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[613]1DVBCWCI2 ;ALB/JER-PROTOCOL EXAMINATION HISTORY FOR COLD INJURIES ;14 MARCH 2003
2 ;;2.7;AMIE;**52**;APR 10, 1995
3TXT ;
4 ;;
5 ;; ATTACHMENT B
6 ;;
7 ;; PROTOCOL EXAMINATION HISTORY FOR COLD INJURIES
8 ;;
9 ;; Age at present______________
10 ;;
11 ;; Age at time of cold injury________________
12 ;;
13 ;;CIRCUMSTANCES OF INJURY
14 ;;_______________________
15 ;;1. WHERE WERE YOU WHEN YOU SUFFERED A COLD INJURY?
16 ;;
17 ;;
18 ;;2. TYPE OF COLD INJURY (IF YOU KNOW)
19 ;;frostbite __
20 ;;frostnip __
21 ;;frozen feet __
22 ;;trenchfoot __
23 ;;immersion foot __
24 ;;other (specify) ____________________________
25 ;;3. PARTS OF BODY AFFECTED BY COLD INJURY
26 ;;hands
27 ;; left __
28 ;; right __
29 ;;feet
30 ;; left __
31 ;; right __
32 ;;ears
33 ;; left __
34 ;; right __
35 ;;cheeks
36 ;; left __
37 ;; right __
38 ;;temples
39 ;; left __
40 ;; right __
41 ;;nose __
42 ;;other (specify)______________________________
43 ;;4. WHAT WAS THE APPROXIMATE DATE OF YOUR COLD INJURY?
44 ;;___________________________
45 ;;5. WHAT WERE THE CONDITIONS AT THE TIME OF THE INJURY?
46 ;; Weather_________________________________
47 ;; Temperature_____________________________
48 ;; Length of your exposure
49 ;; minutes __
50 ;; hours __
51 ;; days __
52 ;; weeks __
53 ;; Wet or dry______________________________
54 ;; Activity of unit at time of exposure______________________________
55 ;;6. HOW DID YOU BECOME AWARE THAT YOU HAD SUFFERED A COLD INJURY?
56 ;;
57 ;;
58 ;;7. WHAT WERE YOUR SYMPTOMS AT THE TIME OF THE INJURY?
59 ;; pain ___
60 ;; swelling ___
61 ;; discoloration-white,red,blue,black ___
62 ;; blisters ___
63 ;; tissue loss, loss of toes or fingers or parts of them ___
64 ;; numbness, tingling ___
65 ;; stiffness ___
66 ;; weakness ___
67 ;; other (specify) ____________________________________
68 ;;
69 ;;TREATMENT
70 ;;_________
71 ;;8. DID YOU SEEK OR RECEIVE TREATMENT AT THE TIME OF THE INJURY?
72 ;; yes __ no __
73 ;;If yes
74 ;; Where were you treated?
75 ;; Hospital yes __ no __
76 ;; Aid station yes __ no __
77 ;; In the field yes __ no __
78 ;; Other (specify) ___________________________
79 ;; If hospitalized, where and for how long?________________________
80 ;; ________________________________________________________________
81 ;; Who treated you?
82 ;; Doctor yes ___ no __
83 ;; Nurse yes ___ no __
84 ;; Medic yes ___ no __
85 ;; Comrades yes ___ no __
86 ;; Self yes ___ no __
87 ;; Other (specify) _______________________________
88 ;; How were you treated?
89 ;; Bedrest yes ___ no __
90 ;; Surgery yes ___ no __
91 ;; Medicines yes ___ no __
92 ;; Other (specify) yes _________________________
93 ;; No treatment yes ___ no __
94 ;;9. AFTER YOUR COLD INJURY, WERE YOU RELIEVED FROM DUTY?
95 ;; yes ___ no __
96 ;; If yes, did you return to duty?
97 ;; yes ___ no __
98 ;; If yes, how long after the injury?
99 ;; hours ___
100 ;; days ___
101 ;; weeks ___
102 ;; months ___
103 ;; other (specify) ____________________________
104 ;;10. THE ACUTE INJURY
105 ;; How long did the symptoms last?
106 ;; hours ___
107 ;; days ___
108 ;; weeks ___
109 ;; months ___
110 ;; other (specify) ____________________________
111 ;; Did the appearance of injured parts return to normal?
112 ;; yes ___ no __
113 ;; If yes, how long did that take?
114 ;; hours ___
115 ;; days ___
116 ;; weeks ___
117 ;; months ___
118 ;; other (specify) _________________________________
119 ;; Were you left with any scars?
120 ;; yes ___ no ___
121 ;; If yes, where? Please describe_______________________________
122 ;;11. DID OTHERS IN YOUR UNIT ALSO HAVE COLD INJURIES?
123 ;; yes ___ no ___
124 ;; If yes, how many?_________________
125 ;; What type of problems did they have?
126 ;;
127 ;;
128 ;;12. HAVE YOU HAD ANY OTHER COLD INJURIES?
129 ;; yes ___ no ___
130 ;; If yes:
131 ;; In service ___
132 ;; Before service ___
133 ;; After service ___
134 ;; Please describe.
135 ;;
136 ;;
137 ;;13. DID ANY SYMPTOMS REMAIN AFTER THE INJURED PART WAS HEALED?
138 ;; If yes:
139 ;; a. Pain ___
140 ;; when
141 ;; all the time ___
142 ;; worse in cold weather ___
143 ;; worse at night ___
144 ;; other (specify) ___________________
145 ;; where
146 ;; tips of fingers or toes ___
147 ;; in joints of fingers or toes ___
148 ;; in arches of feet ___
149 ;; in legs ___
150 ;; all over affected parts ___
151 ;; other (specify) ___________________
152 ;; Type of pain
153 ;; sharp ___
154 ;; dull ___
155 ;; burning ___
156 ;; heaviness ___
157 ;; other (specify) ___________________
158 ;; b. Numbness ___
159 ;; c. Tingling or pins and needles feeling ___
160 ;; d. Weakness of hands, feet, legs ___
161 ;; e, Swelling ___
162 ;; f. Changes in color of affected parts ___
163 ;; g. Sensitive to cold ___
164 ;; h. Excessive sweating of feet or
165 ;; other affected parts ___
166 ;; i. Fungus infection (athlete's foot, for
167 ;; example) ___
168 ;; j. Ulcers of injured parts ___
169 ;; k. Misshapen nails ___
170 ;; l. Breakdown of skin of injured parts ___
171 ;; m. Decrease or loss of sensation ___
172 ;; n. Change in thickness of skin of affected
173 ;; parts (thicker or thinner) ___
174 ;; o. Skin cancer diagnosed in affected area ___
175 ;; p. Arthritis diagnosed in affected area ___
176 ;; q. Other (specify) ______________________________
177 ;;
178 ;;AFTER SERVICE
179 ;;_____________
180 ;;14. DID YOU TAKE ANY SPECIAL PRECAUTIONS OR MAKE CHANGES IN YOUR LIFE
181 ;;OR LIFESTYLE AFTER SERVICE SPECIFICALLY BECAUSE OF THE COLD INJURY?
182 ;;PLEASE EXPLAIN.
183 ;;
184 ;;
185 ;;15. OCCUPATIONAL EFFECTS
186 ;; What was your occupation prior to service?
187 ;;
188 ;; How long did you have that job?
189 ;;
190 ;; What was your occupation after service?
191 ;;
192 ;; How long did you have that job?
193 ;;
194 ;; Did the cold injury have any effect on your work?
195 ;; yes ___ no ___
196 ;; If yes, what was the effect?
197 ;;
198 ;;
199 ;;16. TREATMENT AFTER SERVICE
200 ;; Did you receive any treatment after service for problems that you
201 ;; felt were related to the cold injury?
202 ;; yes ___ no ___
203 ;; If yes, what were you treated for?
204 ;;
205 ;; Where were you treated?
206 ;;
207 ;; When?
208 ;;
209 ;;CURRENT SITUATION AND TREATMENT
210 ;;_______________________________
211 ;;17. HAVE YOU DISCUSSED YOUR COLD INJURY WITH YOUR CURRENT DOCTORS?
212 ;; yes ___ no ___
213 ;; If yes, have they recommended or prescribed any treatment, special
214 ;; foot care, etc.?
215 ;; yes ___ no ___
216 ;;18. ARE YOU RECEIVING ANY TREATMENT NOW FOR PROBLEMS YOU BELIEVE ARE
217 ;;RELATED TO THE COLD INJURY?
218 ;; yes ___ no ___
219 ;; What is the treatment?
220 ;;
221 ;;
222 ;; Where are you being treated?
223 ;;
224 ;;
225 ;;19. WHAT DO YOU BELIEVE IS THE MAJOR PROBLEM YOUR COLD INJURY IS
226 ;;CAUSING YOU NOW?
227 ;;
228 ;;
229 ;;
230 ;;20. IS THERE ANYTHING ELSE YOU WOULD LIKE US TO KNOW ABOUT YOUR COLD
231 ;;INJURY OR ITS AFTEREFFECTS?
232 ;; yes ___ no ___
233 ;; If yes, please explain.
234 ;;
235 ;;
236 ;;21. ARE THERE ANY QUESTIONS YOU HAVE FOR YOUR DOCTOR ABOUT THE
237 ;;EFFECTS OF YOUR COLD INJURY
238 ;; yes ___ no ___
239 ;; If yes, please explain.
240 ;;
241 ;;
242 ;;
243 ;;
244 ;;22. HOW WOULD YOU DESCRIBE YOUR OVERALL STATE OF HEALTH AT PRESENT?
245 ;;
246 ;; Briefly describe any problems you have other than the effects of cold injury.
247 ;;
248 ;;
249 ;;
250 ;;
251 ;; Signed:______________________________________Date:_______________
252 ;;END
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