CLIENT QUESTIONNAIRE - PERSONAL INJURY

ALL INFORMATION SUPPLIED IN QUESTIONNAIRE IS CONFIDENTIAL AND PROTECTED BY ATTORNEY CLIENT PRIVILEGE

PERSONAL INFORMATION FOR THE PERSON INJURED OR DECEASED













*Caution: You may want to review any web-based social sites of content that would portray you in an unfavorable light.

INFORMATION ABOUT THE PERSON WHO IS SEEKING TO SERVE IN A REPRESENTATIVE CAPACITY OR IS ASSERTING A LOSS OF CONSORTIUM CLAIM (PR OF THE ESTATE, PARENT OF MINOR CHILD, FAMILY MEMBER OF INCAPACITATED PERSON, SPOUSE OF INJURED PARTY, ETC.)















*Caution: You may want to review any web-based social sites of content that would portray you in an unfavorable light.


FAMILY INFORMATION FOR THE INJURED PERSON

























EMPLOYMENT INFORMATION FOR THE INJURED PERSON

























HEALTH INSURANCE INFORMATION FOR THE INJURED PERSON




EDUCATION INFORMATION FOR THE INJURED PERSON

Please state all of your educational experience below beginning with your high school.












HEALTH CARE PROVIDERS FOR THE INJURED PERSON

Please provide the names, addresses and dates of treatment for all your doctors, hospital visits, nursing care, physical therapy, massage, etc. If you had any different primary care physicians than you have now in the past ten years, please also list them.
















WITNESSES

WITNESS 1







WITNESS 2







WITNESS 3







WITNESS 4







MEDICAL EXPENSES FOR THE INJURED PERSON


TYPE OF EXPENSE/AMOUNT













CONFINEMENT OF PERSON DUE TO HIS/HER INJURIES

If you were ever confined to a bed, home or hospital for your injuries/illness alleged to be caused by the malpractice, please complete the following. (If not applicable, please indicate N/A.)

PROVIDE LENGTH OF TIME AND DATES




PHARMACIES WHO FILLED PRESCRIPTIONS FOR THE INJURED PERSON

Please list the names and addresses of pharmacies from which you obtained medications/prescriptions relative to your injury/illness.





MEDICATIONS USED BY THE INJURED PERSON

Please list the medication you are taking and if they are new since your injury.













PERSON WHO CAUSED ACCIDENT OR INJURIES TO POTENTIAL CLIENT

Please identify the person, company or hospital that you believe injured you.


BASIS OF YOUR CLAIM OF NEGLIGENCE

Please indicate why you believe the above person, company or hospital did something wrong which caused your injury.


CURRENT SYMPTOMS OF THE INJURED PERSON

Please list in detail the symptoms you currently suffer either continuously or intermittently since your injury, indicate how often you experience each of these symptoms, rate the pain you suffer on a scale from 1-10 with 1 being the least pain you have ever suffered and 10 being the most, and specify what if any medications or treatments you are taking or receiving for these symptoms.


PROGNOSIS FROM DOCTORS OF THE INJURED PERSON

If your doctors have indicated to you whether they believe your symptoms are likely to be permanent or whether they believe that your symptoms will resolve over time, please indicate what you were told.


LIMITATIONS/ALTERATIONS IN LIFESTYLE OF THE INJURED PERSON

Please list activities that you are no longer able to perform or perform with difficulty.


PRIOR GENERAL HISTORY OF THE INJURED PERSON

Prior to this injury, have you ever sought medical treatment at any time in your life for similar symptoms? If yes, to the best of your ability provide the approximate date and the health care provider involved and describe the circumstances.


Other than the injury you are complaining of, do you have any other significant health problems not related to this injury? If yes, please describe in detail including any medications you are taking.


Since the date of your injury, have you been involved in any other accidents or incidents that may have aggravated your symptoms? If yes, describe in detail.


Have you ever received any type of mental health counseling? If yes, where and when.


Have you ever been injured on the job and filed a workers’ compensation claim? If yes, provide the date and details of claim.


Is there any significant family history for the type of symptoms that you listed above that you are currently experiencing related to this injury?


Have you ever used tobacco products of any type?



If yes, indicate the time period of use, the product type (e.g. cigarettes), and the approximate number consumed per day


Do you regularly drink alcoholic beverages? If yes, what type, how often and how many per day or week.


Have you ever received any treatment for any type of substance abuse (alcohol or drugs)? If yes, where and when.


PRIOR COURT EXPERIENCE OF THE INJURED PERSON

Have you ever been convicted of a crime other than a traffic ticket? If yes, please describe in detail the offense, date of conviction, sentence and jurisdiction where the conviction occurred.


Have you ever been a plaintiff in a lawsuit? If yes, indicate the date, nature of the legal action and result.


Have you ever filed for bankruptcy or do you have a present intention to do so? If yes, provide details.


OTHER INFORMATION

Please indicate provide any additional information that you believe would be helpful to us in evaluating your possible injury claim that you have not already provided above. In a malpractice case, if another doctor told you there was a mistake in treatment, list the name of the doctor and what was said.


If the victim is deceased, has an estate been opened?

If the victim was under 18 years of age, please complete the questions below.



If parents of minor are divorced or separated, list the custodial parents name, address and phone number.


If the victim is incompetent to handle his/her own affairs, has someone been appointed guardian or conservator for the victim? If so, give name, address, and phone number of person appointed and send copies of documents showing the appointment.


Have you talked with any other attorney regarding your complaint of negligence or harm?



If answer is yes, please state the attorney you talked with and whether you have signed a fee contract with that attorney.






Where did you hear about this firm?