. CARC (CHEMICAL AGENT RESISTANT COMPOUND)? ENTER ONE OF THE FOLLOWING CODES IN

Y=YES N=NO

(199)

 

 

 

 

 

 

BLOCK 199.

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18N. OTHER PAINTS AND/OR SOLVENTS AND/OR PETROCHEMICAL SUBSTANCES? ENTER ONE OF THE

Y=YES N=NO

(200)

 

 

 

 

 

 

FOLLOWING CODES IN BLOCK 200.

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y=YES N=NO

(201)

 

 

18O. DEPLETED URANIUM? ENTER ONE OF THE FOLLOWING CODES IN BLOCK 201.

 

 

 

 

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y=YES N=NO

(202)

 

 

18P. MICROWAVES? ENTER ONE OF THE FOLLOWING CODES IN BLOCK 202.

 

 

 

 

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18Q. PERSONAL PESTICIDE USE, INCLUDING CREAMS, SPRAYS OR FLEA COLLARS? ENTER ONE

Y=YES N=NO

(203)

 

 

 

 

 

 

OF

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18R. NERVE GAS OR OTHER NERVE AGENTS? ENTER ONE OF THE FOLLOWING CODES IN BLOCK

Y=YES N=NO

(204)

 

 

 

 

 

 

204.

 

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

18S. DRUG (PYRIDOSTIGMINE) USED TO PROTECT AGAINST NERVE AGENTS? ENTER ONE OF THE

Y=YES N=NO

(205)

 

 

 

 

 

 

FOLLOWING CODES IN BLOCK 205.

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

18T. MUSTARD GAS OR OTHER AGENTS? ENTER ONE OF THE FOLLOWING CODES IN BLOCK

Y=YES N=NO

(206)

 

 

 

 

 

 

206.

 

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18U. ATE OR DRANK FOOD CONTAMINATED WITH SMOKE, OIL OR OTHER CHEMICAL? ENTER ONE OF

Y=YES N=NO

(207)

 

 

 

 

 

 

THE FOLLOWING CODES IN BLOCK 207.

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

2

 

 

 

 

 

 

JETFORM

 

NAME:

 

 

 

 

 

 

SSN:

 

 

 

 

 

 

 

 

 

 

 

18V. ATE FOOD OTHER THAN PROVIDED BY ARMED FORCES? ENTER ONE OF THE FOLLOWING

Y=YES N=NO

(208)

 

 

CODES

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

18W. BATHED IN OR DRANK WATER CONTAMINATED WITH SMOKE OR OTHER CHEMICAL? ENTER ONE

Y=YES N=NO

(209)

 

 

 

 

 

 

OF THE FOLLOWING CODES IN BLOCK 209.

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18X. BATHED IN WATER OTHER THAN PROVIDED BY ARMED FORCES? ENTER ONE OF THE FOLLOW-

Y=YES N=NO

(210)

 

 

 

 

 

 

ING CODES IN BLOCK 210.

 

 

 

 

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y=YES N=NO

(211)

 

 

18Y. IMMUNIZATION AGAINST ANTHRAX? ENTER ONE OF THE FOLLOWING CODES IN BLOCK 211.

 

 

 

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y=YES N=NO

(212)

 

 

18Z. IMMUNIZATION AGAINST BOTULISM? ENTER ONE OF THE FOLLOWING CODES IN BLOCK 212.

 

 

 

U=UNKNOWN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18Z1. OTHER EXPOSURES? ENTER HERE AND IN CHR ONLY.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19. DID VETERAN HAVE ANY OF THE FOLLOWING EXPERIENCES WHILE IN THE PERSIAN GULF? ENTER APPROPRIATE CODE.

19A. DID YOU EVER GO ON COMBAT PATROLS OR HAVE OTHER VERY DANGEROUS DUTY? ENTER

 

(213)

ONE OF THE FOLLOWING CODES IN BLOCK 213

 

 

1 =NO 2=1-3X 3=4-12X 4=13-50X 5=51+TIMES

 

 

 

 

 

 

 

 

19B. WERE YOU EVER UNDER ENEMY FIRE (INCLUDING "SCUDS")? ENTER ONE OF THE FOLLOWING

 

(214)

CODES IN BLOCK 214

 

 

1 = NEVER 2=1 DAY 3=<1 WEEK 4=1-<4 WEEKS 5=4 WEEKS OR MORE

 

 

 

 

 

 

 

 

19C. WHAT PERCENTAGE OF PEOPLE IN YOUR UNIT WERE KILLED (KIA), WOUNDED OR MISSING IN AC-

 

(215)

TION (MIA), ENTER ONE OF THE FOLLOWING CODES IN BLOCK 215.

 

 

1=NONE 2=1-25% 3=26-50% 4=51-75% 5=76% OR MORE

 

 

 

 

 

 

 

 

19D. HOW OFTEN DID YOU SEE SOMEONE HIT BY INCOMING OR OUTGOING ROUNDS? ENTER ONE OF

 

(216)

THE FOLLOWING CODES IN BLOCK 216.

 

 

1=NEVER 2=1-2X 3=3-12X 4=13-50X 5=51 OR MORE TIMES

 

 

 

 

 

 

 

 

19E. HOW OFTEN WERE YOU IN DANGER OF BEING INJURED OR KILLED (I.E. PINNED DOWN, OVERRUN,

 

(217)

AMBUSHED, NEAR MISS, ETC.)? ENTER ONE OF THE FOLLOWING CODES IN BLOCK 217.

 

 

1=NEVER 2=1-2X 3=3-12X 4=13-50X 5=51 OR MORE TIMES

 

 

 

 

 

 

 

 

19F. DID YOU WITNESS CHEMICAL ALARMS? ENTER ONE OF THE FOLLOWING CODES IN BLOCK

 

(218)

218.

Y=YES N=NO

 

 

 

 

U=UNKNOWN

 

 

 

 

20. VETERAN’S HEALTH (VETERAN’S EVALUATION)

 

 

 

 

 

 

 

 

20A. WHICH BEST DESCRIBES VETERAN’S HEALTH AFTER PERSIAN GULF SERVICE? ENTER ONE OF

 

(219)

THE FOLLOWING CODES IN BLOCK 219.

 

 

1=Very Good 2=Good 3=Fair 4=Poor 5=Very Poor

 

 

 

 

 

 

 

 

21. VETERAN’S FUNCTIONAL IMPAIRMENT

 

 

 

 

 

 

 

 

21A. WHICH BEST DESCRIBES VETERAN’S OWN ASSESSMENT OF FUNCTIONAL IMPAIRMENT? ENTER

 

(220)

ONE OF THE FOLLOWING CODES IN BLOCK 220

 

 

1=NO IMPAIRMENT 2=SLIGHT IMPAIRMENT 3=MODERATE IMPAIRMENT 4=SEVERE IMPAIRMENT

 

 

 

 

 

21B. HOW MANY WORKDAYS WERE LOST BY VETERAN DUE TO ILLNESS IN THE PAST 90 DAYS? ENTER NUMBER OF DAYS LOST IN BLOCKS 221-222.

(221)

(222)

22.EVIDENCE OF BIRTH DEFECTS AND INFANT DEATH(S) AMONG VETERAN’S CHILDREN AND PROB- LEMS WITH PREGNANCY AND INFERTILITY.

22A. HOW MANY CHILDREN DOES VETERAN HAVE? ENTER NUMBER IN BLOCKS 223 AND 224. (I.E. 05). IF NONE, LEAVE BLANK AND GO TO ITEM 22C.

(223)

(224)

3

JETFORM

 

 

--

-

NAME:

 

 

 

 

 

SSN:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22B. HOW MANY OF THESE CHILDREN WERE BORN WITH BIRTH DEFECTS? (BIRTH DEFECTS ARE

 

(225)

(226)

 

 

ANY STRUCTURAL, FUNCTIONAL, OR BIOCHEMICAL ABNORMALITY AT BIRTH WHETHER GE-

 

 

 

 

 

NETICALLY DETERMINED OR INDUCED DURING GESTATION THAT IS NOT DUE TO INJURIES SUF-

 

 

 

 

 

FERED DURING BIRTH.) ENTER NUMBER IN BLOCKS 225 AND 226. IF NONE, GO TO ITEM 22C.

 

 

 

 

 

 

 

 

 

 

 

22B1.HOW MANY OF THESE CHILDREN WERE CONCEIVED BEFORE GULF SERVICE? ENTER THE NUM-

 

(227)

(228)

 

 

BER OF CHILDREN IN BLOCKS 227 AND 228. IF NONE, LEAVE BLANK AND GO TO ITEM 22B2.

 

 

 

 

 

 

 

 

 

 

 

22B1(a) STATE MATERNAL AGE AT CONCEPTION OF FIRST CHILD CONCEIVED BEFORE GULF

 

(229)

(230)

 

 

SERVICE? ENTER AGE IN BLOCKS 229 AND 230.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22B2.HOW MANY OF THESE CHILDREN WERE CONCEIVED DURING AND AFTER GULF SERVICE? EN-

 

(231)

(232)

 

 

TER NUMBER IN BLOCK 231 AND 232. IF NONE, LEAVE BLANK AND GO TO ITEM 22C.

 

 

 

 

 

 

 

 

 

 

 

 

22B2(a) STATE MATERNAL AGE AT CONCEPTION OF FIRST CHILD CONCEIVED DURING AND AFTER

 

(233)

(234)

 

 

GULF SERVICE? ENTER AGE IN BLOCKS 229 AND 230.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22C. HAS VETERAN OR SPOUSE HAD INFERTILITY PROBLEMS? (INFERTILITY PROBLEMS OF

 

(235)

 

 

VETERAN

 

 

 

 

 

OR SPOUSE BECOMING PREGNANT. NOTE: INFERTILITY - RELATIVE STERILITY DEFINED AS IN-

 

 

 

 

 

ABILITY TO CONCEIVE AFTER 12 OR MORE MONTHS OF INTERCOURSE WITHOUT USE OF CON-

 

 

 

 

 

TRACEPTION AND WHEN NEITHER SPOUSE IS SURGICALLY STERILIZED.) ENTER ONE OF THE

Y=YES N=NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22C1.HAS VETERAN OR SPOUSE HAD INFERTILITY BEFORE GULF SERVICE? ENTER ONE OF THE FOL-

 

(236)

 

 

LOWING CODES IN BLOCK 236. IF NO, GO TO ITEM 22C2.

Y=YES N=NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22C1(a). STATE MATERNAL AGE DURING FIRST ATTEMPTS TO CONCEIVE. ENTER AGE IN BLOCKS

 

(237)

(238)

 

 

237 AND 238.

 

 

 

 

 

 

 

 

 

 

22C2.HAS VETERAN OR SPOUSE HAD INFERTILITY AFTER RETURN FROM GULF SERVICE? ENTER ONE

 

(239)

 

 

OF THE FOLLOWING CODES IN BLOCK 239. IF NO, GO TO ITEM 22D.

Y=YES N=NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22C2(a). STATE MATERNAL AGE DURING FIRST ATTEMPTS TO CONCEIVE. ENTER AGE IN BLOCKS

 

(240)

(241)

 

 

240 AND 241.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22D. HAS VETERAN OR SPOUSE HAD MISCARRIAGE(S) (NOTE: MISCARRIAGES ARE SPONTANEOUS

 

(242)

 

 

EXPLUSION OF THE PRODUCTS OF CONCEPTION BEFORE 20 WEEKS OF GESTATION - SPONTA-

 

 

 

 

 

NEOUS ABORTION) ENTER ONE OF THE FOLLOWING CODES IN BLOCK 242. IF NO, GO TO ITEM

 

 

 

 

 

22E.

Y=YES N=NO

 

 

 

 

 

 

 

 

 

22D1.HAS VETERAN OR SPOUSE HAD MISCARRIAGES BEFORE PERSIAN GULF? ENTER ONE OF THE

 

(243)

 

 

FOLLOWING CODES IN BLOCK 243. IF NO, GO TO ITEM 22D2.

Y=YES N=NO

 

 

 

 

 

 

 

 

 

 

 

22D1(a). STATE MATERNAL AGE AT CONCEPTION. ENTER AGE IN BLOCKS 244 AND 245.

 

(244)

(245)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22D2.HAS VETERAN OR SPOUSE HAD MISCARRIAGES AFTER PERSIAN GULF? ENTER ONE OF THE

 

(246)

 

 

FOLLOWING CODES IN BLOCK 246. IF NO, GO TO ITEM 22E.

Y=YES N=N O

 

 

 

 

 

 

 

 

 

 

 

22D2(a).STATE MATERNAL AGE AT CONCEPTION, ENTER AGE IN BLOCKS 247 AND 248.

 

(247)

(248)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22E. HAS VETERAN OR SPOUSE HAD STILL BIRTH(S)? (NOTE: STILL BIRTH IS BIRTH AFTER 20 WEEKS

 

(249)

 

 

OF GESTATION OF AN INFANT WHO SHOWED NO EVIDENCE OF LIFE AFTER BIRTH.) ENTER ONE

 

 

 

 

 

OF THE FOLLOWING CODES IN BLOCK 249. IF NO, GO TO ITEM 22F.

Y=YES N=N O

 

 

 

 

 

 

 

 

 

22E1.HAS VETERAN OR SPOUSE HAD STILL BIRTH(S) BEFORE GULF SERVICE? ENTER ONE OF THE

 

(250)

 

 

FOLLOWING CODES IN BLOCK 250. IF NO, GO TO ITEM 22E2.

Y=YES N=N O

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22E1(a).STATE MATERNAL AGE AT CONCEPTION. ENTER AGE IN BLOCKS 251 AND 252.

 

(251)

(252)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22E2.HAS VETERAN OR SPOUSE HAD STILL BIRTH(S) AFTER RETURN FROM GULF SERVICE? ENTER

 

(253)

 

 

ONE OF THE FOLLOWING CODES IN BLOCK 253. IF NO, GO TO ITEM 22F.

Y=YES N=N O

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22E2(a).STATE MATERNAL AGE AT CONCEPTION. ENTER AGE IN BLOCKS 254 AND 255.

 

(254)

(255)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22F. HAS VETERAN OR SPOUSE HAD INFANT DEATH(S). (NOTE: DEATH THAT OCCURRED WITHIN ONE

 

(256)

 

 

YEAR OF BIRTH AMONG BABIES BORN ALIVE.) ENTER ONE OF THE FOLLOWING CODES IN BLOCK

 

 

 

 

 

256. IF NO, GO TO ITEM 22G.

Y=YES N=N O

 

 

 

 

 

 

 

 

 

22F1.HAS VETERAN OR SPOUSE HAD INFANT DEATH(S) BEFORE GULF SERVICE? ENTER ONE OF THE

 

(257)

 

 

FOLLOWING CODES IN BLOCK 257. IF NO, GO TO ITEM 22F2.

Y--YES N=N O

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22F1(a). STATE MATERNAL AGE AT CONCEPTION. ENTER AGE IN BLOCKS 258 AND 259.

 

(258)

(259)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22F2.HAS VETERAN OR SPOUSE HAD INFANT DEATH(S) AFTER GULF SERVICE? ENTER ONE OF THE

 

(260)

 

 

FOLLOWING CODES IN BLOCK 260. IF NO, GO TO ITEM 22G.

Y=YES N=N O

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

 

 

 

 

 

JETFORM

(413-417)

NAME:

SSN:

22F2(A) STATE MATERNAL AGE AT CONCEPTION. ENTER AGE IN BLOCKS 261 AND 262.

(261-262)

22G IF A WOMAN VETERAN REPORTS SHE WAS PREGNANT IN PERSIAN GULF, RECORD DATE OF CHILD’S BIRTH AND HOSPITAL OF BIRTH HERE AND IN VETERAN’S CHR ONLY TO FACILITATE FOLLOW-UP, IF NEEDED. (AAC WILL NOT ENTER THIS DATA IN PGR DATABASE).

DATE OF BIRTH

MONTH / DAY / YEAR

NAME OF HOSPITAL

LOCATION

PART II TO BE COMPLETED BY EXAMINING PHYSICIAN

23. DATE OF EXAM

MONTH

DAY

 

YEAR

(263-264)

(265-266)

(267-270)

 

 

 

 

 

 

 

 

 

24.TOTAL NO. OF VETERAN COMPLAINTS.

(271-272)

25A/J. LIST UP TO TEN MAJOR, CURRENT SYMPTOMS, ICD 9 CODES, MO. & YR OF ONSET, DURATION IN MOS AND IF SYMPTOM IS CUR- RENTLY PRESENT ON LINES A-J, ITEMS 1-5. IF VETERAN HAS MORE THAN 10, ENTER THE MOST SEVERE & ADDITIONAL SYMPTOMS IN CHR. MAS CODERS: USE ITEM 2, BLOCKS 271-320 FOR ICD-9-CM CODES.

(1) DESCRIBE SYMPTOM

(2) ICD-9-CODES

(3) MO. & YR OF ONSET

 

(4) DURATION

(5) CURRENTLY

NARRATIVE

 

 

 

 

 

 

 

MONTH

 

YEAR

 

(MONTHS)

PRESENT?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y=YES N=NO

 

(273-322)

 

 

 

 

 

 

 

 

 

(323-382)

 

(383-402)

(403-412)

A

(273-277)

 

 

 

 

 

(323-328)

 

 

 

 

 

 

 

(383-384)

 

 

 

(403)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

(278-282)

 

 

 

 

 

(329-334)

 

 

 

 

 

 

 

(385-386)

 

 

 

(404)

C

(283-287)

 

 

 

 

 

(335-340)

 

 

 

 

 

 

 

(387-388)

 

 

 

(405)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D

(288-292)

 

 

 

 

 

(341-346)

 

 

 

 

 

 

 

(389-390)

 

 

 

(406)

E

(293-297)

 

 

 

 

 

(347-352)

 

 

 

 

 

 

 

(391-392)

 

 

 

(407)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

(298-302)

 

 

 

 

 

(353-358)

 

 

 

 

 

 

 

(393-394)

 

 

 

(408)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

G

(303-307)

 

 

 

 

 

(359-364)

 

 

 

 

 

 

 

(395-396)

 

 

 

(409)

H

(308-312)

 

 

 

 

 

(365-370)

 

 

 

 

 

 

 

(397-398)

 

 

 

(410)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I

(313-317)

 

 

 

 

 

(371-376)

 

 

 

 

 

 

 

(399 400

 

 

 

(411)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

J

(318-322)

 

 

 

 

 

(377-382)

 

 

 

 

 

 

 

(401-402)

 

 

 

(412)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25K. LIST MOST SEVERE SYMPTOM. (A SYMPTOM FROM ITEM A-J, WHICH VETERAN CONSIDERS THE MOST SEVERE l.E.

CHIEF COMPLAINT). ENTER ICD-9-CM CODE IN BLOCKS.

26. DIAGNOSTIC CONSULTATION. ENTER THE FOLLOWING CODES IN BLOCKS 418-435.

1=NO WORKUP, NO CONSULTATION DONE. 3=WORKUP/CONSULTATION DONE. DIAGNOSIS ESTABLISHED. 2=WORKUP/CONSULTATION DONE. UNEXPLAINED ILLNESS 4=WORKUP/CONSULTATION DONE. NO DIAGNOSIS.

A. ALLERGY/IMMUNOLOGY. BLOCK 418

B. AUDIOLOGY. BLOCK 419

C. CARDIOLOGY. BLOCK 420

D. DENTISTRY. BLOCK 421

E. DERMATOLOGY. BLOCK 422

F. EAR, NOSE AND THROAT 423

G. ENDOCRINOLOGY. BLOCK 424

H. GASTROENTEROLOGY. BLOCK 425

(418)

(419)

(420)

(421)

(422)

(423)

(424)

(425)

5

JETFORM

 

NAME:

 

 

 

SSN:

 

 

 

 

 

 

I. HEMATOLOGY/ONCOLOGY. BLOCK 426

 

(426)

 

J. INFECTIOUS DISEASES/PARASITOLOGY. BLOCK 427

 

 

(427)

 

K. NEPHROLOGY. BLOCK 428

 

 

(428)

 

 

 

 

L. NEUROLOGY. BLOCK 429

 

 

(429)

 

 

 

 

M. OCCUPATIONAL MEDICINE. BLOCK 430

 

 

(430)

 

 

 

 

N. PULMONARY. BLOCK 431

 

 

(431)

 

O. PSYCHIATRY. BLOCK 432

 

 

(432)

 

P. PSYCHOLOGY/PSYCHOMETRIC TESTING. BLOCK 433

 

 

(433)

 

 

 

 

Q. RHEUMATOLOGY. BLOCK 434

 

 

(434)

 

 

 

 

R. OTHER, ENTER FOLLOWING CODES IN BLOCK 435

Y=YES(435) N=NO

S. ADDITIONAL WORKUPS/CONSULTATIONS PERFORMED WHICH WERE NOT LISTED IN ITEMS 26A-Q. LIST HERE

6

JETFORM

NAME:

SSN:

27.DIAGNOSIS.LIST UP TO 10 MAJOR DEFINITE MEDICAL DIAGNOSES ON LINES 27A-J. LIST PRIMARY DIAGNOSIS ON LINE A. BLOCKS 436-485 FOR CORRESPONDENCE ICD-9-CM CODES. LEAVE BLANK IF NO DIAGNOSIS IS MADE. MAS CODERS: USE ICD-9-CM CODES IN FIRST FIVE NUMBERED BLOCKS OF EACH DIAGNOSIS

 

DESCRIBE DIAGNOSIS (Narrative)

(27B)

 

 

 

27A.

 

ICD-9-CM (Codes)

 

 

 

 

 

 

(436)

(437)

(438)

(439)

(440)

A. (PRIMARY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(441)

(442)

(443)

(444)

(445)

B.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(446)

(447)

(448)

(449)

(450)

C.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(451)

(452)

(453)

(454)

(455)

D.

 

 

 

 

 

 

 

 

 

 

 

 

 

E

 

(456)

(457)

(458)

(459)

(460)

 

 

 

 

 

 

.

 

 

 

 

 

 

 

 

(461)

(462)

(463)

(464)

(465)

F.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(466)

(467)

(468)

(469)

(470)

G.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(471)

(472)

(473)

(474)

(475)

H.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(476)

(477)

(478)

(479)

(480)

I.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(481)

(482)

(483)

(484)

(485)

J.

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTE: CODERS: DO NOT REPEAT OR LIST SYMPTOM CODE ALREADY LISTED UNDER ITEM 25A-J.

28.BLOCK 486 IF NO DIAGNOSIS IS MADE, ENTER "1" IN BLOCK AT RIGHT, OTHERWISE, LEAVE BLANK. THIS ITEM MUST BE CONSIDERED IN CONJUNCTION WITH ITEM 27 "DIAGNOSIS."

486

29. DISPOSITION (Enter code Y-Yes or N-No)

29A. EXAMINATION COMPLETED?

487

29B. HOSPITALIZED AT VAMC FOR FURTHER

 

488

29C. HOSPITALIZED AT VAMC FOR TREATMENT?

489

Y=Yes

N=No

 

TEST?

 

 

 

 

Y=Yes

N=No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y=Yes

N=No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

29D. REFERRED FOR OUTPATIENT CARE?

490

29E. REFERRED TO PRIVATE PHYSICIAN, NON-VA

 

491

29F. BIOPSY?

 

492

Y=Yes

N=No

 

CLINIC OR NON-VA HOSPITAL?

 

 

Y=Yes

N=No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y=Yes

N=No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

30. AFTER COMPLETION OF PHASE I EXAM (REFER TO PAR 5), THE PHYSICIAN

493

31. HAS PHASE II EXAM (REFER TO CH. 3) BEEN INITIATED?

494

HAS DETERMINED THE VETERAN HAS UNEXPLAINED ILLNESS?

 

Y=Yes

N=No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y=Yes

N=No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

32. UTILIZE THIS SECTION FOR ADDITIONAL INFORMATION (E.G. PAR 1.07- M-10, PT lIl).

33.NAME OF EXAMINER, (PRINT FULL NAME)

34.TITLE OF EXAMINER. (FULL TITLE OF EXAMINER)

35. SIGNATURE OF EXAMINER.

35A. SIGNATURE OF VRP (VETERANS REGISTRY PHYSICIAN)

7

JETFORM

 

NAME:

SSN:

PART III

PHASE II - UNIFORM CASK ASSESSMENT(UCA)

1. WERE THE FOLLOWING TESTS PERFORMED? Enter the following codes in blocks 1-24. Y=YES

N=NO

 

 

 

 

 

 

 

 

 

2. BLOOD TESTS, BLOCKS 1-18; OTHER - BLOCKS 19-24.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(1)

 

(2)

 

 

 

 

 

 

 

 

 

(3)

A. CBC (COMPLETE BLOOD COUNT)

 

B. SED RATE? (SKIN ERETHYMA DOSE)

 

 

C. C-REACTIVE PROTEIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(4)

 

(5)

 

 

(GLUTAMIC

 

 

 

 

(6)

D. RHEMATOID FACTOR?

 

E. FLUORESCENT ANA? (ANTI-NUCLEAR ANTI-BODY)

 

 

 

 

 

 

 

 

 

 

 

 

F. SGOT (AST)?

OXALOACETIC

 

 

 

 

 

 

 

 

 

 

 

 

TRANSAMINASE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(TRANSAMINASE

(7)

 

(8)

 

 

 

 

 

 

 

 

 

(9)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

G. SGPT (ALT)?

GLUTAMIC

 

H. LDH (LACTIC ACID HYDROGENASE)

 

 

I. ALKALINE PHOSPHATASE

 

 

 

 

 

 

 

PYRUVATE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(10)

 

(11)

 

 

 

 

 

 

 

 

 

(12)

J. CPK? CREATINE PHOSPHOKINASE)

 

K. HEPATITIS B SURFACE ANTIBODY?

 

 

L. HEPATITIS B CORE ANTIGEN?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(13)

 

(14)

 

 

 

 

 

 

 

 

 

(15)

(VENEREAL

 

N. VITAMIN B-12

 

 

O. FOLATE?

 

 

 

 

 

 

 

 

 

M. VDRL? DISEASE RESEARCH

 

 

 

 

 

 

 

 

 

 

 

 

LABORATORY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(16)

 

(17)

 

 

 

 

 

 

 

 

 

(18)

P. HIV (HUMAN IMMUNO-

 

Q. T4 (THROXINE TOTAL SERUM)?

 

 

R. TSH (THYROID STIMULATING HORMONE)?

 

 

 

DEFICIENCY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(19)

 

(20)

 

 

 

 

 

 

 

 

 

(21)

 

 

 

4. TB SKIN TEST (PPD)?

 

 

5. CHEST XRAY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. URINALYSIS

 

 

(TUBERCULOSIS SKIN TEST

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PURIFIED PROTEIN DERIVATIVE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(22)

 

(23)

 

 

 

 

 

 

 

 

 

(24)

 

 

 

6A. SCID FOR DSM-III-R

 

 

6B. CAPS PTSD SCALE

 

 

 

 

 

 

6. PSYCHIATRIC EVALUATION?

 

(STRUCTURED CLINICAL INTERVIEW

 

 

(CLINICAL ADMINISTERED POST

 

 

 

 

 

 

 

 

FOR DIAGNOSIS)

 

 

TRAUMATIC STRESS DISORDER)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. LIST DIAGNOSES: MAS CODERS: ENTER ICD-9-CM CODE IN BLOCKS 25-39. IF NONE, LEAVE BLANK.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIBE DIAGNOSES (Narrative)

 

 

 

 

ICD-9-CODES

 

 

 

 

 

 

 

 

 

 

(25)

 

(26)

(27)

 

(28)

 

(29)

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(30)

 

(31)

(32)

 

(33)

 

(34)

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(35)

 

(36)

(37)

 

(38)

 

(39)

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. PSYCHOLOGY-NEUROPSYCHOLOGICAL

(40)

8A. LIST DIAGNOSES. MAS CODERS: ENTER ICD-9-CM CODES IN BLOCKS 41-55. IF NONE, LEAVE BLANK

 

 

 

TEST? Enter code in block 40)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIBE DIAGNOSES (Narrative)

 

 

 

 

ICD-9-CODES

 

 

 

 

 

 

 

 

 

 

 

Y=Yes

N=No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(41)

 

(42)

(43)

 

(44)

 

(45)

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(46)

 

(47)

(48)

 

(49)

 

(50)

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(51)

 

(52)

(53)

 

(54)

 

(55)

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9. INFECTIOUS DISEASE - SCREENING EXAM?

(56)

9A. LIST DIAGNOSES. MAS CODERS: ENTER ICD-9-CM CODES IN BLOCKS 57-66. IF NONE, LEAVE BLANK

 

 

 

(Enter code in block 56)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIBE DIAGNOSES (Narrative)

 

 

 

 

ICD-9-CODES

 

 

Y=Yes

N=No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(57)

 

(58)

(59)

 

(60)

 

(61)

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(62)

 

(63)

(64)

 

(65)

 

(66)

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. DENTAL EXAM? (Enter code in block 67)

(67)

10A. LIST DIAGNOSES. MAS CODERS: ENTER ICD-9-CM CODES IN BLOCKS 68-77. IF NONE, LEAVE BLANK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y=Yes

N=No

 

DESCRIBE DIAGNOSES (Narrative)

 

 

 

 

ICD-9-CODES

 

 

 

 

 

 

 

 

 

 

(68)

 

(69)

(70)

 

(71 )

 

(72)

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(73)

 

(74)

(75)

 

(76)

 

(77)

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8

JETFORM

 

 

 

 

 

NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SSN:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. DIARRHEA AND/OR ABDOMINAL PAIN

 

 

 

 

 

 

11A. Gl (GASTROINTESTINAL) CONSULT?

78

 

 

11B. LIST DIAGNOSES. MAS CODERS: ENTER ICD-9-CM CODES IN BLOCKS 79-98. IF NONE, LEAVE BLANK.

 

 

 

(Enter code in block 78)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIBE DIAGNOSES (Narrative)

 

 

ICD-9 CODES

 

 

 

Y=Yes

N=No

 

 

 

 

(79)

(80)

(81)

(82)

(83)

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(84)

(85)

(86)

(87)

(88)

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(89)

(90)

(91)

(92)

(93)

 

 

 

 

 

3.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

 

 

(94)

(95)

(96)

(97)

(98)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. HEADACHE AND/OR MEMORY LOSS

 

 

 

 

 

 

12A. NEUROLOGY CONSULT?

99

 

 

12B. LIST DIAGNOSES. MAS CODERS: ENTER ICD-9-CM CODES IN BLOCKS 100-109. IF NONE, LEAVE BLANK.

 

 

 

(Enter code in block 99)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIBE DIAGNOSES (Narrative)

 

 

ICD-9-CODES

 

 

 

Y=Yes

N=No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(100)

 

(102)

(103)

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(106)

 

(108)

(109)

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. MUSCLE ACHES AND/OR NUMBNESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13A. NEUROLOGY CONSULT?

110

 

 

13B. LIST DIAGNOSES. MAS CODERS: ENTER ICD-9-CM CODES IN BLOCKS 111-120. IF NONE, LEAVE BLANK.

 

 

 

(Enter code in block 110)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIBE DIAGNOSES (Narrative)

 

 

ICD-9-CODES

 

 

 

Y = Yes

N = No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(111)

(112)

(113)

(114)

(115)

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(116)

(117)

(118)

(119)

(120)

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. CHRONIC FATIGUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14A. CHRONIC FATIGUE?

121

 

 

14B. LIST DIAGNOSES. MAS CODERS: ENTER ICD-9-CM CODES IN BLOCKS 122-131. IF NONE, LEAVE BLANK.

 

 

 

 

 

 

 

 

 

 

 

(Enter code in block 121)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIBE DIAGNOSES (Narrative)

 

 

ICD-9-CODES

 

 

 

Y=Yes

N=No

 

 

 

 

 

 

(122)

(123)

(124)

(125)

(126)

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(127)

(128)

(129)

(130)

(131)

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15. JOINT PAIN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15A. RHEUMATOLOGY CONSULT?

132

 

 

15B. LIST DIAGNOSES. MAS CODERS: ENTER ICD-9-CM CODES IN BLOCKS 133-142. IF NONE, LEAVE BLANK.

 

 

 

(Enter code In block 132)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIBE DIAGNOSES (Narrative)

 

 

ICD-9-CODES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y=Yes

N=No

 

 

 

 

 

(133)

(134)

(135)

(136)

(137)

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(138)

(139)

(140)

(141)

(142)

 

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16. CHRONIC COUGH AND/OR SHORTNESS OF BREATH

 

 

 

 

 

 

16A. PULMONARY CONSULT?

143

 

 

16B. LIST DIAGNOSES. MAS CODERS: ENTER ICD-9-CM CODES IN BLOCKS 144-153. IF NONE, LEAVE BLANK.

 

 

 

(Enter code in block 143)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIBE DIAGNOSES (Narrative)

 

 

ICD-9-CODES

 

 

 

Y=Yes

N=No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(144)

(145)

(146)

(147)

(148)

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(149)

(150)

(151)

(152)

(153)

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17. SKIN RASH

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

17A. DERMATOLOGY CONSULT?

154

 

 

17B. LIST DIAGNOSES. MAS CODERS: ENTER ICD-9-CM CODES IN BLOCKS 155-164. IF NONE, LEAVE BLANK.

 

 

 

(Enter code in block 154)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIBE DIAGNOSES (Narrative)

 

ICD-9-CODES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y=Yes

N=No

 

 

 

(155)

(156)

(157)

(156)

(159)

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(160)

(161)

(162)

(163)

(164)

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18. VERTIGO AND/OR TINNITUS

 

 

 

 

 

 

18A. AUDIOLOGY?

165

 

 

18B. LIST DIAGNOSES. MAS CODERS: ENTER ICD-9-CM CODES IN BLOCKS 166-175. IF NONE, LEAVE BLANK.

 

 

 

(Enter code in block 165

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIBE DIAGNOSES (Narrative)

 

ICD-9-CODES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y=Yes

N=No

 

 

 

(166)

(167)

(168)

(169)

(170)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(171)

(172)

(173)

(174)

(175)

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9

JetForm

 

 

 

 

NAME:

 

 

 

 

 

 

 

 

 

 

SSN:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19. CHEST PAIN AND/OR PALPITATIONS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19A. CARDIOLOGY CONSULT

176

 

19B. LIST DIAGNOSES. MAS CODERS ENTER ICD-9-CM CODES IN BLOCKS 177-186. IF NONE, LEAVE BLANK.

 

 

(Enter code in block 176)

 

 

DESCRIBE DIAGNOSES (Narrative)

 

ICD-9-CODES

 

 

 

 

 

1.

 

 

(177)

(178)

(179)

(180)

(181)

Y=YES

N=NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

 

(182)

(183)

(184)

(185)

(186)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20. REPRODUCTIVE CONCERNS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20A. MALES - UROLOGY CONSULT?

187

 

18B. LIST DIAGNOSES. MAS CODERS ENTER ICD-9-CM CODES IN BLOCKS 189-198. IF NONE, LEAVE BLANK.

 

 

(Enter code in block 187

 

 

DESCRIBE DIAGNOSES (Narrative)

 

ICD-9-CODES

 

 

 

 

 

 

 

 

 

 

 

 

Y=YES

N=NO

 

1.

 

(189)

(190)

(191)

(192)

(193)

 

 

 

 

 

 

 

 

 

 

 

20B. FEMALES - GYN CONSULT?

188

 

 

 

 

 

 

 

 

 

(Enter code in block 188)

 

2.

 

 

(194)

(195)

(196)

(197)

(198)

Y=YES

N=NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21. FINAL DIAGNOSES: PHASES II

21A. DIAGNOSES. LIST UP TO 10 MAJOR DEFINITE MEDICAL DIAGNOSES ON LINES 20A-J. LIST PRIMARY DIAGNOSIS ON LINE A. BLOCKS 199-248 OR CORRESPONDING ICD-9-CM CODES. LEAVE BLANK IF NO DlAGNOSIS IS MADE. MAS CODERS: USE ICD-9-CM CODES IN FIRST FIVE NUMBERED BLOCKS OF EACH DIAGNOSIS

DESCRIBE DIAGNOSES (Narrative)

 

ICD-9-CODES

 

 

(199)

(200)

(201)

 

(202)

(203)

A. (PRIMARY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(204)

(205)

(206)

 

(207)

(208)

B.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(209)

(210)

(211)

 

(212)

(213)

C.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(214)

(215)

(216)

 

(217)

(218)

D.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(219)

(220)

(221)

 

(222)

(223)

E.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(224)

(225)

(226)

 

(227)

(228)

F.

 

 

 

 

 

 

 

 

 

 

 

 

 

G.

(229)

(230)

(231)

 

(232)

(233)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(234)

(235)

(236)

 

(237)

(238)

H.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(239)

(240)

(241)

 

(242)

(243)

I.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(244)

(245)

(246)

 

(247)

(248)

J.

 

 

 

 

 

 

 

 

 

 

 

 

 

22. AFTER COMPLETING PHASE II, UNIFORM CASE ASSESSMENT PROTOCOL, THE PHYSICIAN FEELS THAT THE VETERAN HAS AN

 

(249)

 

 

UNEXPLAINED ILLNESS? (Enter code in block 249 Y=YES N=NO

 

 

 

 

 

 

 

 

 

 

 

 

 

10

JETFORM