<table>
<colgroup>
<col style="width: 26%" />
<col style="width: 2%" />
<col style="width: 6%" />
<col style="width: 2%" />
<col style="width: 4%" />
<col style="width: 0%" />
<col style="width: 7%" />
<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="15"><h1 id="demographics">Demographics</h1></td>
</tr>
<tr class="even">
<td colspan="3">Last Name</td>
<td colspan="7">First Name</td>
<td colspan="5">Middle Name</td>
</tr>
<tr class="odd">
<td colspan="7">Social Security Number</td>
<td colspan="8">Date of Birth</td>
</tr>
<tr class="even">
<td colspan="15">Address</td>
</tr>
<tr class="odd">
<td colspan="9">City</td>
<td colspan="3">State</td>
<td>Zip Code</td>
<td colspan="2">Plus 4</td>
</tr>
<tr class="even">
<td colspan="15">County</td>
</tr>
<tr class="odd">
<td>Sex</td>
<td colspan="3">F = Female<br />
M = Male</td>
<td colspan="2"></td>
<td colspan="2">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="15"><h1 id="race">Race</h1></td>
</tr>
<tr class="odd">
<td colspan="11"><p>Race Code</p>
<p>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</p></td>
<td colspan="4"><p>Collection Method</p>
<p>1 = Observer 3 = Self-identification<br />
2 = Proxy 4 = Unknown</p></td>
</tr>
<tr class="even">
<td colspan="11"></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="11"></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="11"></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="11"></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="15"><h1 id="ethnicity">Ethnicity</h1></td>
</tr>
<tr class="odd">
<td colspan="11"><p>Ethnicity Code</p>
<p>1 = Hispanic or Latino 3 = Declined to answer<br />
2 = Not Hispanic or Latino 4 = Unknown by patient</p></td>
<td colspan="4"><p>Collection Method</p>
<p>1 = Observer 3 = Self-identification<br />
2 = Proxy 4 = Unknown</p></td>
</tr>
<tr class="even">
<td colspan="11"></td>
<td colspan="4"></td>
</tr>
<tr class="odd">
<td colspan="11"></td>
<td colspan="4"></td>
</tr>
<tr class="even">
<td colspan="15"><h1 id="periods-of-service">Periods of
Service</h1></td>
</tr>
<tr class="odd">
<td colspan="2"><p>Branch of Service</p>
<p>1 = Army 4 = Marines<br />
2 = Air Force 5 = Coast Guard<br />
3 = Navy 6 = Other</p></td>
<td colspan="3">Start Date</td>
<td colspan="3">End Date</td>
<td colspan="7">Remarks</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="3"></td>
<td colspan="7"></td>
</tr>
</tbody>
</table>

+------------------------+---------+---------+----------+---------+---+
| # General              |         |         |          |         |   |
+------------------------+---------+---------+----------+---------+---+
| Facility Number        | F       |         | Date of  |         |   |
|                        | acility |         | Exam     |         |   |
|                        | Suffix  |         |          |         |   |
+------------------------+---------+---------+----------+---------+---+
| Examiner Name          |         | E       |          |         |   |
|                        |         | xaminer |          |         |   |
|                        |         | Title   |          |         |   |
+------------------------+---------+---------+----------+---------+---+
| Examiner Signature     |         | Private |          |         |   |
|                        |         | Phy     |          |         |   |
|                        |         | sician? |          |         |   |
|                        |         |         |          |         |   |
|                        |         | *Y =    |          |         |   |
|                        |         | Yes; N  |          |         |   |
|                        |         | = No*   |          |         |   |
+------------------------+---------+---------+----------+---------+---+
| Remarks                |         |         |          |         |   |
+------------------------+---------+---------+----------+---------+---+
| # Blood Tests          |         |         |          |         |   |
+------------------------+---------+---------+----------+---------+---+
| CBC (Complete Blood    |         |         |          | Y = Yes |   |
| Count)                 |         |         |          | N = No  |   |
+------------------------+---------+---------+----------+---------+---+
| SED Rate (Skin         |         |         |          | Y = Yes |   |
| Erythema Dose)         |         |         |          | N = No  |   |
+------------------------+---------+---------+----------+---------+---+
| C-Reactive Protein     |         |         |          | Y = Yes |   |
|                        |         |         |          | N = No  |   |
+------------------------+---------+---------+----------+---------+---+
| Rheumatoid Factor      |         |         |          | Y = Yes |   |
|                        |         |         |          | N = No  |   |
+------------------------+---------+---------+----------+---------+---+
| Fluorescent ANA        |         |         |          | Y = Yes |   |
| (Anti-Nuclear          |         |         |          | N = No  |   |
| Anti-Body)             |         |         |          |         |   |
+------------------------+---------+---------+----------+---------+---+
| SGOT (AST) (Glutamic   |         |         |          | Y = Yes |   |
| Oxaloacetic            |         |         |          | N = No  |   |
| Transaminase)          |         |         |          |         |   |
+------------------------+---------+---------+----------+---------+---+
| SGPT (ALT)             |         |         |          | Y = Yes |   |
| (Transaminase Glutamic |         |         |          | N = No  |   |
| Pyruvate)              |         |         |          |         |   |
+------------------------+---------+---------+----------+---------+---+
| LDH (Lactic Acid       |         |         |          | Y = Yes |   |
| Hydroganese)           |         |         |          | N = No  |   |
+------------------------+---------+---------+----------+---------+---+
| Alkaline Phosphatase   |         |         |          | Y = Yes |   |
|                        |         |         |          | N = No  |   |
+------------------------+---------+---------+----------+---------+---+
| CPK (Creatine          |         |         |          | Y = Yes |   |
| Phosphokinase)         |         |         |          | N = No  |   |
+------------------------+---------+---------+----------+---------+---+
| Hepatitis B Surface    |         |         |          | Y = Yes |   |
| Antibody               |         |         |          | N = No  |   |
+------------------------+---------+---------+----------+---------+---+
| Hepatitis B Core       |         |         |          | Y = Yes |   |
| Antigen                |         |         |          | N = No  |   |
+------------------------+---------+---------+----------+---------+---+
| VDRL (Venereal Disease |         |         |          | Y = Yes |   |
| Research Laboratory)   |         |         |          | N = No  |   |
+------------------------+---------+---------+----------+---------+---+
| Vitamin B-12           |         |         |          | Y = Yes |   |
|                        |         |         |          | N = No  |   |
+------------------------+---------+---------+----------+---------+---+
| Folate                 |         |         |          | Y = Yes |   |
|                        |         |         |          | N = No  |   |
+------------------------+---------+---------+----------+---------+---+
| HIV (Human             |         |         |          | Y = Yes |   |
| Immuno-Deficiency)     |         |         |          | N = No  |   |
+------------------------+---------+---------+----------+---------+---+
| T4 (Thyroxine Total    |         |         |          | Y = Yes |   |
| Serum)                 |         |         |          | N = No  |   |
+------------------------+---------+---------+----------+---------+---+
| TSH (Thyroid           |         |         |          | Y = Yes |   |
| Stimulating Hormone)   |         |         |          | N = No  |   |
+------------------------+---------+---------+----------+---------+---+

+--------------------------------------------------------+---------+---+
| # Other Tests                                          |         |   |
+--------------------------------------------------------+---------+---+
| Urinalysis                                             | Y = Yes |   |
|                                                        | N = No  |   |
+--------------------------------------------------------+---------+---+
| TB Skin Test (PPD) (Tuberculosis Skin Test Purified    | Y = Yes |   |
| Derivative)                                            | N = No  |   |
+--------------------------------------------------------+---------+---+
| Chest X-Ray                                            | Y = Yes |   |
|                                                        | N = No  |   |
+--------------------------------------------------------+---------+---+
| Psychiatric Evaluation                                 | Y = Yes |   |
|                                                        | N = No  |   |
+--------------------------------------------------------+---------+---+
| SCID for DSM-IV (Fourth Edition) (Structured Clinical  | Y = Yes |   |
| Interview for Diagnosis)                               | N = No  |   |
+--------------------------------------------------------+---------+---+
| CAPS (Clinician Administered Post-Traumatic Stress     | Y = Yes |   |
| Disorder Scale)                                        | N = No  |   |
+--------------------------------------------------------+---------+---+
| # Consultations                                        |         |   |
+--------------------------------------------------------+---------+---+
| Neuropsychology test                                   | Y = Yes |   |
|                                                        | N = No  |   |
+--------------------------------------------------------+---------+---+
| Infectious Disease Screening Exam                      | Y = Yes |   |
|                                                        | N = No  |   |
+--------------------------------------------------------+---------+---+
| Dental Exam                                            | Y = Yes |   |
|                                                        | N = No  |   |
+--------------------------------------------------------+---------+---+
| GI (Gastrointestinal) consult                          | Y = Yes |   |
|                                                        | N = No  |   |
+--------------------------------------------------------+---------+---+
| **Headache and/or Memory Loss**                        |         |   |
+--------------------------------------------------------+---------+---+
| Neurology consult (Headache and/or Memory Loss)        | Y = Yes |   |
|                                                        | N = No  |   |
+--------------------------------------------------------+---------+---+
| **Muscle Aches and/or Numbness**                       |         |   |
+--------------------------------------------------------+---------+---+
| Neurology consult (Muscle Aches and/or Numbness)       | Y = Yes |   |
|                                                        | N = No  |   |
+--------------------------------------------------------+---------+---+
| **Chronic Fatigue**                                    |         |   |
+--------------------------------------------------------+---------+---+
| Chronic Fatigue                                        | Y = Yes |   |
|                                                        | N = No  |   |
+--------------------------------------------------------+---------+---+
| **Joint Pain**                                         |         |   |
+--------------------------------------------------------+---------+---+
| Rheumatology consult                                   | Y = Yes |   |
|                                                        | N = No  |   |
+--------------------------------------------------------+---------+---+
| **Chronic cough and /or Shortness of Breath**          |         |   |
+--------------------------------------------------------+---------+---+
| Pulmonary consult                                      | Y = Yes |   |
|                                                        | N = No  |   |
+--------------------------------------------------------+---------+---+
| **Skin Rash**                                          |         |   |
+--------------------------------------------------------+---------+---+
| Dermatology consult                                    | Y = Yes |   |
|                                                        | N = No  |   |
+--------------------------------------------------------+---------+---+
| **Vertigo and/or Tinnitus**                            |         |   |
+--------------------------------------------------------+---------+---+
| Audiology consult                                      | Y = Yes |   |
|                                                        | N = No  |   |
+--------------------------------------------------------+---------+---+
| **Cardiology**                                         |         |   |
+--------------------------------------------------------+---------+---+
| Cardiology consult                                     | Y = Yes |   |
|                                                        | N = No  |   |
+--------------------------------------------------------+---------+---+
| **Reproductive Concerns**                              |         |   |
+--------------------------------------------------------+---------+---+
| Urology consult                                        | Y = Yes |   |
|                                                        | N = No  |   |
+--------------------------------------------------------+---------+---+
| GYN consult                                            | Y = Yes |   |
|                                                        | N = No  |   |
+--------------------------------------------------------+---------+---+

+--------------------------------------------------------+---+-----+---+
| # Diagnoses                                            |   |     |   |
+--------------------------------------------------------+---+-----+---+
| Description                                            |   | IC  |   |
|                                                        |   | D-9 |   |
|                                                        |   | C   |   |
|                                                        |   | ode |   |
+--------------------------------------------------------+---+-----+---+
|                                                        |   |     |   |
+--------------------------------------------------------+---+-----+---+
|                                                        |   |     |   |
+--------------------------------------------------------+---+-----+---+
|                                                        |   |     |   |
+--------------------------------------------------------+---+-----+---+
|                                                        |   |     |   |
+--------------------------------------------------------+---+-----+---+
|                                                        |   |     |   |
+--------------------------------------------------------+---+-----+---+
|                                                        |   |     |   |
+--------------------------------------------------------+---+-----+---+
|                                                        |   |     |   |
+--------------------------------------------------------+---+-----+---+
|                                                        |   |     |   |
+--------------------------------------------------------+---+-----+---+
|                                                        |   |     |   |
+--------------------------------------------------------+---+-----+---+
|                                                        |   |     |   |
+--------------------------------------------------------+---+-----+---+
|                                                        |   |     |   |
+--------------------------------------------------------+---+-----+---+
|                                                        |   |     |   |
+--------------------------------------------------------+---+-----+---+
|                                                        |   |     |   |
+--------------------------------------------------------+---+-----+---+
|                                                        |   |     |   |
+--------------------------------------------------------+---+-----+---+
|                                                        |   |     |   |
+--------------------------------------------------------+---+-----+---+
|                                                        |   |     |   |
+--------------------------------------------------------+---+-----+---+
|                                                        |   |     |   |
+--------------------------------------------------------+---+-----+---+
|                                                        |   |     |   |
+--------------------------------------------------------+---+-----+---+
|                                                        |   |     |   |
+--------------------------------------------------------+---+-----+---+
|                                                        |   |     |   |
+--------------------------------------------------------+---+-----+---+
|                                                        |   |     |   |
+--------------------------------------------------------+---+-----+---+
|                                                        |   |     |   |
+--------------------------------------------------------+---+-----+---+
|                                                        |   |     |   |
+--------------------------------------------------------+---+-----+---+
|                                                        |   |     |   |
+--------------------------------------------------------+---+-----+---+
| # Unexplained Illness                                  |   |     |   |
+--------------------------------------------------------+---+-----+---+
| After completing Phase II, Uniform Case Assessment     | Y |     |   |
| Protocol, the physician feels that the veteran has an  | = |     |   |
| unexplained illness?                                   | Y |     |   |
|                                                        | e |     |   |
|                                                        | s |     |   |
|                                                        | N |     |   |
|                                                        | = |     |   |
|                                                        | N |     |   |
|                                                        | o |     |   |
+--------------------------------------------------------+---+-----+---+