First Name
Middle Initial
Last Name
Street Address
Address (cont.)
City
Province
Postal Code
Home Phone
Work Phone
Email Address
Date of Birth (mm/dd/yy)
Health Card Number
Gender	MaleFemale
Seat Assignment
While on or after the Sky Service flight 560 have you experienced or do you continue to experience any of the following symptoms:	Trouble    Sleeping Yes No Loss of Appetite Yes No Weight Loss Yes No Nightmares Yes No Feelings of Anxiousness Yes No Sweaty palms Yes No Dizziness Yes No Crying Yes No Fear of Flying Yes No
Have you received medical treatment or been hospitalized for injuries sustained during or as a result of this flight?	Yes No
If yes, provide the names, addresses and phone numbers of all medical professionals, the illness diagnosed and the date you were told your illness was related to Flight 560.
What illnesses or conditions are you suffering from today, if any?
Have you experienced or do you continue to experience any of the following symptoms:	Ear aches: Yes No    Unusual sound in ears (ringing, etc.): Yes No    Headaches: Yes No    Discomfort in shoulders: Yes No    Discomfort in arms: Yes No    Discomfort in legs: Yes No    Discomfort in back: Yes No   Soreness in the joints (such as wrists): Yes No    Bumps or bruises: Yes No    Minor cuts: Yes No Menstrual difficulties Yes No
Have you received medical treatment or been hospitalized for injuries sustained during or as a result of Flight 560?	Yes No
What kind of medical treatment did you receive?
All Treating Doctor's Names & Addresses
All Treating Hospitals Names & Addresses
Do you have family members who were affected by your experience on Flight 560?	Yes No
Name & Relationship to you
Employment Information (if you are claiming lost wages) Employer (or last employer)
Employer Address and Telephone Number
Type of Employment/title
Dates missed from work due to injury or illness
Rate of pay