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Online 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These files and their contents will not be published without the persons permission.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.

Title
First name
Surname
Address
Town
Postcode
Telephone
Occupation
Date of birth
E-mail address


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

Ear, nose & throat infection
Infected wound
Skin
Gastro-int. (stomach)
Viral (meningitis, hepatitis, chicken pox etc)
Non-specific viral
Respiratory (chest)
Eye
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 (please specify)
When did you go in the polluted water?
Where did you go into the polluted water?
Did you lose work due to the illness?
Would you be willing to work with media on your
illness if necessary?
Are you a member of Surfers Against Sewage?


Back


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