Questionnaire for the Gulf War Veteran Parent of a Birth-Defected Child
QUESTIONNAIRE FOR THE 1991 GULF WAR VETERAN REGARDING HIS OR HER CHILD
BORN WITH ONE OR MORE BIRTH DEFECTS AFTER 1991
1.) GULF WAR VETERAN’S NAME: ____________________________________________
ADDRESS: _______________________________________________________________
TELEPHONE (HM):_____________________ TELEPHONE (WK): _________________
2.) CHILD’S NAME: __________________________________________________________
3.) CHILD’S DATE OF BIRTH: _______/_______/_______
4.) CHILD’S PLACE OF BIRTH (CITY AND STATE): ______________________________
5.) CHILD’S S.S.#: _______________________ VET PARENT’S.S.#: ___________________
6.) CHILD’S CURRENT ADDRESS: ________________________________________________
7.) PHONE NUMBER WHERE CHILD LIVES: ______________________________________
8.) NAME OF CHILD’S LEGAL GUARDIAN: ______________________________________
(IF OTHER THAN THE GULF WAR VETERAN)
ADDRESS: _________________________________________________________________
TELEPHONE: _______________________________________________________________
9.) NAME OF MOTHER (IF DIFFERENT FROM VETERAN): _________________________
ADDRESS: _________________________________________________________________
TELEPHONE: _______________________________________________________________
10.) NAME OF FATHER (IF DIFFERENT FROM VETERAN): _________________________
ADDRESS: _________________________________________________________________
TELEPHONE: _______________________________________________________________
11.) NAME OF ANY STEP-PARENT(S): ___________________________________________
ADDRESS: _________________________________________________________________
TELEPHONE: _______________________________________________________________
12.) PLEASE DESCRIBE ANY BIRTH DEFECTS SUFFERED BY YOUR CHILD: ____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
13.) PLEASE IDENTIFY THE DOCTOR(S) THAT DIAGNOSED YOUR CHILD’S BIRTH DEFECT, AND STATE HIS/HER ADDRESS AND TELEPHONE #:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
14.) OTHER SIGNIFICANT ILLNESSES IN YOUR CHILD’S LIFETIME AND THE DATES OF EACH (PLEASE LIST):
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
15.) PLEASE STATE THE NAME AND ADDRESSES OF EACH TREATING DOCTOR THAT YOUR CHILD HAS HAD:
DOCTOR’S NAME: ______________________________ ADDRESS: ___________________
______________________________________________________________________________
TELEPHONE #: __________________________________YEARS TREATED: ____________
CONDITION TREATED FOR: ___________________________________________________
DOCTOR’S NAME: ______________________________ ADDRESS: ___________________
______________________________________________________________________________
TELEPHONE #: __________________________________YEARS TREATED: ____________
CONDITION TREATED FOR: ___________________________________________________
DOCTOR’S NAME: ______________________________ ADDRESS: ___________________
______________________________________________________________________________
TELEPHONE #: __________________________________YEARS TREATED: ____________
CONDITION TREATED FOR: ___________________________________________________
DOCTOR’S NAME: ______________________________ ADDRESS: ___________________
______________________________________________________________________________
TELEPHONE #: __________________________________YEARS TREATED: ____________
CONDITION TREATED FOR: ___________________________________________________
DOCTOR’S NAME: ______________________________ ADDRESS: ___________________
______________________________________________________________________________
TELEPHONE #: __________________________________YEARS TREATED: ____________
CONDITION TREATED FOR: ___________________________________________________
DOCTOR’S NAME: ______________________________ ADDRESS: ___________________
______________________________________________________________________________
TELEPHONE #: __________________________________YEARS TREATED: ____________
CONDITION TREATED FOR: ___________________________________________________
16.) HAS YOUR CHILD EVER BEEN IN THE HOSPITAL? YES ____/ NO ____. IF YES, WHAT WAS YOUR CHILD IN THE HOSPITAL FOR AND GIVE THE NAME, LOCATION AND DATE OF EACH HOSPITALIZATION: ____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
17.) HAS YOU CHILD EVER HAD SURGERY? YES ____/ NO ____. IF YES, WHAT FOR AND THE APPROXIMATE DATES:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
18.) IS YOUR CHILD CURRENTLY TAKING ANY MEDICATIONS? YES ____/ NO ____. IF YES, WHAT MEDICATION, FOR HOW LONG, AND FOR WHAT?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
19.) FOR ALL OF THE ABOVE MENTIONED SYMPTOMS IN WHICH THE ANSWER IS YES, PLEASE DESCRIBE IN GREATER DETAIL IN THE SPACE PROVIDED; OR ATTACH ADDITIONAL PAGES: ____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
SIGNED: _____________________________________ ________________________
1991 Gulf War Veteran Date
PITTS & ASSOCIATES
and
MALONEY, MARTIN & MITCHELL, L.L.P.
Attorneys at Law
AUTHORIZATION FOR MEDICAL INFORMATION
My signature herein authorizes physicians, hospitals and any and all other health care providers to furnish full and complete medical records concerning the undersigned to my attorneys, PITTS & ASSOCIATES and MALONEY, MARTIN & MITCHELL, L.L.P., or to any representative of their offices. These documents are needed in litigation concerning my child’s birth defect(s) due to my chemical warfare agent exposure during the 1991 Gulf War.
This Authorization also includes examination of all hospital records and x-rays and the furnishings of any and all information, including opinions, which will or might aid the attorneys named above in the prosecution of claims against the entities liable for injuries sustained by me.
Please do not disclose the above named information to any insurance adjuster or any other person without retaining additional written authority from me. A photocopy of this authorization issued by PITTS & ASSOCIATES and MALONEY, MARTIN & MITCHELL, L.L.P., on my behalf, is acceptable as a medical authorization as stated herein.
Thank you for your cooperation.
Dated: __________________________________
Client’s Signature: __________________________________
Client’s Name: __________________________________
(printed)
As Guardian for: __________________________________
Child’s Name (printed)
Child’s Date of Birth: __________________________________
Child’s’ SSN#: __________________________________
These forms can be recovered and printed out by clicking on the files listed below. The documents are in PDF format so you will need a PDF Reader to view and print out.
Download Forms:
Questionnaire, Agreements and Medical Release, Birth Defects
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