Chronic Multisymptom Illness Claim Intake Form

Full Name

First NameLast Name

Date of Birth

Date

Contact Information (Email)

example@example.com

Contact Information (Phone Number)

Please enter a valid phone number.Format: (000) 000-0000.

Current Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

When did your symptoms first begin?

Date

Please select all symptoms you are experiencing:

How would you rate the severity of your symptoms?

How have your symptoms affected your daily life? (Select all that apply)

Please provide details of any medical diagnoses received related to your symptoms.

Are you currently receiving any treatment for your symptoms?

If yes, please list the treatments and healthcare providers (leave blank if not applicable).

Upload any supporting medical documentation (optional)

Signature (please sign below to authorize claim submission)