A publication of Vietnam Veterans of America, Inc. ®
An organization chartered by the U.S. Congress

February 1999/March 1999

Women Veterans Committee Report

Women's Health Study

Conducted By The VVA National Agent Orange/Dioxin Committee

This committee has elected to gather information regarding the health problems of the wives and significant others of Vietnam veterans and the female veterans who were in Vietnam and exposed to Agent Orange (the study group).  We also need to gather the same information from women who have not been married to or had an intimate relationship with an in-country Vietnam veteran (the control group).

If the response from this survey is large enough, we will use the statistics as a tool to request an indepth scientific health study.  Please take a few minutes to answer our questions and return the form to the address listed below.

Did you serve in the military:  [ ] Yes     [ ] No
 
    In Vietnam/Era:                 [ ] Yes     [ ] No    If so when 
 
    What branch of military

DOB:            /       /           (optional)

Was your spouse/significant other in Vietnam/Era: [ ] Yes     [ ]No
 
    If so, when                                      What branch of military                                  

    How long have you been with your veteran?                                         (approximately)

Do you have or have you ever had any of the following conditions?
 
When Diagnosed At What Age
Cervical Cancer [ ] Yes [ ] No         
Ovarian Cancer [ ] Yes [ ] No    
Uterine Cancer [ ] Yes [ ] No    
Vaginal Cancer [ ] Yes [ ] No    
Fallopian Tube Cancer [ ] Yes [ ] No    
Ovarian Cysts [ ] Yes [ ] No    
Fibroid Tumors [ ] Yes [ ] No    
Endometriosis [ ] Yes [ ] No    
Chronic Yeast Infections [ ] Yes [ ] No    
Chronic Yeast Infections [ ] Yes [ ] No    
Chronic Urinary Tract Infections [ ] Yes [ ] No    
Ectopic Pregnancies [ ] Yes [ ] No    
Miscarriages, If so how many? [ ] Yes [ ] No    
Infant Death [ ] Yes [ ] No    
Children w/Birth defects [ ] Yes [ ] No    
Children w/Learning disabilities [ ] Yes [ ] No    
Rheumatoid Arthritis [ ] Yes [ ] No    
Lupus [ ] Yes [ ] No    
Other  [ ] Yes [ ] No    
Thyroid Problems [ ] Yes [ ] No    
Metabolism Problems [ ] Yes [ ] No    
Diabetes (high blood sugar) [ ] Yes [ ] No    
Hypoglycemia (low blood sugar) [ ] Yes [ ] No    
Hormonal Disorders [ ] Yes [ ] No    
Any Neuromuscular Problems? [ ] Yes [ ] No    
Family history of cancer? [ ] Yes [ ] No    
 
Release of Information:

    By signing this release of information, I understand that the information contained herein is to be used for scientific purposes only and permit the disclosure of its contents to the appropriate research facility.
 

                                                                                                                                                              
Name                                                                                                                                            Telephone Number

 

                                                                                                                                                               
Address
 

                                                                                                                                                               
City                                                                                                                   State                                           Zip Code
 

May we contact you in the event we need further information?  [ ] Yes   [ ] No
 

                                                                                                                                                              
Your Signature
 
 

Thank you for participating in this. Please send to:
Vietnam Veterans of America, Inc.
 

Ms. Tonya Lowrey
 
8719 Colesville Road, Suite 100, Suite 400
Silver Spring, Maryland  20910-3710

 
(If additional space for comments is needed, please attach separate paper)
 
 
  

E-mail us at feedback@vva.org
 

     Home | Membership | Publications | Events | Government Relations | Contact Us
Press Releases | Benefits | Meetings & Special Events | Collectibles | Contributions and Sponsorships | Site Index

Vietnam Veterans of America  
8719 Colesville Road, Suite 100, Suite 400
Silver Spring, Maryland  20910-3710
301-585-4000, Fax 301-585-0519, 1-800-VVA-1316  

Copyright 2005 by the Vietnam Veterans of America. All rights reserved.