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Medical Malpractice Questionnaire

1 Step 1

Personal Information

Injury Information

Employment Information

Current Prescription Medications Being Taken, Including Current Dosage and Name of Prescribing Physician or Medical Provider

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?
B. Do you have a history of treatment for chemical dependency?choose yes or no
C. Do you have any hobbies or interests which are limited due to your injury?pick one!
D. Do you have a history of psychiatric or psychological treatment?choose yes or no
E. Do you have a criminal record?choose yes or no
F. Have you ever made any previous claims for personal injuries, medical malpractice, workers’ compensation, or social security disability?choose yes or no
Do you have any Injury Photos to upload?choose yes or no
Do you have any accident photos to upload?choose yes or no
Do you have any x-rays to upload?choose yes or no
Medical Recordschoose yes or no
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