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Theresa Coleman
42 Harbor Rd.
San Francisco CA 94124
Phone 415.282-0967
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 person’s 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 ____
Doctor’s 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 doctor’s 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 Hunter’s Point Naval Shipyard Parcel E Fire? ____________How did you learn about it?____________________________________
Do you have access to a doctor or other medical facility? __________________