Medical Malpractice Questionnaire

Full Name*

Date of Birth*

Address*

Street Address City State ZIP Code

Length of Time at that Address

Home Phone*

Work Phone

Cell Phone

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 therapist, chiropractors, or others who have treated you for this injury:

Name

Tel. Number

Address

Have you ever suffered injuries or had injuries or had illnesses similar to those suffered in this incident? Included Date and Description

Employment Information

Current Employer

Job Position/Title:

Employer’s Address/Phone Number:

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:

Take photographs of your injuries, if possible.
Give no information to anyone other than our office.
Forward copies of all bills or receipts for hospital, x-ray, loss of earnings and medical reports.
Additional instructions will be given to you based on your individual situation.

Call for a FREE case review: (888) 662-2013

Llame para una revisión de caso GRATIS: (888) 662-2013

Medical Malpractice Questionnaire

List all doctors, hospitals, physical therapist, chiropractors, or others who have treated you for this injury:

Employment Information

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

Contact us for a FREE consultation

Las Vegas Office

Reno Office

Henderson Office

Call for a FREE case review: (888) 662-2013 Llame para una revisión de caso GRATIS: (888) 662-2013

Medical Malpractice Questionnaire

List all doctors, hospitals, physical therapist, chiropractors, or others who have treated you for this injury:

Employment Information

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

Contact us for a FREE consultation

Call for a FREE case review: (888) 662-2013

Llame para una revisión de caso GRATIS: (888) 662-2013