Attorneys

Date of the Injury

Cause of the Injury:

Car/Vehicle Accident
Sports/Recreational Accident
Failure to Diagnose
Incorrect diagnosis
Failure to promptly treat the condition
Surgical Error
Medical Error
Emergency room error
Cerebral Palsy
Erb's Palsy
Other

Which symptoms have you experienced?

Headaches
Dizziness
Loss of sleep
Memory loss
Sensitivity to light
Personality change
Difficulty with Numbers
None
Other

What type of injuries do you have?

What is the extent of your injuries?

Have you seen a doctor?

Yes
No

Diagnostic tools that medical professionals have used to determine the extent of the injury:

MRI
CT Scan
PET Scan
EEG
None
Other

Have you undergone physical/occupational therapy?

Yes
No

What are your medical bills?

Have you lost time from work as a result of the injury?

Yes
No

Have you filed any claims?

Yes
No

Have you filed a police report?

Yes
No

Were there any witnesses?

Yes
No

Do you have insurance that covers you for this type of incident?

Yes
No
Not Sure

Do other involved parties have insurance that covers this type of incident?

Yes
No
Not sure

* Please enter the security code shown below: