BURN PITS 360 - Burn Pit Registry
BURN PITS 360  - Company Message











REGISTRY
Name of person affected by Burn Pit Toxins
Are You Registering Yourself Or Someone Else
Is This A Death Entry
Yes
No
Date of Death
Cause Of Death
Age
Date Of Birth
Telephone Number
Email
Address
Military Service Branch
ARMY
MARINES
NAVY
AIRFORCE
COAST GUARD
Current Military Status
Active Duty
Retired
Reservist
Deployment Military Base/FOB/COP
How Far Did You Live From The Burn Pits (miles or meters)
How Far Did You Work From The Burn Pits (miles or meters)
Active Duty Tour Year (LIST START & SEPARATION DATES FOR ALL TOURS)
Status During Tour
Was Pre Deployment Health Exam Normal
Yes
No
Did You Work Directly At The Burn Pits
Yes
No
Were You Given A Mask
Yes
No
Current Health Care Providers/Facilities
Lung Biopsy Performed
Physician & Facility That Performed Lung Biopsy
Are You On Oxygen
Yes
No
How Often Are You On Oxygen
24 hours a day
As Needed
Other
Have You Had A PFT (Pulmonary Function Test)
Yes
No
When Did Symptoms and Illnesses Begin
Symptoms & Diagnosis
Constrictive Bronchiolitis
Sleep Apnea
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
Chest Pain
Memory Loss
Fatigue
Chronic Cough
Choking Spasms
GI Bleeding
Low Vitamin D Level
Low Testosterone Level
Infertility
Intestinal Parasite Infections
Skin Lesions/Rashes
Headaches
Gallbladder Removal
Weight Loss
dyspnea (difficult or labored breathing)
Paralysis
Diarrhea
Lupus
Acid Reflux, Heartburn, Indigestion
Blurred / Impaired Vision
Fibromyalgia
Polyps
Wheezing
Sinus Problems
Hematuria (Blood In Urine)
Heart Disease
Other Symptoms of Illnesses (Please list anything not already included)
Cancer Diagnosis
Yes
No
Active
Remission
Deceased
Date Of Cancer Diagnosis
Types of Cancers
AML-Acute Myeloid Leukemia
Anaplastic Astrocytoma
Bladder
Blood
Bone / Bone Marrow
Brain
Brain Neoplastic Astrocytoma
Breast
Cervix
CML - Chronic Myelogenous Leukemia
Colon
Esophagus
GallBladder
Gastroesophageal Carcinoma
Glioblastoma
Hepatoid Adenocarcinoma
Hodgkins Lymphoma
Kidney
Large Cell Lymphoma
Larynx-Windpipe
Leukemia
Liver
Lung
Lymphoma
Lymphoblastic Lymphoma
Meningioma (Brain Tumor)
Mouth/Tounge/Lip
Neuroendocrine Carcinoma
Non Hodgkins Diffuse Large Cell Lymphoma
Ovary
Pancreas
Prostate
Rectum
Renal Cell Carcinoma
Skin (Melanoma)
Skin (Non-Melanoma)
Soft Tissue
Stomach
Synovial Sarcoma
Testicular
Throat-Pharynx
Thyroid
Uterus
Other
Cancer type Not Listed
Have You Ever Smoked
Yes
No
If Yes How Many Years Did You Smoke
If Yes How Many Packs Per Day
Do You Still Smoke
Yes
No
How Many Years Since You Stopped Smoking
Are You Receiving Service Connected Compensation For Burn Pit Exposures?
Yes
No
Was Your VA Compensation Claim Denied
Services/Assistance Needed
Legal Services
Compensation/ Disability Benefits
Death Benefits
Caregiver Benefits
Services needed, not listed
 
 Please be sure to also register for the VA National Burn Pit Registry @ https://veteran.mobilehealth.va.gov/AHBurnPitRegistry/#page/home 
 
 
 
 
 
 
 
 
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