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
This message was sent on 11 Jun 1996