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Silicosis case evaluation form

  * Fields Required
* First Name:
* Last Name:
Address:
Address 2:
City:
State:
ZIP:
Telephone: () -
* E-mail Address:
 
If you are inquiring on behalf of another person, please give their name and answer the following questions on their behalf:
Name of person:
Date of Birth / /
* Have you been diagnosed with silicosis? Yes No
If Yes:
     * When were you first informed of the diagnosis? /
How long have you been having problems breathing? Years   Months
Do you require oxygen to breath? Yes No
 
Did your exposure to silica occur through work? Yes No
If Yes:
     What was your occupation? 1. 2. 3.
If No:
     How do you believe you were exposed?
 
When did your exposure first occur? Years Ago
How long were you exposed for? Years   Months
In which states did your exposure occur?
    State
1.
2.
3.
 
Have you ever been diagnosed with any of the following medical conditions?
Asbestosis: Yes No
Lung Cancer: Yes No
Other Cancer: Yes No
Tuberculosis: Yes No
Emphysema: Yes No
Schleroderma: Yes No
Lupus: Yes No
Rhematoid arthritis: Yes No
Accelerated Pulmonary Fibrosis: Yes No
Kidney Disease: Yes No
Other:
 
Do you smoke? Yes No
If Yes:
     How many packs per day? packs/day
If No:
     Did you ever smoke? Yes No
     If Yes:
          When did you quit? /
 
Would you like to make any other comments about your case?
 

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