Welding Rod
Injury

Title

First Name

Middle Initial

Last Name

Email Address

Phone Number (day)

Phone Number (eve)

Address

City

State that you currently reside in

Zip

Have you been diagnosed with Parkinson's disease by a medical doctor or experienced Parkinson's- like symptoms?
Yes No

Do you suffer from tremors or trembling in hands, arms, legs, jaw or face?
Yes No

Are you experiencing any slowness of movement or impaired balance or coordination?
Yes No

Are you experiencing and stiffness of the limbs and trunk?
Yes No

Have you worked in an industrial setting where you may have been exposed to manganese fumes?
Yes No

How long did you work in the welding industry?

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