RECORD OF PROCEEDINGS
AIR FORCE BOARD FOR CORRECTION OF MILITARY RECORDS


IN THE MATTER OF:	DOCKET NUMBER:  BC-2007-02405-4
		
		COUNSEL:  NO

		HEARING DESIRED:  NO


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APPLICANT REQUESTS THAT:

1.  The entry in his official medical records, dated 20 Sep 65, stating his headaches were relieved by proper eyeglasses in 1965 be changed to read “Headaches from Dec 1961 to 1 Oct 65.  Eyeglasses (new) on 12 Jul 62 provided some relief from headaches.” 

2.  The entry in his official medical records, dated 25 Jan 62, stating “Same as old Rx, no change” be deleted from his records.

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APPLICANT CONTENDS THAT:

1.  His physician incorrectly recorded that his headaches were relieved by proper glasses in 1965.  He actually received his eyeglasses in 1961, not 1965.  At the time of his examination in 1965, he told his provider his eye glasses relieved his eye strain headaches, but not his migraine headaches, which he believed were caused by potassium nitrate (KNO3) and stress.  He has had the headaches since 1961.  The new glasses he received in 1962 helped, but did not eliminate the headaches.  

2.  The statement “Same as old Rx, no change” entered on 25 Jan 62 is incorrect.  The 3 Oct 61 documentation shows a different Rx from the new glass in 1962. 

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RESUME OF CASE: 

On 21 Feb 08, the Board considered and denied the applicant’s original request to correct his records to show he received eyeglasses in 1961 rather than 1965.  In the original case, the applicant contended the problems with his eyes started in 1961, and the doctor erroneously recorded 1965 in his medical record.  The Air Force advisory in the original case recommended denial, citing AFR 168-4, Administration of Medical Activities, 18 Jan 87 which states that to correct medical documentation without creating suspicion of record tampering, the following procedures should be used:  If an error is identified near in time to the date of the erroneous entry and the practitioner(s) involved has presented memory of the circumstances (general), then the corrective steps are taken.   For an accounting of the facts and circumstances surrounding the applicant’s original request and the rationale of the earlier decision by the Board, see the Record of Proceedings (ROP) at Exhibit F. 

On 3 Jun 10, the Board notified the applicant that a subsequent, undated, request for reconsideration by the applicant would not be considered due to the fact that the  new application contained no new relevant evidence, and was essentially a similar request that was previously considered and denied.  For an accounting of the facts and circumstances surrounding the applicant’s request for reconsideration and the rationale of the earlier decision by the Board, see the Record of Proceedings (ROP) at Exhibit H. 

On 29 Dec 10, the Board notified the applicant that a subsequent, undated, request for reconsideration by the applicant would not be considered due to the fact that the  new application contained no new relevant evidence, and was essentially a similar request that was previously considered and denied (Exhibit J).

On 22 Mar 13, the applicant submitted new information pertaining to his original case for AFBCMR consideration.  The new information consists of medical documentation which includes a DD Form 771, Spectacle Order Form, dated 12 Jul 62, with the applicant’s name on it, and a medical form which appears to be an eye examination conducted on 3 Oct 61. 

The applicant’s complete submission, with attachments, is at Exhibit K.

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AIR FORCE EVALUATION:

The BCMR Medical Consultant recommends denial of the applicant’s reconsideration request to change the note in his medical records, dated 20 Sep 65, concerning his headaches.  The applicant supplied documentation from the DVA indicating he was awarded a 100 percent disability rating for Post-Traumatic Stress Disorder (PTSD), from Sep 04 and zero percent rating for left eye corneal abrasion to include blurry vision.  A review of the applicant’s medical records and of the documentation he submitted reveals no evidence to support changing the record from 1965 to 1961.  The BCMR Consultant, like the evaluator of the DVA, believes it is as likely as not that the applicant did experience headaches during his military service and that these may have been unrelated to the wear of, or lack thereof, corrective lenses.  Aside from the applicant’s claim that his headaches were the result of potassium nitrate and stress, his occupation in welding may also have posed a risk for headaches in operating without personal respiratory protection or in an area with poor ventilation.  The applicant may find these opinions and those of his most recent Compensation and Pension evaluation useful in any subsequent appeal to the DVA for establishing service-connection for headaches.  The BCMR Medical Consultant, otherwise, opines the burden of proof has not been met that warrants the desired date change of the records. 

A complete copy of the BCMR Medical Consultant evaluation is at Exhibit L.

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APPLICANT'S REVIEW OF AIR FORCE EVALUATION:

He takes exception to the BCMR Medical Consultant’s advisory opinion, and feels no one read the “thousands of pages” of his medical history.  He reiterates that the issuance of eye glasses in 1962 helped his headaches (as did drinking beer), but did not relieve his headaches as stated in his medical documentation.  In addition, he did not get new eyeglasses in 1965.  The glasses he initially received in 1961 did not provide relief from his headaches, so he asked for new glasses and got a new pair at Luke AFB, AZ on 12 Jul 62.  Therefore, the statement in his 25 Jan 62 medical documentation referring to his prescription and saying “Same as old Rx, no change” is an error. By looking at his 1961 eyeglass prescription which he provided, you can see it is different.  In addition, the separations doctor should have ordered eye/headache/nervous disorder/dental x-rays on 20 Sep 65.  Any neurological exam from 1962 to present would prove he has a brain ANG II disorder (Exhibit N).

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THE BOARD CONCLUDES THAT:

We have thoroughly reviewed the evidence of record and considered the weight and relevance of the additional documentation provided by the applicant, and whether or not it was discoverable at the time of any previous application.  We have determined that the information submitted with the applicant’s request for reconsideration was available at the time of his initial application.  As the applicant has been previously advised, reconsideration is provided only where newly discovered relevant evidence is presented which was not available when the application was submitted.  Further, the reiteration of facts we have previously addressed, uncorroborated personal observations, or additional arguments on the evidence of record are not adequate grounds for reopening a case.  Therefore, in view of the above and in the absence of new and relevant evidence, we find no basis to reconsider the applicant’s request.

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THE BOARD DETERMINES THAT:

The applicant be notified the additional evidence presented did not meet the criteria for reconsideration by the Board; and the application will only be reconsidered upon the submission of newly discovered relevant evidence not considered with this application.

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The following members of the Board considered AFBCMR Docket Number BC-2007-02405 in Executive Session on 21 Aug 14, under the provisions of AFI 36-2603:

Panel Chair
	Member
	Member

The following documentary evidence was considered:

	Exhibit F.  ROP, dated 8 Apr 08. 
	Exhibit G.  Recon Request Letter, Applicant, undated.
	Exhibit H.  Letter, AFBCMR, dated 3 Jun 10.
	Exhibit I.  Recon Request Letter, Applicant, undated.  
	Exhibit J.  Letter, AFBCMR, dated 29 Dec 10.
	Exhibit K.  DD Form 149, dated 23 Mar 13, w/atchs. 
	Exhibit L.  Letter, BCMR Medical Advisor, dated 2 Jun 14.
	Exhibit M.  Letter, SAF/MRBR, dated 9 Jun 14.
	Exhibit N.  Letter, Applicant, dated 15 Jun 14.