THOR-EXTRA.

Please record below any case which you belive is attributed to an novel or interesting cause.


Centre number
Email Address
Scheme

Date patient seen
Diagnosis
Reference number
Gender   
Age
Post code (First half)
Occupation
Industry
Suspected agent
Symptom onset
Have you reported this case to Thor?
   

Please give reasons for reporting this case, and why you believe this is a novel or interesting cause
 

Please provide us with comments & suggestions on the Thor Extra reporting method or on any other aspect of the scheme

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