Personal Injury Questionnaire

*Name:
*Email Address:

What is the identity of the doctor and/or hospital in question?

What is the age of the person who is claiming injury as a result of the claimed malpractice?

When did you begin the medical treatment in question? When did the treatment end?

Was the treatment rendered at a municipal hospital or clinic?

What occurred that leads you to believe a health care professional caused you harm?

Has any health care professional critized the care provideed to you?

Has the medical care you received caused you an injury? If so what is the nature of the injury or injuries?

Did anyone discuss the risks of the treatment or medication at issue with you?

Do you have any of the relevant medical records in your possession?

If the medical care was provided to a deceased relative has a representative of the Estate already been appointed by the Court?

Was the physician in question assigned to you by a hospital?

Why did you go to the doctor/hospital? What happened?

What is the current status of that condition?

What were you diagnosed with?

What treatment did you receive? What were the results of that treatment?

Are you currently under a doctor's care? For what?

Have you lost any time from work or school as a result of the injuries?

Have you been confined to a hospital or rehabilitation facility as a result of the injuries you have sustained? If so for how long?

What is your diagnosis? Prognosis?