If you were involved in any welding or welding-related activities OR worked for extended periods of time in areas where such activities were conducted, AND now EITHER are suffering from Manganism, manganese induced Parkinsonism or Parkinson's disease, or are suffering from fatigue, feelings of weakness and lethargy, speech disturbances, a mask-like face, tremors, disorientation, loss of memory, impairment of judgment, abnormal gait, and loss of the ability to control muscular movement, and you are interested in us evaluating your condition, please click here to fill out a questionnaire. The information you provide will enable us to determine the viability of any potential claim you may have.

Name:
Address:
City:
State:
Zip:
Daytime phone:
Evening phone:
Mobile phone:
Email address:
Fax Number:
Birth date:
Age:
Social Security #:
Spouse's name:
Health Ins. Co.:
How long did you work around or with welding rods? (years)
Who was the manufacturer?

Please list the names and addresses of each employer or job site where you were exposed to welding fumes, including the approximate dates.
Name	Address	Dates

When did you first suspect that your problems were related to welding rod fumes?

Name and addresss of physician(s) who has linked your problems to welding rod fumes:

Name:	Address:
Name:	Address:

Have you been diagnosed with any of the conditions listed below? Please check all that apply.
Parkinson's Disease	Parkinsonism
Manganism	Neuropathy
Pneumonitis	Asthma
Asbestosis	Silicosis
Anemia
Listed below are certain welding processses. Please check any that you worked with or have been exposed to. Check all that apply.
Shielded Metal Arc Welding	Gas Metal Arc Welding
Gas Tungsten Arc Welding	Flux Colored Arc Welding
Plasma Arc Welding	Sugmerged Arc Welding
Carbon Arc Welding	Electro Slag Welding
Electro Gas Welding	Stand Welding
Beddon Plate Welding	Torch Blazing
Oxygen Cutting	Air Carbon Arc Cutting

 

Milwaukee, WI 53202
Phone: (414) 271-1011

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