SLEEP DISORDER CENTER
Post Deployment
Fields marked with an asterisk (
*
) are required.
Patient Name:
Required
Last 4 of SSN:
Required
Value must be a whole number
1. What is your age?
Required
2. What is your gender?
Male
Female
3. What is your ethnicity?
4. What was your unit of assignment during your most recent deployment?
Required
5. Where were you most recently deployed?
Iraq
Afghanistan
Other
6. Can you provide the specific location in that country?
7. How long were you deployed?
3-6 months
6-9 months
9-12 months
12-15 months
8. How many times had you previously been deployed to Iraq/Afghanistan?
Required
Value must be a whole number
9. Did you experience any environmental exposures during deployment (select all that apply)?
Sandstorms
Chemicals
Burn pits
Other
Smoke
Required
10. Smoking history
a. Did you smoke prior to deployment?
Yes
No
b. Did you smoke during deployment?
Yes
No
c. How many packs per day during deployment?
Does not apply
0.5
1
1.5
2
d. How many years have you smoked overall?
11. Please list your current medications
required
12. Respiratory Illness During Deployment
a. Did you receive medical treatment for any respiratory diseases (select all that apply)?
Does not apply
Bronchitis
Asthma
Influenza
Upper respiratory infection
Seasonal allergies
Pneumonia
Other lung disease
required
b. How many times did you seek medical attention for respiratory illnesses during deployment?
Does not apply
Never
1-2 times
3-4 times
5-6 times
More than six times
Required
c. Did you get treated with any medications (select all that apply)?
Does not apply
Allergy medications
Antibiotics
Nasal steroids
Bronchodilators
Cough medications
Inhaled steroids
required
d. Are you currently taking any of the following medications? (select all that apply)?
Inhaled steroids (Flovent, Asmanex)
Leukotriene antagonists (Singulair)
Beta-agonists (Proventil, Xopenex)
Antihistamines (Zyrtec, Allegra, Claritin)
Combination meds (Advair, Symbicort)
Decongestants (Sudafed)
Nasal steroids (Flonase, Nasonex)
required
13. Respiratory Symptoms
BEFORE DEPLOYMENT, Did you experience any of the following symptoms?
a. Shortness of breath
Never
less 2x/week
2-5x/week
5-6 times
Daily
Required
b. Wheezing
Never
less 2x/week
2-5x/week
5-6 times
Daily
Required
c. Cought
Never
less 2x/week
2-5x/week
5-6 times
Daily
Required
d. Sputum production
Never
less 2x/week
2-5x/week
5-6 times
Daily
Required
e. Decreased exercise tolerance
Never
less 2x/week
2-5x/week
5-6 times
Daily
Required
DURING DEPLOYMENT, Did you experience any of the following symptoms?
a. Shortness of breath
Never
less 2x/week
2-5x/week
5-6 times
Daily
Required
b. Wheezing
Never
less 2x/week
2-5x/week
5-6 times
Daily
Required
c. Cought
Never
less 2x/week
2-5x/week
5-6 times
Daily
Required
d. Sputum production
Never
less 2x/week
2-5x/week
5-6 times
Daily
Required
e. Decreased exercise tolerance
Never
less 2x/week
2-5x/week
5-6 times
Daily
Required
AFTER DEPLOYMENT, Did you experience any of the following symptoms?
a. Shortness of breath
Never
less 2x/week
2-5x/week
5-6 times
Daily
Required
b. Wheezing
Never
less 2x/week
2-5x/week
5-6 times
Daily
Required
c. Cought
Never
less 2x/week
2-5x/week
5-6 times
Daily
Required
d. Sputum production
Never
less 2x/week
2-5x/week
5-6 times
Daily
Required
e. Decreased exercise tolerance
Never
less 2x/week
2-5x/week
5-6 times
Daily
Required
EXPOSURE HISTORY
1. Have you been exposed to blowing dust/sand?
Never
Continuously
Regularly
Occasionally
Required
How severe were the effects of the exposure?
Never
Not noticeable
Mild (slight irritation such as teary eyes and coughing but no affect on activity)
Moderate (irritation such as above but also difficulty breathing slight affect on activity)
Severe (irritation such as above but debilitating, severely reducing activity)
Required
Were there any lasting effects (for more than 24 hours) of the exposure?
None
Cough
Wheezing
Shortness of breath
Decreased exercise
Sputum production
Required
2. Have you been exposed to vehicle exhaust?
None
Continuously
Regularly
Occasionally
Required
How severe were the effects of the exposure?
None
Cough
Wheezing
Shortness of breath
Decreased exercise
Sputum production
Required
3. Have you been exposed to smoke from burning trash?
Never
Continuously
Regularly
Occasionally
Required
How severe were the effects of the exposure?
Not noticeable
Mild (slight irritation such as teary eyes and coughing but no affect on activity)
Moderate (irritation such as above but also difficulty breathing slight affect on activity)
Severe (irritation such as above but debilitating, severely reducing activity)
Required
Were there any lasting effects (for more than 24 hours) of the exposure?
None
Cough
Wheezing
Shortness of breath
Decreased exercise
Sputum production
Required
4. Have you been exposed to smoke/fumes from industry? (metal dust, solvents or exhaust)
Never
Continuously
Regularly
Occasionally
Required
How severe were the effects of the exposure?
Not noticeable
Mild (slight irritation such as teary eyes and coughing but no affect on activity)
Moderate (irritation such as above but also difficulty breathing slight affect on activity)
Severe (irritation such as above but debilitating, severely reducing activity)
Required
Were there any lasting effects (for more than 24 hours) of the exposure?
None
Cough
Wheezing
Shortness of breath
Decreased exercise
Sputum production
Required
SYMPTOM HISTORY
1. How long have you had your current symptoms?
Required
2. Is your shortness of breath only associated with exercise?
Yes
No
3. Does it occur while at rest?
Yes
No
4. Does it occur at nighttime?
Yes
No
5. How quickly does your shortness breath begin after exercising:
Required
6. Do you experience any of the following symptoms with your shortness of breath (select all that apply)?
None
Difficulty letting out a breath
Chest tightness
Cough
Throat tightness
Noisy breathing
Loss of voice
Audible wheezing
Difficulty taking in a breath
Required
7. What was the time on your last APFT run?
Required
8. How much slower is your latest APFT run compared to previous?
Required
9. Current aerobic physical fitness
a. Current level of aerobic fitness:
Not fit
Average fitness
Very fit/competitive
Professional/elite
Required
b. How often do you currently exercise?
None
< 1 hour per week
1-3 hours per week
3-6 hours per week
> 6 hours per week
Required
c. If you were asked to walk briskly for 100 yards (the length of a football field) up a slight incline, what would your exertion level be:
None
No exertion at all
Very light
Light
Somewhat hard (a little heavy breathing, but okay to continue and complete
Hard (heavy breathing)
Very hard (very strenuous, heavy breathing, tired; really would have to push)
Maximal exertion (too strenuous/tired or too much difficulty breathing to complete)
Required
d. Indicate the best description of the change in your aerobic fitness within the last 12 months:
No change
Slightly improved
Very improved
Slightly worse
Much worse
Required
e. To what factor(s) do you attribute the change in your physical fitness (select all that apply)
Don’t know
Conditioning
Weight gain
Injury/illness/shortness of breath
Weight loss
Other
Deconditioning
Required
f. Over what period of time (in months) did the change in your aerobic fitness occur?
Required
Value must be a whole number
g. Was there any specific life change prior to the change in fitness (work, home location, hobbies, smoking)?
Yes
No
If yes, please specify: