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Medical Malpractice Questionnaire
Medical Malpractice Questionnaire
1
Step 1
Personal Information
First Name
your first name
Last Name
your last name
Date of Birth
your date of birth mm/dd/yyyy
date_range
Home Phone
10 digit phone number
Work Phone
10 digit phone number
Cell Phone
10 digit phone number
Email
a valid email
email
Former Names
your former or maiden names
Address
your street address
Unit
your apartment or unit number
City
your city
State
your state
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code
your zip code
How many years have you lived here?
how long have you lived at this addreess
1
0
75
Injury Information
Date of Injury
the date you were injured mm/dd/yyyy
date_range
Describe what malpractice you believe occurred:
more details
0
/
750
Describe all injuries sustained:
more details
0
/
500
List all physicians, hospitals, or others you believe may be responsible for your injuries:
more details
0
/
500
Your health insurance(s) (name and phone number):
more details
0
/
500
Choose how many providers, hospitals, physical therapist, chiropractors, or others who have treated you for this injury. Then fill in each of the spaces with their details.
how many?
0
0
5
1. First Providers Name
the name of the first provider
1. First Provider Address
first providers address
1.Phone
10 digit phone number
Second Providers Name
the name of the second provider
2. Second Provider Address
second providers address
2.Phone
10 digit phone number
Third Providers Name
the name of the third provider
3. Third Provider Address
third providers address
3.Phone
10 digit phone number
Fourth Providers Name
the name of the foruth provider
4. Fourth Provider Address
fourth providers address
4.Phone
10 digit phone number
Fifth Providers Name
the name of the fourth provider
5. Fifth Provider Address
fifth providers address
5.Phone
10 digit phone number
Have you ever suffered injuries or had injuries or had illnesses similar to those suffered in this incident? Included Date and Description
more details
0
/
Employment Information
Current Employer
name of your current employer
Job Position / Title:
your position or tiitle
Employers Address
your employers address
Employers Phone Number
10 digit phone number
Length of Time with Employer
choose how long you have been employed by this employer
0yr(s)
0
75yr(s)
Gross Monthly Income
your gross monthly income
Current Prescription Medications Being Taken, Including Current Dosage and Name of Prescribing Physician or Medical Provider
How many medications are you taking?
choose how many medications you are taking
0
0
10
1. Medication
name and dosage
2. Medication
name and dosage
3. Medication
name and dosage
4. Medication
name and dosage
5. Medication
name and dosage
6. Medication
name and dosage
7. Medication
name and dosage
8. Medication
name and dosage
9. Medication
name and dosage
10. Medication
name and dosage
Current Over-the-Counter Medicines Being Taken
more details
0
/
500
Previous Prescription Medications Taken, Including Dosage and Name of Prescribing Physician
more details
0
/
500
A. Do your injuries prohibit performance of any daily living activities?
example: 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?
Yes
No
A. Please Explain
daily living activities which you can not perform due to your injury
0
/
500
B. Do you have a history of treatment for chemical dependency?
choose yes or no
Yes
No
B. Please Explain
treatment for chemical dependency
0
/
500
C. Do you have any hobbies or interests which are limited due to your injury?
pick one!
Yes
No
C. Please Explain
hobbies and interests which are limited due to your injury
0
/
D. Do you have a history of psychiatric or psychological treatment?
choose yes or no
Yes
No
D. Please Explain
history of psychiatric or psychological treatment
0
/
500
E. Do you have a criminal record?
choose yes or no
Yes
No
E. Please Explain
criminal record
0
/
500
F. Have you ever made any previous claims for personal injuries, medical malpractice, workers’ compensation, or social security disability?
choose yes or no
Yes
No
F. Please Explain
previous claim(s)
0
/
500
Do you have any Injury Photos to upload?
choose yes or no
Yes
No
Injury Photos
upload
cloud_upload
Upload
Do you have any accident photos to upload?
choose yes or no
Yes
No
Accident Photos
upload
cloud_upload
Upload
Do you have any x-rays to upload?
choose yes or no
Yes
No
X-Rays
upload
cloud_upload
Upload
Medical Records
choose yes or no
Yes
No
Medical Recoirds
upload
cloud_upload
Upload
Submit Medical Form
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