BURNPITS 360° - Burn Pit Registry
        BURNPITS 360° -     THE WAR THAT FOLLOWED US HOME
REGISTRY
Burn Pit Victim Name
Age
Telephone Number
Email
Address
Military Service Branch
ARMY
MARINES
NAVY
AIRFORCE
COAST GUARD
Military Status
Active Duty
Retired
Reservist
Military Base/FOB
Where Did You Live On Base (miles or meters)
Active Duty Tour Year (LIST START & SEPARATION DATES FOR ALL TOURS)
MOS During Tour In Iraq
Did You Work Directly At The Burn Pits
Yes
No
Were You Given A Mask
Yes
No
Where did you work (miles or meters)
Lung Biopsy Performed
Physician & Facility That Performed Lung Biopsy
Other Symptoms of Illnesses (Please list anything not already included)
Current Health Care Providers/Facilities
Are You On Oxygen
Yes
No
How Often Are You On Oxygen
24 hours a day
As Needed
Other
Legal Representation
Are You Receiving Service Connected Compensation For Burn Pit Exposures?
Yes
No
Services Needed
Cancer Diagnosis
Yes
No
Active
Remission
Deceased
Cancer-Tye Of
AML-Acute Myeloid Leukemia
Anaplastic Astrocytoma
Large Cell Lymphoma
Renal Cell Carcinoma
Squamous Cell Mouth Cancer
Hepatoid Adenocarcinoma
Hodgkins Lymphoma
Soft Tissue Sarcoma
Acute Lymphoblastic Lymphoma
Neuroendocrine Carcinoma
Gastroesophageal Carcinoma
Aplastic Anemia
Dysgerminoma (Ovarian Cancer)
Lymphatic Cancer
Meningioma (Brain Tumor)
Testicular Cancer
Breast Cancer
Glioblastoma
Agressive Aplastic Anemia
Synovial Sarcoma
CML
gastro esophageal adenocarcinoma
Non Hodgkins Diffuse Large Cell Lymphoma
Brain Neoplastic Astrocytoma

Symptoms & Diagnosis
Shortness Of Breath (MILD) JOGGING
Shortness Of Breath (MODERATE) WALK ONE BLOCK
Shortness Of Breath (SEVERE) ONE ROOM TO OTHER
High Blood Pressure
Nausea
GI Bleeding
Muscle Pain
Muscle Twitching
Joint Stiffness
Joint Pain
Abdominal Pain
Stomach Distention/Bloating
Chronic Cough
Chest Pain
Memory Loss
Fatigue
Chronic Cough
Choking Spasms
GI Bleeding
Low Vitamin D Level
Low Testosterone Level
Infertility
Intestinal Parasite Infections
Skin Lesions
Headaches
Gallbladder Removal
Weight Loss
dyspnea
Paralysis
Diarrhea
Lupus
Acid Reflux
Blurred Vision
Fibromyalgia
Polyps
Was Pre Deployment Health Exam Normal
Yes
No
Have You Had A PFT (Pulmonary Function Test)
Yes
No
Have You Ever Smoked
Yes
No
If Yes How Many Packs Per Day
How Many Years Since You Stopped Smoking
If Yes How Many Years Did You Smoke
Do You Still Smoke
Yes
No
 
 
 
 
 
 
 
 
 
 
 
 
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