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DO HARM FIRST?

Abused in ER Rooms Due to the Need for Emergency P in or Psychi tric Medic tion? Te!! "our Story Here#

PLEASE EMAIL THIS COMPLETED DOCUMENT TO: DOHARMFIRST@GMAIL.COM

If you c nnot re d this document$ SE%E&T A%% TE'T SE%E&T THE SI(E OF PRINT )FONT* THAT IS READA+%E
P,RPOSE$ The -ur-ose of this .uestionn ire is to document ny nd !! buse by emergency room -ersonne! you h /e e0-erienced1 inc!uding -hysic !1 -sycho!ogic !1 emotion !1 /erb !1 nd ny other ty-e of mistre tment due to ny ty-e of subst nce for 2hich you 2ere see3ing -hysic ! or -sychi tric - in re!ief4 E/entu !!y1 this nd other e/idence 2i!! be used for boo3 bout this sub5ect1 bringing this e-idemic of buse to the -ub!ic6s ttention4 E'AMP%E$ "ou fe!! off roof 2hi!e m 3ing re- irs to your house4 "ou h /en6t bro3en ny bones1 but the - in is e0cruci ting4 The st ff m y is ob/ious!y dismissi/e or 2orse reg rding your condition1 denies ny tre tment1 -ur-osefu!!y 3ee-s you 2 iting for hours nd hours to no -ur-ose1 /erb !!y h r sses you1 -hysic !!y h rms you1 nd7or in m ny other 2 ys c uses you h rm4 If you6re !uc3y1 you m y recei/e -rescri-tion for Ibu-rofen4 Or you m y h /e run out of your ' n 0 fe2 d ys e r!y due to tr um tic month4 No2 you6re e0-eriencing m 5or n0iety tt c3s4 "ou 2i!! no !onger be seen by ER st ffs s hum n being4 Inste d1 you h /e become 8Drug See3er48 SI9NIN9 OR NOT SI9NIN9 THIS DO&,MENT$ If you decide to -ro/ide your n me nd sign this document1 your story c n be used in the -! nned boo3 bout this sub5ect1 but your n me 2i!! not be disc!osed4 If you do not -ro/ide your n me nd sign this document1 your story 2i!! sti!! ssist in the 2riting of the boo31 but your story c nnot nd 2i!! not be inc!uded in the boo34 "ou must !so inc!ude cont ct inform tion so th t I m y /erify your story -rior to -ub!ic tion4 This 2i!! be re! ti/e!y short -rocess4 Minors 2i!! not be inc!uded in this .uestionn ire due to cert in ethic ! nd other consider tions4

: A+O,T ME$ I m 2riter of four -ub!ished no/e!s nd h /e M ster6s Degree in &ommunic tion from 9on; g ,ni/ersity4 I m 2riting this boo3 b sed on the end!ess number of horror stories I6/e he rd by those see3ing he!- in emergency rooms b sed on the need for re!ief of -hysic ! or -sychi tric - in4 <hi!e ER rooms try to e0-! in 2 y this m !tre tment b sed on its 8fe r of cre ting or contributing to ddiction18 the medic ! industry itse!f ! be!s ddiction dise se4 And it6s h --y to -rofit from th t dise se4 <hen the -rofits sto- nd the dise se of ddiction st rts costing the hos-it ! time nd money1 the hos-it ! sto-s c !!ing ddiction dise se nd st rts c !!ing you 8Drug See3er18 noting you s such in your medic ! records1 2hen you m y not regu! r!y use ny subst nce t !!1 s in the c se of - in from n ccident4 E/en if you re n ddict1 you deser/e the s me res-ect nd tre tment s nyone e!se in the ER1 m ny of 2hom h /e their o2n 8se!f=inf!icted8 in5uries1 such s o/ere ting1 ! c3 of e0ercise1 etc4 +ut they re not humi!i ted or bused4 They6re regu! r Americ ns4 And it6s !i3e!y their insur nce is better th n yours4 It6s time to sto- this ins nity4 P!e se com-!ete the .uestionn ire1 2hich begins no24

THE QUESTIONNAIRE BEGINS ON THE NEXT PAGE

> THE QUESTIONNAIRE If -ossib!e1 -!e se ty-e your ns2ers on this document4 If not1 -!e se 2rite your ns2ers4 "ou m y use your o2n - -er1 but -!e se number e ch incident s be!o21 nd -!e se number your - ges4 P!e se be honest nd s-e 3 your ! ngu ge4 8&urse 2ords8 m y be necess ry to e0-ress your fee!ings4 If so1 use them4 The entire -ur-ose of this .uestionn ire is to get your story on - -er nd to the -ub!ic4 P!e se chec3 one of the fo!!o2ing choices$ ? @ I do not 2ish to -ro/ide my n me or sign this document4 I underst nd th t my story is im-ort nt nd 2i!! be considered in the 2riting of the boo31 but my story c nnot nd 2i!! not be used in the boo34 ? @ I 2ou!d !i3e to -ro/ide my n me nd sign this document4 +y doing so1 I underst nd th t my story m y be used in boo3 on this sub5ect but 2i!! be re-! ced by fiction ! n me4 My n me 2i!! not be re/e !ed to nyone or for ny -ur-ose4 I underst nd I 2i!! recei/e no - yment of ny 3ind for com-!eting this .uestionn ire1 nor 2i!! I recei/e ny - yment of ny 3ind shou!d my story be used in the -ro-osed boo34 I !so underst nd th t my em i! ddress nd te!e-hone number re re.uired for /erific tion of my story1 shou!d it be used in the boo34 This inform tion1 too1 2i!! be he!d in the strictest confidenti !ity4 N me$ AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA Sign ture$ AAAAAAAAAAAAAAAAAAAAAAAAAAAA D te$ AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA Em i! ddress$ AAAAAAAAAAAAAAAAAAAAAAAAAAAAA Te!e-hone7&e!!$ AAAAAAAAAAAAAAAAAAAAAAAAAAAAAA I1 P u! A4 Toth1 the uthor of the -ro-osed boo3 for 2hich this inform tion is being co!!ected1 hereby ttest nd s2e r by e!ectronic sign ture th t I 2i!! neither re!e se to ny - rty nor -ub!ish ny n mes or other inform tion -ro/ided 2ithin this document4 Shou!d I -ub!ish the stories 2ithin this document1 I sh !! re-! ce ctu ! n mes 2ith fictitious ones4 AAAAAAAAAAAAAAAAAAAAAAAAAAA P u! A4 Toth No/ember :B1 :CD>

M" EMER9EN&" ROOM E'PERIEN&ES

IN&IDENT ED N me7!oc tion of hos-it !$ AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA D te )guessing1 if necess ry1 is fine*$ AAAAAAAAAAAAAAAAAAAAAAAAAA Re son for /isiting emergency room1 inc!uding subst nce in/o!/ed$

P!e se describe e0 ct!y ho2 you 2ere in ny 2 y bused or h rmed during this /isit4 "ou m y ty-e or 2rite on your o2n - -er if you run out of room4 P!e se indic te the Incident E nd number your - ges4 P!e se use ny 2ords necess ry to describe 2h t h --ened4 P!e se be s honest s -ossib!e4

F IN&IDENT E: N me7!oc tion of hos-it !$ AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA D te )guessing1 if necess ry1 is fine*$ AAAAAAAAAAAAAAAAAAAAAAAAAA Re son for /isiting emergency room1 inc!uding subst nce in/o!/ed$

P!e se describe e0 ct!y ho2 you 2ere in ny 2 y bused or h rmed during this /isit4 "ou m y ty-e or 2rite on your o2n - -er if you run out of room4 P!e se indic te the Incident E nd number your - ges4 P!e se use ny 2ords necess ry to describe 2h t h --ened4 P!e se be s honest s -ossib!e4

G IN&IDENT E> N me7!oc tion of hos-it !$ AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA D te )guessing1 if necess ry1 is fine*$ AAAAAAAAAAAAAAAAAAAAAAAAAA D Re son for /isiting emergency room1 inc!uding subst nce in/o!/ed$

P!e se describe e0 ct!y ho2 you 2ere in ny 2 y bused or h rmed during this /isit4 "ou m y ty-e or 2rite on your o2n - -er if you run out of room4 P!e se indic te the Incident E nd number your - ges4 P!e se use ny 2ords necess ry to describe 2h t h --ened4 P!e se be s honest s -ossib!e4

H IN&IDENT EB N me7!oc tion of hos-it !$ AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA D te )guessing1 if necess ry1 is fine*$ AAAAAAAAAAAAAAAAAAAAAAAAAA Re son for /isiting emergency room1 inc!uding subst nce in/o!/ed$

P!e se describe e0 ct!y ho2 you 2ere in ny 2 y bused or h rmed during this /isit4 "ou m y ty-e or 2rite on your o2n - -er if you run out of room4 P!e se indic te the Incident E nd number your - ges4 P!e se use ny 2ords necess ry to describe 2h t h --ened4 P!e se be s honest s -ossib!e4

IF "O, HAIE E'PERIEN&ED MORE THAN FO,R IN&IDENTS OF EMER9EN&" ROOM A+,SE1 P%EASE DES&RI+E EA&H IN&IDENT E'A&T%" AS A+OIE1 +E9INNIN9 <ITH NAME OF HOSPITA%1 DATE1 REASON FOR IISIT1 AND THE DETAI%S OF <HAT HAPPENED4

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