DVBCWCI2 ;ALB/JER-PROTOCOL EXAMINATION HISTORY FOR COLD INJURIES ;14 MARCH 2003 ;;2.7;AMIE;**52**;APR 10, 1995 TXT ; ;; ;; ATTACHMENT B ;; ;; PROTOCOL EXAMINATION HISTORY FOR COLD INJURIES ;; ;; Age at present______________ ;; ;; Age at time of cold injury________________ ;; ;;CIRCUMSTANCES OF INJURY ;;_______________________ ;;1. WHERE WERE YOU WHEN YOU SUFFERED A COLD INJURY? ;; ;; ;;2. TYPE OF COLD INJURY (IF YOU KNOW) ;;frostbite __ ;;frostnip __ ;;frozen feet __ ;;trenchfoot __ ;;immersion foot __ ;;other (specify) ____________________________ ;;3. PARTS OF BODY AFFECTED BY COLD INJURY ;;hands ;; left __ ;; right __ ;;feet ;; left __ ;; right __ ;;ears ;; left __ ;; right __ ;;cheeks ;; left __ ;; right __ ;;temples ;; left __ ;; right __ ;;nose __ ;;other (specify)______________________________ ;;4. WHAT WAS THE APPROXIMATE DATE OF YOUR COLD INJURY? ;;___________________________ ;;5. WHAT WERE THE CONDITIONS AT THE TIME OF THE INJURY? ;; Weather_________________________________ ;; Temperature_____________________________ ;; Length of your exposure ;; minutes __ ;; hours __ ;; days __ ;; weeks __ ;; Wet or dry______________________________ ;; Activity of unit at time of exposure______________________________ ;;6. HOW DID YOU BECOME AWARE THAT YOU HAD SUFFERED A COLD INJURY? ;; ;; ;;7. WHAT WERE YOUR SYMPTOMS AT THE TIME OF THE INJURY? ;; pain ___ ;; swelling ___ ;; discoloration-white,red,blue,black ___ ;; blisters ___ ;; tissue loss, loss of toes or fingers or parts of them ___ ;; numbness, tingling ___ ;; stiffness ___ ;; weakness ___ ;; other (specify) ____________________________________ ;; ;;TREATMENT ;;_________ ;;8. DID YOU SEEK OR RECEIVE TREATMENT AT THE TIME OF THE INJURY? ;; yes __ no __ ;;If yes ;; Where were you treated? ;; Hospital yes __ no __ ;; Aid station yes __ no __ ;; In the field yes __ no __ ;; Other (specify) ___________________________ ;; If hospitalized, where and for how long?________________________ ;; ________________________________________________________________ ;; Who treated you? ;; Doctor yes ___ no __ ;; Nurse yes ___ no __ ;; Medic yes ___ no __ ;; Comrades yes ___ no __ ;; Self yes ___ no __ ;; Other (specify) _______________________________ ;; How were you treated? ;; Bedrest yes ___ no __ ;; Surgery yes ___ no __ ;; Medicines yes ___ no __ ;; Other (specify) yes _________________________ ;; No treatment yes ___ no __ ;;9. AFTER YOUR COLD INJURY, WERE YOU RELIEVED FROM DUTY? ;; yes ___ no __ ;; If yes, did you return to duty? ;; yes ___ no __ ;; If yes, how long after the injury? ;; hours ___ ;; days ___ ;; weeks ___ ;; months ___ ;; other (specify) ____________________________ ;;10. THE ACUTE INJURY ;; How long did the symptoms last? ;; hours ___ ;; days ___ ;; weeks ___ ;; months ___ ;; other (specify) ____________________________ ;; Did the appearance of injured parts return to normal? ;; yes ___ no __ ;; If yes, how long did that take? ;; hours ___ ;; days ___ ;; weeks ___ ;; months ___ ;; other (specify) _________________________________ ;; Were you left with any scars? ;; yes ___ no ___ ;; If yes, where? Please describe_______________________________ ;;11. DID OTHERS IN YOUR UNIT ALSO HAVE COLD INJURIES? ;; yes ___ no ___ ;; If yes, how many?_________________ ;; What type of problems did they have? ;; ;; ;;12. HAVE YOU HAD ANY OTHER COLD INJURIES? ;; yes ___ no ___ ;; If yes: ;; In service ___ ;; Before service ___ ;; After service ___ ;; Please describe. ;; ;; ;;13. DID ANY SYMPTOMS REMAIN AFTER THE INJURED PART WAS HEALED? ;; If yes: ;; a. Pain ___ ;; when ;; all the time ___ ;; worse in cold weather ___ ;; worse at night ___ ;; other (specify) ___________________ ;; where ;; tips of fingers or toes ___ ;; in joints of fingers or toes ___ ;; in arches of feet ___ ;; in legs ___ ;; all over affected parts ___ ;; other (specify) ___________________ ;; Type of pain ;; sharp ___ ;; dull ___ ;; burning ___ ;; heaviness ___ ;; other (specify) ___________________ ;; b. Numbness ___ ;; c. Tingling or pins and needles feeling ___ ;; d. Weakness of hands, feet, legs ___ ;; e, Swelling ___ ;; f. Changes in color of affected parts ___ ;; g. Sensitive to cold ___ ;; h. Excessive sweating of feet or ;; other affected parts ___ ;; i. Fungus infection (athlete's foot, for ;; example) ___ ;; j. Ulcers of injured parts ___ ;; k. Misshapen nails ___ ;; l. Breakdown of skin of injured parts ___ ;; m. Decrease or loss of sensation ___ ;; n. Change in thickness of skin of affected ;; parts (thicker or thinner) ___ ;; o. Skin cancer diagnosed in affected area ___ ;; p. Arthritis diagnosed in affected area ___ ;; q. Other (specify) ______________________________ ;; ;;AFTER SERVICE ;;_____________ ;;14. DID YOU TAKE ANY SPECIAL PRECAUTIONS OR MAKE CHANGES IN YOUR LIFE ;;OR LIFESTYLE AFTER SERVICE SPECIFICALLY BECAUSE OF THE COLD INJURY? ;;PLEASE EXPLAIN. ;; ;; ;;15. OCCUPATIONAL EFFECTS ;; What was your occupation prior to service? ;; ;; How long did you have that job? ;; ;; What was your occupation after service? ;; ;; How long did you have that job? ;; ;; Did the cold injury have any effect on your work? ;; yes ___ no ___ ;; If yes, what was the effect? ;; ;; ;;16. TREATMENT AFTER SERVICE ;; Did you receive any treatment after service for problems that you ;; felt were related to the cold injury? ;; yes ___ no ___ ;; If yes, what were you treated for? ;; ;; Where were you treated? ;; ;; When? ;; ;;CURRENT SITUATION AND TREATMENT ;;_______________________________ ;;17. HAVE YOU DISCUSSED YOUR COLD INJURY WITH YOUR CURRENT DOCTORS? ;; yes ___ no ___ ;; If yes, have they recommended or prescribed any treatment, special ;; foot care, etc.? ;; yes ___ no ___ ;;18. ARE YOU RECEIVING ANY TREATMENT NOW FOR PROBLEMS YOU BELIEVE ARE ;;RELATED TO THE COLD INJURY? ;; yes ___ no ___ ;; What is the treatment? ;; ;; ;; Where are you being treated? ;; ;; ;;19. WHAT DO YOU BELIEVE IS THE MAJOR PROBLEM YOUR COLD INJURY IS ;;CAUSING YOU NOW? ;; ;; ;; ;;20. IS THERE ANYTHING ELSE YOU WOULD LIKE US TO KNOW ABOUT YOUR COLD ;;INJURY OR ITS AFTEREFFECTS? ;; yes ___ no ___ ;; If yes, please explain. ;; ;; ;;21. ARE THERE ANY QUESTIONS YOU HAVE FOR YOUR DOCTOR ABOUT THE ;;EFFECTS OF YOUR COLD INJURY ;; yes ___ no ___ ;; If yes, please explain. ;; ;; ;; ;; ;;22. HOW WOULD YOU DESCRIBE YOUR OVERALL STATE OF HEALTH AT PRESENT? ;; ;; Briefly describe any problems you have other than the effects of cold injury. ;; ;; ;; ;; ;; Signed:______________________________________Date:_______________ ;;END