Medical Malpractice Questionnaire
INJURY INTAKE FORM
It is important that you complete this form as accurately and completely
Describe what malpractice you believe occurred:
Describe all injuries sustained:
List all physicians, hospitals, or others you believe may be responsible
for your injuries:
Your health insurance(s) (name and phone number):
List all doctors, hospitals, physical therapists, chiropractors, or others
who have treated you for this injury:
Have you ever suffered injuries or had illnesses similar to those suffered
in this incident?
Include Date and Description
Employer’s Address/Phone Number:
Current Over-the-Counter Medicines Being Taken:
Previous Prescription Medications Taken, Including Dosage and Name of Prescribing
Do your injuries prohibit performance of any daily living activities? (Examples:
Can you brush your hair? Perform household tasks such as cleaning and
cooking?) If so, for how long have you been unable to perform these activities?
Have you ever made any previous claims for personal injuries, medical malpractice,
workers’ compensation, or social security disability? If yes, please explain:
1. Take photographs of your injuries, if possible.
2. Give no information to anyone other than our office.
3. Forward copies of all bills or receipts for hospital, x-ray, loss of
earnings and medical reports.
4. Additional instructions will be given to you based on your individual