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        Marie Harrison
        4919 Third St.
        San Francisco CA 94124

 

Your Name:  __________________________ Your Age?_____________

Your Street Address: ________________________ ZIP Code: ____________ How Long _____

Your Home Telephone Number: _______________ Work Telephone: ____________

Your Fax Number: __________________ E-Mail: ____________________________

Is it okay to contact you at home? _________________________If so, when________

Do You have medical or other Insurance?____________________________________

Have you or anyone in your household been sick since August 16, 2000? ___________

If yes, please list symptoms & age(s) next to the sick personís name:  _____________________  __________________________, _____________________________, ________________________. ____________________________________(Please include a separate sheet for additional names/symptoms/ages for individuals you cannot list here.)

Did you or any of individuals you have listed, seen a doctor at that time for related symptoms?

Yes ___            No ____

Doctorís name and/or hospital visited? ______________________________________________

Date(s) of medical visit(s)  ____________________.

Do you have available receipt copies for those visits or other proof of medical services?

Did you or any of individuals you have listed, seen a doctor at that time for related symptoms?

Yes ___            No ___

What was the prognosis from the visit(s)? _______________________________________.

Is anyone in your household still sick?   Yes _____   No _____ (If yes, is the individual still under the doctorís care?)   Yes _____            No _____ 

Have you attempted to see a doctor or go to a hospital and were refused service?

Yes _____ No _____  (If yes, please explain and list the Name of Institution or doctor) ____________________________________________________________________

When did you first learn of the Hunterís Point Naval Shipyard Parcel E Fire? ____________How did you learn about it?____________________________________

Do you have access to a doctor or other medical facility? __________________

 

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