Have You Been Diagnosed with Any of the Following

GULF WAR QUESTIONNAIRE Period of active military, naval, or air service on or after September 19, 2001

VA presumes certain chronic, unexplained symptoms existing for 6 months or more are related to Gulf War service without regard to cause. These “presumptive” illnesses must have appeared during active duty in the Southwest Asia theater of military operations or by December 31, 2021 and be at least 10 percent disabling.

Have you been diagnosed with any of the following:

 Chronic Fatigue Syndrome

 Fibromyalgia

 Functional gastrointestinal disorders (a group of conditions marked by chronic or recurrent symptoms related to any part of the gastrointestinal tract.) Irritable bowel syndrome (IBS), functional dyspepsia, functional vomiting, functional constipation, functional bloating, and functional abdominal pain syndrome.

 Undiagnosed illnesses with symptoms that may include but are not limited to: abnormal weight loss, fatigue, cardiovascular disease, muscle and joint pain, headache, menstrual disorders, neurological and psychological problems, skin conditions, respiratory disorders, and sleep disturbances.

Did you have any of the following infectious diseases within 1 year from the date of separation:

 Brucellosis

 Campylobacter jejuni

 Coxiella burnetii (Q fever)

 Malaria

 Mycobacterium tuberculosis (no time limit)

 Nontyphoid Salmonella

 Shigella

 Visceral leishmaniasis (no time limit)

 West Nile virus

If you have had any of the above infectious diseases, have you been diagnosed with any of these diseases:

 Arthritis  Cardiovascular, nervous, and respiratory system infections

 Chronic meningitis and meninjgoencephalitis

 Deafness

 Demyelinating meningovascular syndromes

 Episcleritis

 Fatigue, inattention, amnesia, and depression.

 Guillain-Barre syndrome

 Hepatic abnormalities, including granulomatous hepatitis

 Multifocal choroiditis

 Myelitis-radiculoneuritis

 Nummular keratitis

 Papilledema

 Optic neuritis

 Orchioepididymitis and infections of the genitourinary system

 Sensorineural hearing loss

 Spondylities

 Uveitis

 Chronic hepatitis

 Endocarditis

 Osteomyelitis

 Post-Q-fever chronic fatigue syndrome

 Vascular infection

 Demyelinating polyneuropathy

 Hematologic manifestations

 Immune-complex glomerulonephristis

 Neurologic disease, neuropsychiatric disease, or both

 Irreversible tissue damage from severe forms of pulmonary and extrapulmonary tuberculosis

 Reactive Arthritis (manifested within 3 months of the infection)  Delayed presentation of the acute clinical syndrome

 Post-kala-azar dermal leishmaniasis (manifested with 2 years of the infection)

 Reactivation of visceral leishmaniasis in the context of future immunosuppression

 Variable physical, functional, or cognitive disability (West Nile virus)

Were you exposed to airborne hazards, including smoke from open burn pits (trash fires) or oil-well fires? Y/N

Do you have any embedded fragments (shrapnel) in your body? Y/N

If yes, have you enrolled in the Toxic Embedded Fragments registry? Y/N Contact an OEF/OIF/OND Clinical Coordinator to register.

Have you had a Gulf War Registry health exam? Y/N

To schedule a registry evaluation, contact an Environmental Health Coordinator at any VA medical facility.