<table>
<colgroup>
<col style="width: 19%" />
<col style="width: 7%" />
<col style="width: 7%" />
<col style="width: 2%" />
<col style="width: 2%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 2%" />
<col style="width: 7%" />
<col style="width: 0%" />
<col style="width: 5%" />
<col style="width: 1%" />
<col style="width: 3%" />
<col style="width: 15%" />
<col style="width: 9%" />
<col style="width: 5%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="16"><h1 id="demographics">Demographics</h1></td>
</tr>
<tr class="even">
<td colspan="4">Last Name</td>
<td colspan="7">First Name</td>
<td colspan="5">Middle Name</td>
</tr>
<tr class="odd">
<td colspan="8">Social Security Number</td>
<td colspan="8">Date of Birth <em>(mm/dd/yyyy)</em></td>
</tr>
<tr class="even">
<td colspan="16">Address</td>
</tr>
<tr class="odd">
<td colspan="10">City</td>
<td colspan="3">State</td>
<td>Zip Code</td>
<td colspan="2">Plus 4</td>
</tr>
<tr class="even">
<td colspan="16">County</td>
</tr>
<tr class="odd">
<td colspan="2">Sex</td>
<td colspan="3">F = Female<br />
M = Male</td>
<td></td>
<td colspan="3">Marital Status</td>
<td colspan="6">1 = Married 4 = Widowed<br />
2 = Divorced 5 = Single, Never Married<br />
3 = Separated</td>
<td></td>
</tr>
<tr class="even">
<td colspan="16"><h1 id="race">Race</h1></td>
</tr>
<tr class="odd">
<td colspan="16">Enter all races that apply below. One entry per
row.</td>
</tr>
<tr class="even">
<td colspan="12">1 = American Indian or Alaskan Native 5 = White<br />
2 = Asian 6 = Declined to answer<br />
3 = Black or African American 7 = Unknown by patient<br />
4 = Native Hawaiian or other Pacific Islander</td>
<td colspan="4">1 = Observer 3 = Self-identification<br />
2 = Proxy 4 = Unknown</td>
</tr>
<tr class="odd">
<td colspan="12"><h1 id="race-code">Race Code</h1></td>
<td colspan="4"><h1 id="collection-method">Collection Method</h1></td>
</tr>
<tr class="even">
<td colspan="12"></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="12"></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="12"></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="12"></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="16"><h1 id="ethnicity">Ethnicity</h1></td>
</tr>
<tr class="odd">
<td colspan="16">Enter all ethnicities that apply. One entry per
row.</td>
</tr>
<tr class="even">
<td colspan="12">1 = Hispanic or Latino 3 = Declined to answer<br />
2 = Not Hispanic or Latino 4 = Unknown by patient</td>
<td colspan="4">1 = Observer 3 = Self-identification<br />
2 = Proxy 4 = Unknown</td>
</tr>
<tr class="odd">
<td colspan="12"><h1 id="ethnicity-code">Ethnicity Code</h1></td>
<td colspan="4"><h1 id="collection-method-1">Collection Method</h1></td>
</tr>
<tr class="even">
<td colspan="12"></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="12"></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="16"><h1 id="periods-of-service">Periods of
Service</h1></td>
</tr>
<tr class="odd">
<td colspan="16">Enter all periods of service that apply. One entry per
row.</td>
</tr>
<tr class="even">
<td colspan="16">1 = Army 2 = Air Force 3 = Navy 4 = Marines 5 = Coast
Guard 6 = Other</td>
</tr>
<tr class="odd">
<td><h1 id="branch-of-service">Branch of Service</h1></td>
<td colspan="2"><h1 id="start-date">Start Date</h1>
<p>(mm/dd/yyyy)</p></td>
<td colspan="4"><h1 id="end-date">End Date</h1>
<p>(mm/dd/yyyy)</p></td>
<td colspan="9"><h1 id="remarks">Remarks</h1></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="9"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="9"></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="9"></td>
</tr>
<tr class="odd">
<td></td>
<td colspan="2"></td>
<td colspan="4"></td>
<td colspan="9"></td>
</tr>
</tbody>
</table>

+------------------------+---------+---------+----------------+------+
| # General              |         |         |                |      |
+------------------------+---------+---------+----------------+------+
| Facility Number        | F       |         | Date of Exam   |      |
|                        | acility |         |                |      |
|                        | Suffix  |         |                |      |
+------------------------+---------+---------+----------------+------+
| Examiner Name          |         | E       |                |      |
|                        |         | xaminer |                |      |
|                        |         | Title   |                |      |
+------------------------+---------+---------+----------------+------+
| Examiner Signature     |         | Private |                | Yes\ |
|                        |         | Phy     |                | No   |
|                        |         | sician? |                |      |
+------------------------+---------+---------+----------------+------+
| Remarks                |         |         |                |      |
+------------------------+---------+---------+----------------+------+
| # NP Radium Treatments |         |         |                |      |
+------------------------+---------+---------+----------------+------+
| Did veteran receive    |         |         |                | Yes\ |
| nasopharyngeal radium  |         |         |                | No\  |
| treatments while in    |         |         |                | Unk  |
| active military,       |         |         |                | nown |
| naval, or air service? |         |         |                |      |
+------------------------+---------+---------+----------------+------+
| # Birth Defects        |         |         |                |      |
+------------------------+---------+---------+----------------+------+
| Has the veteran        |         |         |                | Yes\ |
| reported birth defects |         |         |                | No\  |
| among veteran\'s       |         |         |                | Unk  |
| children or            |         |         |                | nown |
| grandchildren?         |         |         |                |      |
+------------------------+---------+---------+----------------+------+
| # Possible Radio       |         |         |                |      |
| genic-Related Diseases |         |         |                |      |
+------------------------+---------+---------+----------------+------+
| Has the veteran been   |         |         |                | Yes\ |
| diagnosed with any     |         |         |                | No\  |
| possibly               |         |         |                | Unk  |
| radiogenic-related     |         |         |                | nown |
| diseases? ***(If No,   |         |         |                |      |
| stop here)***          |         |         |                |      |
+------------------------+---------+---------+----------------+------+
| Leukemia, Lymphoid     |         |         |                | Yes\ |
| (except chronic        |         |         |                | No\  |
| lymphatic leukemia)    |         |         |                | Unk  |
|                        |         |         |                | nown |
+------------------------+---------+---------+----------------+------+
| Leukemia, Myeloid      |         |         |                | Yes\ |
|                        |         |         |                | No\  |
|                        |         |         |                | Unk  |
|                        |         |         |                | nown |
+------------------------+---------+---------+----------------+------+
| Leukemia, Monocytic    |         |         |                | Yes\ |
|                        |         |         |                | No\  |
|                        |         |         |                | Unk  |
|                        |         |         |                | nown |
+------------------------+---------+---------+----------------+------+
| Leukemia, Hairy Cell   |         |         |                | Yes\ |
|                        |         |         |                | No\  |
|                        |         |         |                | Unk  |
|                        |         |         |                | nown |
+------------------------+---------+---------+----------------+------+
| Leukemia, Other        |         |         |                | Yes\ |
|                        |         |         |                | No\  |
|                        |         |         |                | Unk  |
|                        |         |         |                | nown |
+------------------------+---------+---------+----------------+------+
| Leukemia, Unspecified  |         |         |                | Yes\ |
| Cell Type              |         |         |                | No\  |
|                        |         |         |                | Unk  |
|                        |         |         |                | nown |
+------------------------+---------+---------+----------------+------+
| Thyroid Cancer         |         |         |                | Yes\ |
|                        |         |         |                | No\  |
|                        |         |         |                | Unk  |
|                        |         |         |                | nown |
+------------------------+---------+---------+----------------+------+
| Breast Cancer          |         |         |                | Yes\ |
|                        |         |         |                | No\  |
|                        |         |         |                | Unk  |
|                        |         |         |                | nown |
+------------------------+---------+---------+----------------+------+
| Lung Cancer (malignant |         |         |                | Yes\ |
| neoplasm of trachea,   |         |         |                | No\  |
| bronchus, & lung)      |         |         |                | Unk  |
|                        |         |         |                | nown |
+------------------------+---------+---------+----------------+------+
| Bone Cancer            |         |         |                | Yes\ |
|                        |         |         |                | No\  |
|                        |         |         |                | Unk  |
|                        |         |         |                | nown |
+------------------------+---------+---------+----------------+------+

+---------------------------------------------------------------+------+
| # Possible Radiogenic-Related Diseases (continued)            |      |
+---------------------------------------------------------------+------+
| Primary Liver Cancer                                          | Yes\ |
|                                                               | No\  |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+
| Skin Cancer                                                   | Yes\ |
|                                                               | No\  |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+
| Esophageal Cancer                                             | Yes\ |
|                                                               | No\  |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+
| Stomach Cancer                                                | Yes\ |
|                                                               | No\  |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+
| Colon Cancer                                                  | Yes\ |
|                                                               | No\  |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+
| Pancreatic Cancer                                             | Yes\ |
|                                                               | No\  |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+
| Kidney Cancer                                                 | Yes\ |
|                                                               | No\  |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+
| Urinary Bladder Cancer                                        | Yes\ |
|                                                               | No\  |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+
| Salivary Gland Cancer (malignant neoplasm of major salivary   | Yes\ |
| gland)                                                        | No\  |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+
| Multiple Myeloma                                              | Yes\ |
|                                                               | No\  |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+
| Posterior Subcapsular cataracts                               | Yes\ |
|                                                               | No\  |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+
| Nonmalignant Thyroid Nodular Disease                          | Yes\ |
|                                                               | No\  |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+
| Ovarian Cancer                                                | Yes\ |
|                                                               | No\  |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+
| Parathyroid Adenoma                                           | Yes\ |
|                                                               | No\  |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+
| Malignant Tumors of the Brain & Central Nervous System        | Yes\ |
|                                                               | No\  |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+
| Lymphomas other than Hodgkin's Disease                        | Yes\ |
|                                                               | No\  |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+
| Cancer of the Rectum                                          | Yes\ |
|                                                               | No\  |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+
| Cancer of the Small Intestine                                 | Yes\ |
|                                                               | No\  |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+
| Cancer of the Pharynx                                         | Yes\ |
|                                                               | No\  |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+
| Cancer of the Bile Duct                                       | Yes\ |
|                                                               | No\  |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+
| Cancer of the Gall Bladder                                    | Yes  |
|                                                               |      |
|                                                               | No   |
|                                                               |      |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+
| Cancer of the Renal Pelves, Ureters, & Urethra                | Yes\ |
|                                                               | No\  |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+

+---------------------------------------------------------------+------+
| # Possible Radiogenic-Related Diseases (continued)            |      |
+---------------------------------------------------------------+------+
| Cancer of the Prostate                                        | Yes\ |
|                                                               | No\  |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+
| Bronchio-Alveolar Carcinoma (a rare lung disease)             | Yes\ |
|                                                               | No\  |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+
| Benign Neoplasm of the Brain and Central Nervous System       | Yes\ |
|                                                               | No\  |
|                                                               | Unk  |
|                                                               | nown |
+---------------------------------------------------------------+------+
| # Possible Radiogenic-Related Diseases (continued)            |      |
+---------------------------------------------------------------+------+
| Any other malignancies (cancers) not previously listed? *(if  | Yes\ |
| yes, describe)*                                               | No   |
+---------------------------------------------------------------+------+
|                                                               |      |
+---------------------------------------------------------------+------+
| Other possible Radiogenic Diseases (other conditions may be   | Yes\ |
| recognized in the future)? *(if yes, describe)*               | No   |
+---------------------------------------------------------------+------+
|                                                               |      |
+---------------------------------------------------------------+------+