GULF WAR VETERAN OF 1991     
PROSPECTIVE CLIENT QUESTIONNAIRE



GULF WAR VETERAN OF 1991
PROSPECTIVE CLIENT QUESTIONNAIRE


PLEASE ANSWER THE QUESTIONS AS COMPLETELY AS POSSIBLE. Not answering any questions, will require additional calls from our office to complete this form. Please use reverse side of each page or attach additional pages to provide additional information if required. Please make reference to the question number when writing on the reverse side of the page.

Today’s Date _______/_______/_______

1.) Name ____________________________________________________________________
(including nicknames, aliases, maiden name)

2.) Current Resident Address ______________________________________ Apt #___________
Street Address, Apt. #, PO Box

3.) City ________________________________ State _____________ Zip Code ____________

4.) Phone Numbers (home) _________________ (work) _________________ Age __________

5.) Date of Birth _______/_______/_______ Place of Birth ______________________________
City, State, County

6.) Driver’s License No. ____________ State of Issue _____ Social Security No. ____________

7.) Name, Address, Telephone Number and relationship of a person not living with you who will always know how to contact you:

Name of Contact Person: _________________________________________________________
Address: ______________________________________________________________________
City, State, & Zip Code __________________________________________________________
Telephone Number _______________________________ Relationship ____________________

8.) Please list each resident address you have lived at in the last 10 years and approximate dates of when you lived there: (Please list exact address including street address, city, state, and county if possible, Starting with your most recent address and working backwards.

_____________________________________ From _____/_____/_____ To _____/_____/_____
Street Address/City/State

_____________________________________ From _____/_____/_____ To _____/_____/_____
Street Address/City/State

_____________________________________ From _____/_____/_____ To _____/_____/_____
Street Address/City/State

9.) Are you a smoker? Yes ____/ No ____/ Quit ____. If quit smoking, give approximate dates when you started smoking and when you quit smoking: _________________________________

10.) Have you registered with the U.S. Government Persian Gulf Registry for Gulf War Illness?
Yes _____/ No _____. If you have, was it through the Veteran’s Administration or the Department of Defense; and please state what year you registered: ________________________

11.) If you have registered, please state the location of the hospitals or clinics where you were evaluated for Gulf War Illness; and state the year(s) the evaluation(s) occurred in: ______________________________________________________________________________

12.) Do you have further evaluation scheduled or to be scheduled? Yes _____/ No _____
If so, What and When? ___________________________________________________________

13.) Marital Status: Single _____/ Married _____/ Divorced _____/ Widowed _____. If still married, please state full name of spouse including maiden name: ____________________________________________________________________Date of Marriage: ___________________

14.) Number of children _____. If you have children, please provide the following information regarding each of your children. This will include information on ALL children born naturally to you or legally adopted by you. This does NOT include stepchildren or grandchildren. Please include full name, age, and if the mother or father of the child is different from the above listed spouse, please include full name of other parent and current address:

A.) Child’s Name _______________ Date of Birth ___/___/___ Social Security # ____________
Current Address ___________________________________ Phone # ____________________

B.) Child’s Name _______________ Date of Birth ___/___/___ Social Security # ____________
Current Address ___________________________________ Phone # ____________________

C.) Child’s Name _______________ Date of Birth ___/___/___ Social Security # ____________
Current Address ___________________________________ Phone # ____________________

D.) Child’s Name _______________ Date of Birth ___/___/___ Social Security # ____________
Current Address ___________________________________ Phone # ____________________

15.) Do any of your children born after the 1991 Gulf War suffer from any birth defects? Yes ___/ No ___.
If so, please describe:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

16.) Were you ever a member of the armed forces? Yes __/ No __. Branch served in: _________
Military Occupation: __________ Highest Rank Attained:_______ Period of Service: _________
Type of Discharge:____________________ Date of Discharge ___________________________
Did you serve in the 1991 Gulf War? Yes ___/ No ___. Dates in Persian Gulf Area: _________________________________________________________________________________________________________

Briefly, what were your duties in the Gulf War? _________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

17.) What military unit were you in during the 1991 Gulf War? ___________________________
Location(s) in which you served in the Persian Gulf (to the best of your knowledge):
_____________________________________ Dates from ____/____/____/ To ____/____/____
_____________________________________ Dates from ____/____/____/ To ____/____/____
_____________________________________ Dates from ____/____/____/ To ____/____/____

18.) Describe in detail (including date, time and location to the extent possible) of any and all incidents where you believe that you were subjected to chemical warfare agent exposure during the 1991 Gulf War (especially including any chemical alarm incidents):
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

19.) Were you given any pills during the Gulf War to protect you from chemical warfare agent?
Yes __/ No __ Did you take them? Yes __/ No __. If yes, please describe what they looked like, when you took them, how often, how many, and describe if you had any reaction or adverse physical symptoms in the 3 days after taking the pill or pills: _________________________________________________________________________________________________________
_________________________________________________________________________________________________________

20.) During Desert Shield/Desert Storm, did you have any physical reaction to any inoculation within the 72 hours afterwards? Yes ___/ No ___. If yes, please describe: _________________________________________________________________________________________________________

21.) Were you inoculated for anthrax? Yes ___/ No ___; or for botulin toxin? Yes ___/ No___. If yes, please state when, to the best of your memory, and in what geographical location:________________________________________________________________________________________________

22.) Please describe the extent, if any, to which you know that you were exposed during the 1991 Gulf War, to enemy tanks or vehicles that had been hit by U.S. depleted uranium munitions, including duration of exposure and physical proximity (if unknown, simply state ): _________________________________________________________________________________________________________
_________________________________________________________________________________________________________

23.) Please describe the extent, if any, to which you were exposed to smoke from oil field fires in Kuwait during the 1991 Gulf War or afterward, including duration and physical proximity, etc.:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

24.) Please describe the extent, if any, to which you know that your bivouac during the 1991 Gulf War was sprayed with pesticides, including extent and duration, and any physical reaction that you had to the spraying, if any: _________________________________________________________________________________________________________
_________________________________________________________________________________________________________

25.) Please describe the extent to which you sprayed yourself with DEET insecticide during the 1991 Gulf War: _________________________________________________________________________________________________________
_________________________________________________________________________________________________________

26.) Did you ever put flea collars on yourself during the 1991 Gulf War? Yes ___/ No ___. If yes, please describe how often: _________________________________________________________________________________________________________
_________________________________________________________________________________________________________

27.) Did you adjust back to civilian or post-Persian Gulf War campaign military life without a great amount of physiological stress? Yes ___/ No ___. If you did experience a great deal of psychological stress in the adjustment, please state the extent and duration of the stress: _________________________________________________________________________________________________________
_________________________________________________________________________________________________________

28.) Have you been rated by the Veteran’s Administration with any service-connected disability from your service in the 1991 Gulf War? Yes ___/ No ___. If yes, please state the percentage of disability, the date that it was awarded, and the amount of your monthly disability payments: _________________________________________________________________________________________________________
_________________________________________________________________________________________________________
29.) If you have not been rated by the V.A. for service-connected disability, have you applied for it? Yes ___/ No ___. If yes, when did you apply and what is the status of the application? _________________________________________________________________________________________________________

30.) Have you applied for Social Security disability? Yes ___/ No ___. If yes, please state when and what the disposition of you application has been:
_________________________________________________________________________________________________________

31.) Regarding Lost Income

From your income tax records or social security earnings statement, please list your earned income for the following years:

1988 _______________ 1996 _______________
1989 _______________ 1997 _______________
1990 _______________ 1998 _______________
1991 _______________ 1999 _______________
1992 _______________ 2000 _______________
1993 _______________ 2001 _______________
1994 _______________ 2002 _______________
1995 _______________

Note: If you have a copy of your social security earnings statement, please include a copy of it with your completed questionnaire. You may obtain a copy from the Social Security Administration by calling 1-800-772-1213.

32.) Regarding your present occupation, if any, please state:
Job title: ______________________________________________________________________
Nature of your duties: __________________________________________________________
Name of Employer: _______________________________________________________________
Address of Employer: ____________________________________________________________
Please state when you started this job: _________________________________________
Other than the above, please state briefly the nature of your other employment since the 1991 Gulf War; if any: _________________________________________________________________________________________________________
_________________________________________________________________________________________________________

33.) Please list the schools that you have attended, including high school, college, military or vocational schools or correspondence courses. Please state the following information on each:

Name ______________________________________ Location __________________________
Years of attendance ___________________ Grade Completed/Degree _____________________

Name ______________________________________ Location __________________________
Years of attendance ___________________ Grade Completed/Degree _____________________

Name ______________________________________ Location __________________________
Years of attendance ___________________ Grade Completed/Degree _____________________

Name ______________________________________ Location __________________________
Years of attendance ___________________ Grade Completed/Degree _____________________

34.) Have you ever been convicted of any crime other than a traffic related offense? Yes__/No __.
If yes, please give the following information on each conviction: Date, Place, Nature of Crime, Amount of Fine, Imprisonment, Probation or Parole: _________________________________________________________________________________________________________
_________________________________________________________________________________________________________

35.)
MEDICAL HISTORY


Have you ever been diagnosed by a medical doctor as having any of the following illnesses? If so, please state the year or years that this condition was diagnosed:

ILLNESS YES NO YEAR OF DIAGNOSIS
AIDS _____ _____ _____________________
ILLNESS YES NO YEAR OF DIAGNOSIS
ALS (Lou Gehrig’s Disease) _____ _____ _____________________
Angina  (recurring chest pain) _____ _____ _____________________
Arthritis _____ _____ _____________________
Asthma _____ _____ _____________________
Bladder problems _____ _____ _____________________
Blood Disease _____ _____ _____________________
Bronchitis _____ _____ _____________________
Cancer _____ _____ _____________________
Colitis _____ _____ _____________________
Depression _____ _____ _____________________
Diabetes _____ _____ _____________________
Emphysema _____ _____ _____________________
Gallstones _____ _____ _____________________
Gallbladder problems _____ _____ _____________________
Gout _____ _____ _____________________
Gulf War Illness _____ _____ _____________________
High Blood Pressure _____ _____ _____________________
Heart Attack _____ _____ _____________________
Hepatitis _____ _____ _____________________
High trigllycerides _____ _____ _____________________
Immune disorders _____ _____ _____________________


ILLNESS YES NO YEAR OF DIAGNOSIS
Kidney disease _____ _____ _____________________
Leishimaniasis _____ _____ _____________________
Nervous disease _____ _____ _____________________
Nephritis _____ _____ _____________________
Leukemia _____ _____ _____________________
Liver disease _____ _____ _____________________
Manic depression _____ _____ _____________________
Multiple Chemical Sensitivity _____ _____ _____________________
Pneumonia _____ _____ _____________________
Prostate disease _____ _____ _____________________
Meningitis _____ _____ _____________________
Neurological disorder of the brain _____ _____ _____________________
Non-Hodgkin’s lymphoma _____ _____ _____________________
Psoriasis _____ _____ _____________________
Rheumatism _____ _____ _____________________
Schizophrenia _____ _____ _____________________
Seizures/Epilepsy _____ _____ _____________________
Thyroid disease _____ _____ _____________________
Tuberculosis _____ _____ _____________________
Ulcer _____ _____ _____________________

Other significant illnesses that you have been diagnosed with, and the year of diagnosis (please list):
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
____________________________________________________________________________________________________________

Note: If we accept you as a client and if you are ever diagnosed as having a terminal medical condition by a medical doctor you must promptly notify your attorneys by phone and in writing of this diagnosis.

36.) Please state the name, address and telephone number of each doctor that has treated you since the 1991 Gulf War:

Doctor’s name ____________________________ Address_____________________________
_________________________________________ Tel. _______________________________
Year(s) treated __________________ Condition treated for _____________________________

Doctor’s name ____________________________ Address_____________________________
_________________________________________ Tel. _______________________________
Year(s) treated __________________ Condition treated for ____________________________

Doctor’s name ____________________________ Address_____________________________
_________________________________________ Tel. _______________________________
Year(s) treated __________________ Condition treated for ____________________________

Doctor’s name ____________________________ Address_____________________________
_________________________________________ Tel. _______________________________
Year(s) treated __________________ Condition treated for ____________________________

Doctor’s name ____________________________ Address_____________________________
_________________________________________ Tel. _______________________________
Year(s) treated __________________ Condition treated for ____________________________

37.) Have you ever been hospitalized? Yes ___/ No ___. If yes, please state where you were in the hospital, what for, and what year was each hospitalization: _________________________________________________________________________________________________________
_________________________________________________________________________________________________________
38.) Have you ever had surgery? Yes ___/ No ___. If yes, what was it for and in what year:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

39.) Are you currently taking any medications? Yes ___/ No ___. If yes, please state what kinds and what they are for: _________________________________________________________________________________________________________
_________________________________________________________________________________________________________

40.) Listed below are symptoms, some of which are not associated with Gulf War Illness. Please check the appropriate boxes and if you marked yes, please state what year or years that you have had this symptom, and describe the frequency of the symptom.


SYMPTOMS YES NO DESCRIBE
post-Gulf War		 DESCRIBE
pre-Gulf War
Anxiety ____ ____ _________________ _________________
Bleeding gums ____ ____ _________________ _________________
Blurred vision ____ ____ _________________ _________________
Chronic fatigue ____ ____ _________________ _________________
Chest pain ____ ____ _________________ _________________
Chronic sneezing and runny nose ____ ____ _________________ _________________
Constipation ____ ____ _________________ _________________
Depression ____ ____ _________________ _________________
Diarrhea ____ ____ _________________ _________________
Difficulty remembering ____ ____ _________________ _________________
Difficulty sleeping ____ ____ _________________ _________________
Dizziness ____ ____ _________________ _________________
Eye pain ____ ____ _________________ _________________
Eye redness ____ ____ _________________ _________________
Fainting ____ ____ _________________ _________________
Falling ____ ____ _________________ _________________
Frequent cough ____ ____ _________________ _________________


SYMPTOMS YES NO DESCRIBE
pre-Gulf War		 DESCRIBE
post-Gulf War
Fever ____ ____ _________________ _________________
Frequent urination ____ ____ _________________ _________________
Hair loss ____ ____ _________________ _________________
Headache ____ ____ _________________ _________________
Hives (skin reaction) ____ ____ _________________ _________________
Hot and cold flashes ____ ____ _________________ _________________
Joint pain ____ ____ _________________ _________________
Joint stiffness ____ ____ _________________ _________________
Loss of balance ____ ____ _________________ _________________
Loss of hearing ____ ____ _________________ _________________
Memory loss ____ ____ _________________ _________________
Moodiness ____ ____ _________________ _________________
Muscle pain ____ ____ _________________ _________________
Nausea ____ ____ _________________ _________________
Nervousness ____ ____ _________________ _________________
Night sweats ____ ____ _________________ _________________
Numbness in feet or hands ____ ____ _________________ _________________
Poor concentration ____ ____ _________________ _________________
Sensitive to chemicals ____ ____ _________________ _________________
Skin rashes ____ ____ _________________ _________________


SYMPTOMS YES NO DESCRIBE
pre-Gulf War		 DESCRIBE
post-Gulf War
Semen gives "burning" sensation to wife ____ ____ _________________ _________________
Shortness of breath ____ ____ _________________ _________________
Stomach pain ____ ____ _________________ _________________
Sexual problems ____ ____ _________________ _________________
Sore throat ____ ____ _________________ _________________
Trouble finding words ____ ____ _________________ _________________
Unrefreshing sleep ____ ____ _________________ _________________
Vision problems ____ ____ _________________ _________________
Vomiting ____ ____ _________________ _________________
Wheezing ____ ____ _________________ _________________
Weight loss ____ ____ _________________ _________________
Weight gain ____ ____ _________________ _________________


41.) Other unlisted physical symptoms that you have experienced since the Persian Gulf War, if any: Please list: _________________________________________________________________________________________________________
_________________________________________________________________________________________________________

42.) For Females: Have you ever been pregnant? Yes ____ / No ____.
If yes, did you have a miscarriage? Yes ____ / No ____.
How many miscarriages have you had, and in what years: _______________________________
Please describe any difficulties with menstruation you have had since the Persian Gulf War:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
If never pregnant, have you had any difficulty becoming pregnant? Yes ____/ No ____.

43.)For Males and Females: For all of the symptoms mentioned in this questionnaire, in which the answer is yes, you may describe them in greater detail if you would like to: _________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

44.) Have you signed anything with any other law firm concerning illness from the 1991 Gulf War? Yes ____ / No ____. If yes, please state their name, address, and telephone number and what kind of legal matter they are currently representing you on: _________________________________________________________________________________________________________
_________________________________________________________________________________________________________
________________________________________________________________________________________________________


SIGNED: _____________________________________ ________________________
                1991 Gulf War Veteran                                          Date


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