Headache history form fbb/FB



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DX ______ TBI/HEADACHE Questionnaire WAMC UI#

______ DATE SEEN __/__/__

______ HEADACHE HISTORY FORM FBB/FB





DEMOGRAPHICS

NAME:


AGE:

RANK:

SEX: Female Male

RACE: African American Native American Asian American Caucasian Hispanic Other

MOS:

State of Origin:

Highest Educational Level Completed:

School grade: 6 7 8 9 10 11 12

GED HS Some College College Degree Masters Degree Professional Degree


Marital Status:

Single Married Separated Divorced Widow Other












MILITARY HISTORY

ENTRY YEAR:

Deployments 0 1 2 3 4 5 6 7 8 9 10 other ____

Panama Kosovo Desert Storm OIF 1 OEF OIF 2 other




INJURIES or MAJOR EVENTS




#1 Date of injury:

BLAST (TYPE): IED MORTAR ROCKET LANDMINE OTHER

JUMP MOTOR VEHICLE ACCIDENT FALL FIGHT

OTHER: PENETRATING

#2 Date of injury:

BLAST (TYPE): IED MORTAR ROCKET LANDMINE OTHER

JUMP MOTOR VEHICLE ACCIDENT FALL FIGHT

OTHER: PENETRATING

#3 Date of injury:

BLAST (TYPE): IED MORTAR ROCKET LANDMINE OTHER

JUMP MOTOR VEHICLE ACCIDENT FALL FIGHT

OTHER: PENETRATING

#4 Date of injury:

BLAST (TYPE): IED MORTAR ROCKET LANDMINE OTHER

JUMP MOTOR VEHICLE ACCIDENT FALL FIGHT

OTHER: PENETRATING

Many soldiers have been exposed to blasts without getting very hurt, though they felt them. Estimate how many blasts you REALLY felt ______




How many strong blasts HAVE YOU FELT (rocked, bell rung, nauseas, dizzy, headache) at distances:

less than 10 m_______________

less than 50 m_______________



For SIGNIFICANT OR SIGNATURE mounted blasts please mark on the drawing where you were sitting and where the blast came from (number them 1, 2 3, etc. for the ones above). You can mark more than oneā€¦or if you were unmounted, you could draw a picture below
PAST HISTORY OF HEADACHE PLEASE ANSWER THESE QUESTIONS ABOUT YOUR PAST HISTORY OF HEADACHE BEFORE JOINING THE MILIATRY
questions

YES

NO

Explanation

(If yes put details here)



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