What is your VA disability Rating?
What Branch(es) of Military Were you In
Were you Medically Discharged?
Did you serve in the Continental U.S. Area?
This does NOT include Alaska or Hawaii
This DOES include any training or shore duty
Did you Deploy to Southwest Asia area
(Iraq, Kuwait, Saudi Arabia, Neutral Zone Between Iraq & Saudi Arabia, Bahrain, Qatar, United Arab Emirates, Oman, Gulf of Aden, Gulf of Oman, Waters of the Persian Gulf, the Arabian Sea, and the Red Sea, the Airspace above these locations)
Did you serve outside the Continental U.S. Area?
Other than Southwest Asia Theater of Military Operations
Which Vaccinations or Treatment Protocols are Recorded on your Medical Records?
How long after the Anthrax Series did you first notice symptoms?
Have you been exposed to any of the following: (Multiple Response)
In General, would you say your health is? (Select an Answer)
Do you suffer from any of the following: Neurological Issues?
Neurological Issues - Page 2
Do you suffer from any of the following: Psychological Issues?
Do you suffer from any of the following: Digestive / Gastrointestinal problems?
Do you suffer from any of the following: Excretory System Issues?
Do you suffer from any of the following: Musculoskeletal Issues?
Do you suffer from any of the following: Reproductive System Issues?
Do you suffer from any of the following: Integumentary (Skin) Issues?
Do you suffer from any of the following: Cardiovascular Issues?
Do you suffer from any of the following: Endocrine Issues?
Do you suffer from any OTHER diagnosis?
Separate multiple symptoms by a comma
Leave Blank if not
Have you ever had an Adverse Reaction to Immunization
Have you been diagnosed with Vaccine Immunoglobulin and Antisera Adverse Reaction
Have you (or your partner or spouse) had any problems with infertility, miscarriages, or still births?
Have any of your biological children been diagnosed with birth defects?
Have any of your biological children been diagnosed with other disabilities?
Anthrax vaccine lot # was FAV001