Patient Name:

Last 4 of SSN:

1. What is your age?

2. What is your gender?

Male Female

3. What is your ethnicity?

4. What was your unit of assignment during your most recent deployment?

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?

9. Did you experience any environmental exposures during deployment (select all that apply)?

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?

d. How many years have you smoked overall?

11. Please list your current medications

12. Respiratory Illness During Deployment

a. Did you receive medical treatment for any respiratory diseases (select all that apply)?

b. How many times did you seek medical attention for respiratory illnesses during deployment?

c. Did you get treated with any medications (select all that apply)?

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)

13. Respiratory Symptoms

BEFORE DEPLOYMENT, Did you experience any of the following symptoms?

a. Shortness of breath

b. Wheezing

c. Cought

d. Sputum production

e. Decreased exercise tolerance

DURING DEPLOYMENT, Did you experience any of the following symptoms?

a. Shortness of breath

b. Wheezing

c. Cought

d. Sputum production

e. Decreased exercise tolerance

AFTER DEPLOYMENT, Did you experience any of the following symptoms?

a. Shortness of breath

b. Wheezing

c. Cought

d. Sputum production

e. Decreased exercise tolerance

EXPOSURE HISTORY

1. Have you been exposed to blowing dust/sand?

How severe were the effects of the exposure?

Were there any lasting effects (for more than 24 hours) of the exposure?

2. Have you been exposed to vehicle exhaust?

How severe were the effects of the exposure?

3. Have you been exposed to smoke from burning trash?

How severe were the effects of the exposure?

Were there any lasting effects (for more than 24 hours) of the exposure?

4. Have you been exposed to smoke/fumes from industry? (metal dust, solvents or exhaust)

How severe were the effects of the exposure?

Were there any lasting effects (for more than 24 hours) of the exposure?

SYMPTOM HISTORY

1. How long have you had your current symptoms?

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:

6. Do you experience any of the following symptoms with your shortness of breath (select all that apply)?

7. What was the time on your last APFT run?

8. How much slower is your latest APFT run compared to previous?

9. Current aerobic physical fitness

a. Current level of aerobic fitness:

b. How often do you currently exercise?

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:

d. Indicate the best description of the change in your aerobic fitness within the last 12 months:

e. To what factor(s) do you attribute the change in your physical fitness (select all that apply)

f. Over what period of time (in months) did the change in your aerobic fitness occur?

g. Was there any specific life change prior to the change in fitness (work, home location, hobbies, smoking)?

Yes No

If yes, please specify:

SLEEP DISORDER CENTER

Post Deployment