Forms – Medical Malpractice Questionnaire

By coming to talk with us about your possible case, you claim that you have been injured. We need the following information from you. Please be as thorough and complete as possible. Please answer all questions and think carefully before answering because part of our decision of whether or not our firm can take you case will be based on your answers. If you don’t understand a question, please ask us about it.

* = required fields

Date:                 
Seen by:                 

Victim of Malpractice – Patient Information:

* Name:                 
Date of Birth:                 
* Address:                 
City:                 
State:                 
Zip:                 
* Home Phone:                 
Work Phone:                 
Marital Status:                 
SSN:                 
Employer:                 
Occupation:                 
Highest Year of Education:                 
Number of College Degrees:                 

Family Information:

Spouse's Name:                 
Number of Children:                 
Children's Name(s):                 
Name of Father:                 
Age of Father:                 
Address of Father:                 
City:                 
State:                 
Zip:                 
Name of Mother:                 
Age of Mother:                 
Address of Mother:                 
City:                 
State:                 
Zip:                 

Doctor Information

Doctor's Name:                 
Kind of Doctor:                 
Specialty:                 
Address of Doctor:                 
City:                 
State:                 
Zip:                 
Date(s) treating patient:                 
Condition being treated:                 

Nature of treatment:


What was done wrong:


Date(s) of when malpractice was committed:


When and how did you discover malpractice:

Date(s) Committed:                

Hospital(s)/Clinic(s) Information

Hospital(s)/Clinic(s) Name(s):                 
Address of Hospital/Clinic:                 
City:                 
State:                 
Zip:                 
Admission date(s):                 
Reason(s) for admission:                 
Date(s) of other treatment:                 
Condition being treated:                 

Nature of treatment:


What was done wrong:


Date(s) of when malpractice was committed:


When and how did you discover malpractice:

Damages Resulting from Malpractice

Describe the pain, disability, disfigurement that you complain of today:

Amount of lost income:


Explain how loss was computed:

Have you ever been injured? (Yes or No):


How and when were you injured and what were the injuries sustained:

Have you ever had any medical treatment to the same areas of your body that was injured by the negligence you believe occurred?:

If so, what, when and why?:

Have you ever filed any claims or lawsuits? (Yes or No):


If so, against who and what was the nature of your claim?:

Witnesses

Name all of the people who know about the doctor’s malpractice
and also those who know about your damages: