1. What was the date of your injury? |
2. How did your accident occur? |
3. What were your injuries? |
4. Where did you receive healthcare? |
5. Were you admitted as an inpatient? If so, for how many days? |
6. How many medical consultations did you have? Where? |
7. Do you have any residual disability or discomfort? If so, of what kind? |
8. Have you made changes in work or leisure time activities as a result of the injury? If so, of what kind? |
9. Have you stopped skydiving as a result of the injury? |
10. Do you have any experiences from your injury event that you would like to convey? |
11. Will you grant us permission to, if necessary, read your hospital records? |