Permit to be ill

                   NATIONAL HEALTH SERVICE
              Application for Permit to be ill

Name:................................................................
Address:.............................................................
When born and why:...................................................

 1. I hereby make an application to be ill

 2. I declare:
    a. That I have pain in my
         i. head
        ii. stomach
       iii. chest
        iv. arms
         v. other:....................
    b. That my complexion is
         i. ruddy
        ii. pallid
       iii. green
    c. That I have broken my
         i. arm
        ii. leg
       iii. back
        iv. engagement
    d. That during the past 12 hours I have been sick ........ times
    e. That I expect to be sick again in ........ hours
    f. That I am afraid I shall
         i. die
        ii. not die
       iii. live
        iv. not live
    g. That I am off my
         i. food
        ii. drink
       iii. head

 3. The name of my Doctor is .........................................
    The name of my Veterinary surgeon is .............................

 4. I have been taking
      i. salts
     ii. pills
    iii. tablets
     iv. liberties

 5. I am in
      i. bed
     ii. pain
    iii. desperation
     iv. my coffin

 6. What is the effect of a dose of Cascara? .........................
      i. How many times? ........

 7. I can see
      i. spots
     ii. nothing
    iii. animals. If animals, state type and colour:
         .............................................................

 8. I have spots on my ...............................................
      i. They do / do not itch
     ii. I am / am not scratching them

 9. I am / am not pregnant. (In case of male patients, further details
    should be given on a separate sheet. Blankets should not be used.)

10. I am
      i. depressed
     ii. elated
    iii. about to shoot myself (Note: In this case a firearms license
         is required)

11. I would be willing to take
      i. medicine
     ii. treatment
    iii. medicine and treatment
     iv. treatment and medicine
      v. poison (State preference, and whether fast or slow)

12. I request admission to
      i. hospital
     ii. asylum
    iii. mortuary

13. I request the services of a
      i. doctor
     ii. midwife
    iii. nurse (State whether day, night, wet, dry, blonde, brunette,
         young and / or willing)
     iv. undertaker

14. I believe my complaint to be .....................................

    In case a permit cannot be issued for this complaint would you be
    willing to accept another illness, malady or disease?
    State Yes or No: ........

This form should be submitted, in triplicate, to the Local Health
Officer.  Should the applicant die before the permit is issued the
Local Health Officer should be notified and a new application for a
permit to be declared dead (Form R.I.P.) should be submitted by a
relative or creditor.

Permits are not transferable, but a permit for a common cold may be
used by all members of an applicants family, provided that all the
colds, upto a maximum of six, are caught within 14 days of the date
of issue.

Declaration:
I declare that all the above answers are as true as those on my
petrol application.

...................               ....................................
Date                              Signature


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This message was sent on 11 Jun 1996