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
--- Routine Detail --- with STRUCTURED ROUTINE LISTING ---[H[J[2J[HDVBCWCI2 9977 printed Oct 16, 2024@17:50:51 Page 2
DVBCWCI2 ;ALB/JER-PROTOCOL EXAMINATION HISTORY FOR COLD INJURIES ;14 MARCH 2003
+1 ;;2.7;AMIE;**52**;APR 10, 1995
TXT ;
+1 ;;
+2 ;; ATTACHMENT B
+3 ;;
+4 ;; PROTOCOL EXAMINATION HISTORY FOR COLD INJURIES
+5 ;;
+6 ;; Age at present______________
+7 ;;
+8 ;; Age at time of cold injury________________
+9 ;;
+10 ;;CIRCUMSTANCES OF INJURY
+11 ;;_______________________
+12 ;;1. WHERE WERE YOU WHEN YOU SUFFERED A COLD INJURY?
+13 ;;
+14 ;;
+15 ;;2. TYPE OF COLD INJURY (IF YOU KNOW)
+16 ;;frostbite __
+17 ;;frostnip __
+18 ;;frozen feet __
+19 ;;trenchfoot __
+20 ;;immersion foot __
+21 ;;other (specify) ____________________________
+22 ;;3. PARTS OF BODY AFFECTED BY COLD INJURY
+23 ;;hands
+24 ;; left __
+25 ;; right __
+26 ;;feet
+27 ;; left __
+28 ;; right __
+29 ;;ears
+30 ;; left __
+31 ;; right __
+32 ;;cheeks
+33 ;; left __
+34 ;; right __
+35 ;;temples
+36 ;; left __
+37 ;; right __
+38 ;;nose __
+39 ;;other (specify)______________________________
+40 ;;4. WHAT WAS THE APPROXIMATE DATE OF YOUR COLD INJURY?
+41 ;;___________________________
+42 ;;5. WHAT WERE THE CONDITIONS AT THE TIME OF THE INJURY?
+43 ;; Weather_________________________________
+44 ;; Temperature_____________________________
+45 ;; Length of your exposure
+46 ;; minutes __
+47 ;; hours __
+48 ;; days __
+49 ;; weeks __
+50 ;; Wet or dry______________________________
+51 ;; Activity of unit at time of exposure______________________________
+52 ;;6. HOW DID YOU BECOME AWARE THAT YOU HAD SUFFERED A COLD INJURY?
+53 ;;
+54 ;;
+55 ;;7. WHAT WERE YOUR SYMPTOMS AT THE TIME OF THE INJURY?
+56 ;; pain ___
+57 ;; swelling ___
+58 ;; discoloration-white,red,blue,black ___
+59 ;; blisters ___
+60 ;; tissue loss, loss of toes or fingers or parts of them ___
+61 ;; numbness, tingling ___
+62 ;; stiffness ___
+63 ;; weakness ___
+64 ;; other (specify) ____________________________________
+65 ;;
+66 ;;TREATMENT
+67 ;;_________
+68 ;;8. DID YOU SEEK OR RECEIVE TREATMENT AT THE TIME OF THE INJURY?
+69 ;; yes __ no __
+70 ;;If yes
+71 ;; Where were you treated?
+72 ;; Hospital yes __ no __
+73 ;; Aid station yes __ no __
+74 ;; In the field yes __ no __
+75 ;; Other (specify) ___________________________
+76 ;; If hospitalized, where and for how long?________________________
+77 ;; ________________________________________________________________
+78 ;; Who treated you?
+79 ;; Doctor yes ___ no __
+80 ;; Nurse yes ___ no __
+81 ;; Medic yes ___ no __
+82 ;; Comrades yes ___ no __
+83 ;; Self yes ___ no __
+84 ;; Other (specify) _______________________________
+85 ;; How were you treated?
+86 ;; Bedrest yes ___ no __
+87 ;; Surgery yes ___ no __
+88 ;; Medicines yes ___ no __
+89 ;; Other (specify) yes _________________________
+90 ;; No treatment yes ___ no __
+91 ;;9. AFTER YOUR COLD INJURY, WERE YOU RELIEVED FROM DUTY?
+92 ;; yes ___ no __
+93 ;; If yes, did you return to duty?
+94 ;; yes ___ no __
+95 ;; If yes, how long after the injury?
+96 ;; hours ___
+97 ;; days ___
+98 ;; weeks ___
+99 ;; months ___
+100 ;; other (specify) ____________________________
+101 ;;10. THE ACUTE INJURY
+102 ;; How long did the symptoms last?
+103 ;; hours ___
+104 ;; days ___
+105 ;; weeks ___
+106 ;; months ___
+107 ;; other (specify) ____________________________
+108 ;; Did the appearance of injured parts return to normal?
+109 ;; yes ___ no __
+110 ;; If yes, how long did that take?
+111 ;; hours ___
+112 ;; days ___
+113 ;; weeks ___
+114 ;; months ___
+115 ;; other (specify) _________________________________
+116 ;; Were you left with any scars?
+117 ;; yes ___ no ___
+118 ;; If yes, where? Please describe_______________________________
+119 ;;11. DID OTHERS IN YOUR UNIT ALSO HAVE COLD INJURIES?
+120 ;; yes ___ no ___
+121 ;; If yes, how many?_________________
+122 ;; What type of problems did they have?
+123 ;;
+124 ;;
+125 ;;12. HAVE YOU HAD ANY OTHER COLD INJURIES?
+126 ;; yes ___ no ___
+127 ;; If yes:
+128 ;; In service ___
+129 ;; Before service ___
+130 ;; After service ___
+131 ;; Please describe.
+132 ;;
+133 ;;
+134 ;;13. DID ANY SYMPTOMS REMAIN AFTER THE INJURED PART WAS HEALED?
+135 ;; If yes:
+136 ;; a. Pain ___
+137 ;; when
+138 ;; all the time ___
+139 ;; worse in cold weather ___
+140 ;; worse at night ___
+141 ;; other (specify) ___________________
+142 ;; where
+143 ;; tips of fingers or toes ___
+144 ;; in joints of fingers or toes ___
+145 ;; in arches of feet ___
+146 ;; in legs ___
+147 ;; all over affected parts ___
+148 ;; other (specify) ___________________
+149 ;; Type of pain
+150 ;; sharp ___
+151 ;; dull ___
+152 ;; burning ___
+153 ;; heaviness ___
+154 ;; other (specify) ___________________
+155 ;; b. Numbness ___
+156 ;; c. Tingling or pins and needles feeling ___
+157 ;; d. Weakness of hands, feet, legs ___
+158 ;; e, Swelling ___
+159 ;; f. Changes in color of affected parts ___
+160 ;; g. Sensitive to cold ___
+161 ;; h. Excessive sweating of feet or
+162 ;; other affected parts ___
+163 ;; i. Fungus infection (athlete's foot, for
+164 ;; example) ___
+165 ;; j. Ulcers of injured parts ___
+166 ;; k. Misshapen nails ___
+167 ;; l. Breakdown of skin of injured parts ___
+168 ;; m. Decrease or loss of sensation ___
+169 ;; n. Change in thickness of skin of affected
+170 ;; parts (thicker or thinner) ___
+171 ;; o. Skin cancer diagnosed in affected area ___
+172 ;; p. Arthritis diagnosed in affected area ___
+173 ;; q. Other (specify) ______________________________
+174 ;;
+175 ;;AFTER SERVICE
+176 ;;_____________
+177 ;;14. DID YOU TAKE ANY SPECIAL PRECAUTIONS OR MAKE CHANGES IN YOUR LIFE
+178 ;;OR LIFESTYLE AFTER SERVICE SPECIFICALLY BECAUSE OF THE COLD INJURY?
+179 ;;PLEASE EXPLAIN.
+180 ;;
+181 ;;
+182 ;;15. OCCUPATIONAL EFFECTS
+183 ;; What was your occupation prior to service?
+184 ;;
+185 ;; How long did you have that job?
+186 ;;
+187 ;; What was your occupation after service?
+188 ;;
+189 ;; How long did you have that job?
+190 ;;
+191 ;; Did the cold injury have any effect on your work?
+192 ;; yes ___ no ___
+193 ;; If yes, what was the effect?
+194 ;;
+195 ;;
+196 ;;16. TREATMENT AFTER SERVICE
+197 ;; Did you receive any treatment after service for problems that you
+198 ;; felt were related to the cold injury?
+199 ;; yes ___ no ___
+200 ;; If yes, what were you treated for?
+201 ;;
+202 ;; Where were you treated?
+203 ;;
+204 ;; When?
+205 ;;
+206 ;;CURRENT SITUATION AND TREATMENT
+207 ;;_______________________________
+208 ;;17. HAVE YOU DISCUSSED YOUR COLD INJURY WITH YOUR CURRENT DOCTORS?
+209 ;; yes ___ no ___
+210 ;; If yes, have they recommended or prescribed any treatment, special
+211 ;; foot care, etc.?
+212 ;; yes ___ no ___
+213 ;;18. ARE YOU RECEIVING ANY TREATMENT NOW FOR PROBLEMS YOU BELIEVE ARE
+214 ;;RELATED TO THE COLD INJURY?
+215 ;; yes ___ no ___
+216 ;; What is the treatment?
+217 ;;
+218 ;;
+219 ;; Where are you being treated?
+220 ;;
+221 ;;
+222 ;;19. WHAT DO YOU BELIEVE IS THE MAJOR PROBLEM YOUR COLD INJURY IS
+223 ;;CAUSING YOU NOW?
+224 ;;
+225 ;;
+226 ;;
+227 ;;20. IS THERE ANYTHING ELSE YOU WOULD LIKE US TO KNOW ABOUT YOUR COLD
+228 ;;INJURY OR ITS AFTEREFFECTS?
+229 ;; yes ___ no ___
+230 ;; If yes, please explain.
+231 ;;
+232 ;;
+233 ;;21. ARE THERE ANY QUESTIONS YOU HAVE FOR YOUR DOCTOR ABOUT THE
+234 ;;EFFECTS OF YOUR COLD INJURY
+235 ;; yes ___ no ___
+236 ;; If yes, please explain.
+237 ;;
+238 ;;
+239 ;;
+240 ;;
+241 ;;22. HOW WOULD YOU DESCRIBE YOUR OVERALL STATE OF HEALTH AT PRESENT?
+242 ;;
+243 ;; Briefly describe any problems you have other than the effects of cold injury.
+244 ;;
+245 ;;
+246 ;;
+247 ;;
+248 ;; Signed:______________________________________Date:_______________
+249 ;;END
