This is excerpted from the VHA Gulf War Handbook.  These are the tests (from the VA healthcare protocol) which are authorized for veterans with the related conditions.  Providing you are eligible for VA care and treatment, you should review this to make sure you have been adequately evaluated for your condition(s).

March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX F
F-1
UNIFORM CASE ASSESSMENT PROTOCOL (UCAP)
1. Phase I-Level Laboratory Evaluations
a. Complete Blood Count (CBC),
b. Urinalysis, and
c. Blood Chemistry - SMA-6. (SMA is a Manufacturer’s Trademark for a Chemistry
Analyzer)
2. Phase II-Level Evaluation Protocol. Phase II-Level Evaluations are recommended for those
veterans after complete clinically-indicated evaluations are conducted and the clinician
determines that the patient has an unexplained illness. Individuals who, after completing Phase I
or registry evaluations, have a disability and do not have a clearly defined diagnosis which
explains their symptoms, must receive the following supplemental baseline laboratory tests and
consultations.
a. Supplemental Baseline Laboratory Tests
(1) CBC,
(2) Sedimentation Rate Erythrocyte Sedimentation Rate (ESR),
(3) C-Reactive Protein,
(4) Rheumatoid Factor,
(5) Anti-Nuclear Antibody (ANA),
(6) Liver Function,
(7) Creatine Phosphokinase (CPK),
(8) Hepatitis Serology,
(9) Human Immunodeficiency (HIV),
(10) Venereal Disease Research Laboratory (VDRL),
(11) B-12 and Folate,
(12) Thyroid Function Test,
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX F
F-2
(13) Urinalysis, and
(14) Tuberculosis (TB) skin test Purified Protein Derivative (PPD).
b. Consultations, to include:
(1) Dental, but only if participant’s annual screening is not done.
(2) Infectious Disease.
(3) Psychiatry, but only with physician-administered instruments.
(a) Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental
Disorders, Third Edition, Revised (DSM III-R). NOTE: Delete modules for mania and
psychosis.
(b) Clinician Administered Post-traumatic Stress Disorder (PTSD) Scale (CAPS).
(4) Neuropsychological Testing, but only as indicated by a psychiatry consult.
c. Symptom-specific Examination. Individuals who have the following symptoms need to
have the listed minimum work-up.
(1) Diarrhea, to include:
(a) Gastrointestinal (GI) consult,
(b) Stool for Ova and Parasites (O&P),
(c) Stool Leukocytes,
(d) Stool culture,
(e) Stool volume,
(f) Colonoscopy with biopsies, and
(g) Esophagastroduodenoscopy (EGD) with biopsies and aspiration.
(2) Abdominal pain to include:
(a) GI consult,
(b) EGD with biopsy and aspiration,
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX F
F-3
(c) Colonoscopy with biopsy,
(d) Abdominal Ultrasound,
(e) Upper Gastrointestinal (UGI) series with small bowel follow-through, and
(f) Abdominal Computed Tomography (CT) Scan.
(3) Headache
(a) Magnetic Resonance Imaging (MRI) of the head, and
(b) Lumbar Puncture (LP) to include:
1. Glucose,
2. Protein,
3. Cell Count,
4. VDRL,
5. Oligoclonal (lgG),
6. Myelin basic protein,
7. Opening pressure, and
8. Neurology.
(4) Muscle Aches and/or Numbness
(a) Electromyogram (EMG), and
(b) Nerve Conduction Velocity (NCV).
(5) Memory Loss, only if verified by neuropsychological testing, to include:
(a) Magnetic Resonance Imaging (MRI),
(b) LP, NOTE: See tests on headache evaluation.
(c) Neurology consult,
(d) Neuro-psychological testing,
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX F
F-4
(6) Vertigo and/or Tinnitus, to include:
(a) Audiogram,
(b) Electronystamogram (ENG), and
(c) Brainstem Auditory Evoked Response (BAER).
(7) Chronic Fatigue, to include:
(a) Polysomnography, and
(b) Multiple Sleep Latency Test (MSLT).
(8) Chronic Cough and/or Shortness of Breath, to include:
(a) Pulmonary Consult,
(b) Pulmonary Function Test (PFT) with exercise and Arterial Blood Gases (ABG),
(c) If routine PFT’s are negative, perform Methacholine challenge test, and
(d) Bronchoscopy with biopsy and/or lavage which is to be considered if PFTs are normal.
(9) Chest Pain and/or Palpitations, to include:
(a) Electrocardiogram (ECG),
(b) Exercise Stress Test, and
(c) Holter monitor.
(10) Skin Rash, to include:
(a) Dermatology consult, and
(b) Consider a biopsy.
(11) Reproductive Concerns, to include for:
(a) Males, an urology consult; and
(b) Females, a gynecology (GYN) consult.
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX F
F-5
(c) Additional elements recommended for the evaluation of Gulf War veterans with
complaints of Reproductive Health Problems (RHP):
1. Detailed genitourinary history and/or problems, e.g.,:
a. Sexual,
b. Genitourinary symptoms,
c. Menstrual,
d. Contraceptive practices,
e. Pregnancy-related,
f. Conception,
g. Birth defects,
h. Congenital disorders,
i. Menopause,
j. Prior infections,
k Prior surgery, and
l. Exposures to toxic agents, etc.
2. Detailed genital and/or pelvic examination.
3. Laboratory and ancillary testing, e.g.;
a. Pap tests; and
b. Tests for genitourinary infections.
4. Urologist consultation for male veterans who have RHP that cannot be diagnosed or
managed successfully by primary care practitioners.
5. Gynecology consultation for female veterans who have RHP that cannot be diagnosed or
managed successfully by primary care practitioners.
(d) Additional elements for evaluation of Gulf War veterans with complaints of infertility.
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX F
F-6
1. Detailed menstrual and reproductive history (such as the Infertility Questionnaire utilized
by Walter Reed Army Medical Center).
2. Semen analysis, e.g.:
a. Volume,
b. pH,
c. Liquefaction,
d. Sperm concentration,
e. Motility,
f. Progressive motility,
g. Sperm viability,
h. Leukocytes, and
i. Morphology.
3. Referral to an infertility specialist or program.
(e) Additional elements for evaluation of GW veterans with complaints related to birth
defects or genetic disorders in offspring conceived during or after GW service.
1. Detailed history of congenital or genetic disorders (such as the Patient Genetic Screen
Questionnaire utilized by Walter Reed Army Medical Center).
2. Detailed occupational exposures questionnaire (such as Worker and Supervisor
Questionnaires utilized by National Naval Medical Center).
3. Referral to a genetic disease specialist or program.
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX G
G-1
INSTRUCTIONS FOR COMPLETING GULF WAR
UNIFORM CASE ASSESSMENT PROTOCOL (UCAP), PHASE II, PART III
1. General Instructions for Completing Department of Veterans Affairs (VA) Gulf War
Registry Examination, Uniform Case Assessment Protocol (UCAP), Phase II.
a. The Phase II examination needs to be offered to all eligible Gulf War (including Operation
Iraqi Freedom) veterans with unexplained illnesses. The Phase II examination needs to be
performed after the completion of the Phase I registry examination and a thorough clinicallybased
evaluation of the veteran’s symptoms as deemed necessary by the examining physician.
b. Phase II needs to be performed at the local VA medical facility or if the medical expertise
is unavailable, local referral must be made to the nearest regional tertiary care center or War
Related Illness and Injury Study Center (WRIISC). NOTE: Refer to VHA Handbook 1303.5 or
website http://www.va.gov/environagents and video entitled War and Health: Treating War-Related
Illnesses at VA’s WRIISCs.
2. Instructions for Completing Part III, Phase II
a. Tests and Consultations. Only those entries which are related to the veteran’s symptoms
and deemed necessary by the examining physicians need to be completed; leave test and consult
questions that are not applicable blank Select either (Y)es or (N)o from the pull-down menu.
NOTE: Refer to website http://vaww.registries.aac.va.gov for instructions.
(1) Item 1. Were the following tests performed? Enter one of the following codes from the
pull-down menu:
(2) Item 2. Blood Tests
(a) Complete Blood Count (CBC)?
(b) Skin Erethyma Dose (SED) Rate?
(c) C-Reactive Protein?
(d) Rheumatoid Factor?
(e) Fluorescent Anti-Nuclear Antibody (ANA)?
(f) SGOT (AST) (Glutamic Oxaloacetic Transaminase)?
(g) SGPT (ALT) (Transaminase Glutamic Pyruvate)?
(h) Lactic Acid Hydrogenase (LDH)?
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX G
G-2
(i) Alkaline Phosphatase?
(j) Creatine Phosphokinase (CPK)?
(k) Hepatitis B Surface Antibody?
(l) Hepatitis B Core Antigen?
(m) Venereal Disease Research Laboratory (VDRL)?
(n) Vitamin B-12?
(o) Folate?
(p) Human Immuno-deficiency (HIV)?
(q) Thyroxine Total Serum (T4)?
(r) Thyroid Stimulating Hormone (TSH)?
(3) Item 3. Urinalysis?
(4) Item 4. Tuberculosis (TB) Skin Test Purified Protein Derivative (PPD)?
(5) Item 5. Chest X-ray?
(6) Item 6. Psychiatric Consultation?
(a) Item 6A. Structured Clinical Interview for Diagnosis (SCID) for Diagnostic and
Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R). Was the SCID
interview given?
(b) Item 6B. Clinical Administered Post-traumatic Stress Disorder (PTSD) Scale (CAPS).
Was the CAPS performed?
(c) Item 7. List of Diagnoses. Designated physician staff or clinical staff are to provide
narrative description of diagnoses. If none, leave blank. NOTE: Coders: Enter International
Classification of Diseases, Clinical Modification, 9th Edition (ICD-9) codes as required.
b. SYMPTOM-SPECIFIC EXAMINATIONS, PHASE II NOTE: Complete only those
questions which are appropriate to the veteran’s symptoms; otherwise leave these blank.
(1) Item 8. Psychology-Neuropsychological Test.
March 7, 2005 VHA HANDBOOK 1303.2
APPENDIX G
G-3
(a) Was this test performed?
(b) List of Diagnoses and ICD-9 codes.
(2) Item 9. Infectious Disease-Screening Examination.
(a) Was this examination performed?
(b) List of Diagnoses and ICD-9 codes.
(3) Item 10. Dental Examination.
(a) If there was a medical indication, was this examination performed?
(b) List of Diagnoses and ICD-9 codes.
(4) Item 11. Diarrhea and/or Abdominal Pain.
(a) Did patient receive a GI (Gastroenterology) consult?
(b) List Diagnoses and ICD-9 codes.
(5) Item 12. Headache and/or Memory Loss.
(a) Did patient receive neurology consult?
(b) List Diagnoses and ICD-9 codes
(6) Item 13. Muscle Aches or Numbness.
(a) Did patient receive a neurology consult?
(b) List Diagnoses and ICD-9 codes.
(7) Item 14. Chronic Fatigue.
(a) Did patient receive consult(s) relating to chronic fatigue?
(b) List Diagnoses and ICD-9 codes.
(8) Item 15. Joint Pain.
(a) Rheumatology Consult. Did patient receive rheumatology consult?
(b). List Diagnoses and ICD-9 codes.
VHA HANDBOOK 1303.2 March 7, 2005
APPENDIX G
G-4
(9) Item 16. Chronic Cough and/or Shortness of Breath.
(a) Pulmonary Consult. Did patient receive pulmonary consult?
(b) List Diagnoses and ICD-9 codes.
(10) Item 17. Skin Rash.
(a) Dermatology Consult. Did patient receive a dermatology consult?
(b) List Diagnoses and ICD-9 codes.
(11) Item 18. Vertigo and/or Tinnitus.
(a) Audiology consult? Did patient receive an audiology consult?
(b) List Diagnoses and ICD-9 codes.
(12) Item 19. Chest Pain and/or Palpitations.
(a) Cardiology Consult. Did patient receive a cardiology consult?
(b) List Diagnoses and ICD-9 codes.
(13) Item 20. Reproductive Concerns.
(a) Did male patient receive a urology consult?
(b) Did female patient receive a gynecology consult?
(c) List Diagnoses and ICD-9 codes.
(14) Item 21. Final Diagnoses. List up to ten major definite medical diagnoses, with the
primary diagnosis listed on line 21A with ICD-9 codes. If no diagnosis is made, leave these
lines blank as well as the ICD-9 codes.
(15) Item 22. After completing the Uniform Case Assessment Protocol (UCAP), Phase II,
Part III, does the physician feel that the veteran has an unexplained illness? Enter either Y(es) or
N(o) from the pull-down menu.