Medical Malpractice Questionnaire

Medical Malpractice Questionnaire

INJURY INTAKE FORM

It is important that you complete this form as accurately and completely as possible.
Full Name
Date of Birth
Social Security Number
Address
City
State
Zip Code
Length of Time at that Address
Home Phone
Work Phone
Cell Phone
Facsimile Number
Email
Former/Maiden Name(s)
Date of Injury:
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:
Name:
Address:
Tel. Number:
Name:
Address:
Tel. Number:
Name:
Address:
Tel. Number:
Name:
Address:
Tel. Number:
Have you ever suffered injuries or had illnesses similar to those suffered in this incident?
Include Date and Description
Employment Information:
Current Employer:
Employer’s Address/Phone Number:
Job Position/Title:
Length of Time with Employer:
Gross Monthly Income:
Have you lost wages due to injury?
How many days/ months?
Expect to lose income in the future?
Marital Status:
Current Prescription Medications Being Taken, Including Current Dosage and Name of Prescribing Physician or Medical Provider:
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
Current Over-the-Counter Medicines Being Taken:
Previous Prescription Medications Taken, Including Dosage and Name of Prescribing Physician:
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?
Hobbies/Interests:
Does illness prevent you from these hobbies/interests?
Do you have a history of treatment for chemical dependency?
Do you have a history of psychiatric or psychological treatment?
Explain:
Do you have a criminal record?
Explain:
Have you ever made any previous claims for personal injuries, medical malpractice, workers’ compensation, or social security disability? If yes, please explain:
General instructions:
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 situation.

We Represent People. Not Faceless Insurance Companies.

Connect with our attorneys for a free case evaluation