Medical Response Form

This is a short simple form to establish a basic file on people who have experienced health problems that may have been caused by exposure to polluted waters.

These files and their contents will not be published without the persons permission. We may use a summary of cases but would not use peoples actual names without permission.

We may approach you if we feel that your case would be useful in furthering SAS’ aims and objectives.

Your Title

Your Name (required)

Your Address including Postcode

Occupation

Date of Birth

Your Email (required)

Details of health problems. Please specify the type of illness (tick as appropriate)

Did you visit a doctor?

Do medical records exist?

Were swabs / blood tests taken? If so what were the results.

Has a doctor expressed an opinion on the cause of illness? Please give details below.

Were you:
 Swimming Surfing Windsurfing Diving/Snorkelling Paddling Other

When did you go into the water?

Where did you go into the water?

Did you lose work due to the illness?

Would you be willing to work with the media on your illness if necessary?

Are you a member of Surfers Against Sewage?