Medical Malpractice Questionnaire

First Name*
Last Name*
Date of Birth*
Date Format: MM slash DD slash YYYY
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
Date Format: MM slash DD slash YYYY
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:
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.
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Call for a FREE case review: (702) 570-0000

Llame para una revisión de caso GRATIS: (702) 570-0000

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

Shook & Stone

Shook & Stone

Shook & Stone

Call for a FREE case review: (702) 570-0000 Llame para una revisión de caso GRATIS: (702) 570-0000

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: (702) 570-0000

Llame para una revisión de caso GRATIS: (702) 570-0000