Medical Conditions Treated for in the Military, Medical Conditions You Now Have!

**Note **** Please fill out SECTION I: VETERAN'S INFORMATION.  Only Sign second page block 22A (SIGNATURE OF CLAIMANT)
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SECTION III - MEDICAL HISTORY. Check each item "Yes" or "No". All "Yes" items must be fully explained in Section IV
1. Double vision
2. Detached retina or surgery to repair a detached retina
3. Cataracts or surgery for cataracts
4. Eye surgery to improve vision (RK, PRK, LASIK, etc.)
5. Night blindness
6. Glaucoma
7. Strabismus or "lazy eye" or any surgery to correct these
8. Any other eye condition, injury or surgery
9. Worn/wear contact lenses or glasses (Bring your contact lens kit and solution so you can remove contacts during vision testing, or for best results remove 72 hours prior. Bring your eyeglasses no matter how old they are.)
10. Loss of vision in either eye
11. Color vision deficiency or color blindness
12. Perforated ear drum or tubes in ear drum(s)
13. Ear surgery, to include mastoidectomy or repair of perforated ear drum
14. Loss of balance or vertigo
15. Hearing loss or wear a hearing aid
16. Ear, nose, or throat trouble including tonsillectomy
17. Chronic sinus infections or recurrent nose bleeds
18. Absence of, or disturbance of sense of smell
19. Any surgery of your face, mandible or jaw
20. Do you wear dental braces or plan to wear braces? (If so, your orthodontist must submit a letter stating that active orthodontic treatment will be completed prior to active duty date: release form/ sample format can be found in the Recruiter's Medical Guide.)
21. Tooth or gum problems (other than cavities)
22. Asthma
23. Wheezing
24. Shortness of breath
25. Bronchitis
26. Other breathing problems worsened by exercise, weather, pollens, etc.
27. Used inhaler(s) or steroids for breathing problem(s)
28. Chronic cough or frequent coughing at night
29. Collapsed lung or other lung condition
30. History of chest, chest wall, or breast surgery
31. Heart murmur, valve problem or mitral valve prolapse
32. Palpitation, pounding heart or abnormal heartbeat
33. Heart surgery
34. Pain or pressure in the chest
35. An abnormal electrocardiogram (EKG)
36. Any other heart problems
37. Stomach, esophageal or intestinal ulcer
38. Difficulty swallowing
39. Frequent indigestion or heartburn
40. Gall bladder trouble or gallstones
41. Jaundice (except neonatal) or hepatitis (liver disease)
42. Rupture/hernia
43. Surgery to remove or repair a portion of the intestine or spleen (other than the appendix)
44. Chronic or recurrent intestinal problem of the small or large bowel such as Irritable Bowel Syndrome, Crohn's disease, Ulcerative Colitis, or Celiac disease
45. Rectal disease, hemorrhoids, or blood from the rectum
46. Hemorrhoid surgery
47. Bariatric surgery (weight loss surgery)
48. A change of menstrual pattern (other than pregnancy)
49. Pregnancy, abortion or miscarriage
50. Any abnormal PAP smear(s)
51. Date of last PAP smear (YYYYMMDD)
52. Diagnosed with endometriosis or ovarian cysts
53. Evaluation, treatment or surgery for any other gynecological (female) disorder
54. Sexually transmitted disease (syphilis, gonorrhea, chlamydia, genital warts, herpes, etc.)
55. First day of last menstrual period (YYYYMMDD)
56. Missing a testicle, testicular implant, or undescended testicle
57. Variocele, hydrocele, or any scrotal mass, swelling or pain
58. Prostate problems
59. Sexually transmitted disease (syphilis, gonorrhea, chlamydia, genital warts, herpes, etc.)
60. Missing a kidney
61. Kidney stone, infection or disease
62. Kidney or urinary tract surgery of any kind
63. Blood or protein in urine
64. Painful or difficult urination
65. Bedwetting or treatment for bedwetting (previous 12 months)
66. Hernia
67. Back pain or back problem
68. Herniated disk
69. Neck pain
70. Back or neck surgery
71. Abnormal curvature of your spine (any part)
72. Painful shoulder, elbow, wrist, hand or fingers
73. Dislocated shoulder, elbow, wrist, hand or fingers
74. Foot trouble (e.g., pain, corns, bunions, warts, ingrown toenails, etc.)
75. Knee trouble (e.g., locking, giving out, or ligament injury, etc.)
76. Painful hip, knee, ankle, foot or toes
77. Dislocated hip, knee, ankle, foot or toes
78. Bone, joint, or other orthopedic deformity
79. Loss of finger or toe, or extra finger or toe
80. Loss of the ability to fully flex (bend) or fully extend a finger, toe, or other joint
81. Impaired use of arms, hands, legs, or feet (any reason)
82. Arthritis, rheumatism, gout, or bursitis
83. Any swollen joint(s)
84. Surgery on any joint/bone (including arthroscopy)
85. Plate(s), screw(s), rod(s) or pin(s) in any bone
86. Pain or swelling at the site of an old fracture
87. Any need to use corrective devices such as prosthetic devices, knee brace(s), back support(s), lifts or orthotics
88. Any other orthopedic, muscle, or sports injury problems

89. High or low blood pressure
90. Raynaud's phenomenon or disease
91. Deep Vein Thrombosis (blood clot; leg or elsewhere)
92. Pulmonary embolism (blood clot in lung)
93. Acne
94. Atopic dermatitis or Eczema
95. Psoriasis
96. Large or painful scars
97. Any other skin problems
98. Anemia (iron deficiency, sickle cell, thalassemia)
99. Blood clots requiring blood thinner medicine
100. Absence or removal of the spleen
101. Prolonged bleeding (after an injury or tooth extraction)
102. Any other blood or circulation problems
103. Adverse reaction to medication (describe reaction in Section IV)
104. Adverse reaction to serum, insect bites, or stings
105. Allergy to foods (milk, eggs, fish, meat, nuts, etc.)
106. Allergy to wool, latex, or other material
107. Tuberculosis or lived with someone who had tuberculosis
108. Positive test for tuberculosis (PPD or blood test)
109. Malaria
110. Disorder(s) of your immune system (including HIV)
111. Car, train, sea, or air sickness
112. Thyroid trouble or goiter

113. High or low blood sugar
114. Diabetes or told that you should be tested for diabetes
115. Cerebrovascular incident (stroke)
116. Frequent or severe headaches, including migraines
117. Taking medication to prevent headaches
118. Lost time from work or school due to frequent or severe headaches
119. A skull fracture
120. A head injury, memory loss, or amnesia
121. A period of unconsciousness or concussion
122. Loss of memory or amnesia, or neurological symptoms
123. Paralysis
124. Meningitis, encephalitis, or other neurological problems
125. Seizures, convulsions, epilepsy or fits
126. Dizziness or fainting spells
127. Any other neurologic problems
128. Sleepwalking or narcolepsy

129. Frequent trouble sleeping

130. Sleep apnea or severe snoring

131. Evaluated or treated for Attention Deficit Disorder (ADD) or Attention Deficit Hyperactivity Disorder (ADHD)
132. Taken (or taking) medication, drugs, or any substance to improve attention, behavior, or physical performance
133. Diagnosed with a learning disorder, to include dyslexia
134. Received counseling of any type
135. Seen a psychiatrist, psychologist, social worker, counselor or other professional for any reason (inpatient or out-patient) including counseling or treatment for school, adjustment, family, marriage, divorce, depression, anxiety, or treatment of alcohol, drug or substance abuse (Applicant or recruiter will request sealed medical supporting documents from health care providers marked "CONFIDENTIAL: MEPS MEDICAL DEPARTMENT" and submit directly to MEPS medical personnel.)
136. Been expelled or suspended from school
137. Been kicked out or removed from your home
138. Been arrested or other encounters with law enforcement
139. Been evaluated or treated, either with medication or counseling, for a mental condition, depression or excessive worry
140. Nervous trouble of any sort (anxiety or panic attacks)
141. Anorexia, bulimia, or other eating disorder
142. Habitual stammering or stuttering
143. Have you ever purposely cut or harmed yourself
144. Have you ever attempted or considered suicide
145. Used illegal drugs or abused prescription drugs
146. Have you been evaluated, treated, or hospitalized for substance abuse, addiction or dependence (including illegal drugs, prescription medications or other substances)
147. Have you been evaluated, treated, or hospitalized for alcohol abuse, dependence, or addiction
148. Post-traumatic Stress Disorder or excessive stress requiring counseling and/or medication following a traumatic experience
149. Any other learning, psychiatric, or behavioral problems
150. Tumor, growth, cyst, or cancer of any type
151. Cold injury, frostbite or cold intolerance
152. Heat injury, heat stroke or heat intolerance
153. Are you taking any medications, to include over the counter medications (OTCs), vitamin, herbal, or nutritional supplements (If "yes", list all in Section IV.)
154. Any recent unexplained gain or loss of weight
155. Artificial or replacement body part (eye, bone, palate, hip, knee, joint, leg, arm, etc.)
156. Have you ever had any illness or injury other than those already noted? (If "yes", specify when, where and give details in Section IV.)
157. Have you ever been treated in an Emergency Room? (If "yes", explain in Section IV.)
158. Have you ever been a patient in any type of hospital (including being kept overnight)? (If "yes", specify when, where, why, and name of doctor and complete address of hospital in Section IV.)
159. Have you ever had, or have you been advised to have any operations or surgery? (If "yes", describe and give age at which occurred in Section IV.)
160. Have you ever been rejected for military Service for any reason? (If "yes", give date and reason in Section IV.)
161. Have you ever been discharged from the military Service for any reason? (If "yes", give date, reason, and type of discharge, whether honorable, other than honorable, for unfitness or unsuitability in Section IV.)
162. Have you ever been refused employment or been unable to hold a job or stay in school because of any of the following: (If "yes", answer a - d below and give reasons in Section IV.)
     a. Sensitivity to chemicals, dust, sunlight, etc.
     b. Inability to perform certain motions
     c. Inability to stand, sit, kneel, lie down, etc.
     d. Other medical reasons
163. Applied for and/or received disability evaluation and/or compensation for an injury or other medical conditions (If "yes", provide details in Section IV.)
164. Have you ever been denied life insurance? (If "yes", provide reason(s) in Section IV.)

SECTION IV - APPLICANT COMMENTS. Explain all "Yes" answers to questions 1 - 164 above. Begin with the Item Number. Describe answer(s) fully: provide date(s) of problem(s)/condition(s); provide names of Health Care Providers (HCPs), Clinic(s) and/or Hospital(s) along with the City and State; explain what was done (e.g., evaluation and/or treatment); and describe your current medical status. Attach additional sheet(s) if necessary and sign and date each additional page. Obtain and attach copies of applicable medical evaluation and treatment records.