Information for Your Lawyer: Medical Background

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If you are suing a doctor, hospital, pharmaceutical company, medical device manufacturer, or other similar person or entity, you will want to hire an experienced attorney to best represent your interests. During your first few meetings with that attorney, there is a lot of information you will have to provide in order to ultimately prove fault. The following intake form can be filled out, in advance of those meetings. This form will enable your attorney to learn a little bit about your background, and a lot about your case. For example, your attorney will obviously need to know about your medical situation. In addition, he or she may want to know about your employment status and your income. If you have lost time from work due to your illness or hospitalization, your attorney may be able to help you recover those lost wages.

See belox for an Intake Form that will help you and your attorney with the advancement of any possible medical malpractice claims that you have.

 

Intake Form: Illness & Hospitalization

 

Name: ________________________________

 

Date of Birth: __________________________

 

Social Security Number: __________________

 

Address:

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Length of Time at that Address: _______ years _______ months

 

Previous Address(es) (for last 10 years):

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Home Telephone Number: _______________

 

Work Telephone Number: ____________________

 

Facsimile Number: ____________________

 

E-mail Address: ____________________

 

Former Name(s): ________________________________________

 

Current Employer: ____________________

 

Job Position/Title: ____________________

 

Employer’s Address:

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Length of Time with Employer: _______ years

 

Gross Monthly Income: $_________________

 

Marital Status: _________________________________

 

Previous Marriage(s): Yes ____ No ____ How ended?_________________

 

Children

Name Date of Birth Living in home?

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Do you have medical or health insurance? ___________________Yes/No

If Yes, provide information on policy (insurance company, etc.) : _______

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Are your premium payments up-to-date? ______________Yes/No

If No, provide explanation: ___________________________________________

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Date of Onset of Illness or Dates of Hospitalization: _____________________________

 

Present Medical Diagnosis: _________________________________________________

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Description of How Illness Was Contracted or Why Hospitalization Was Required:

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Names and Locations of All Medical Providers Seen for Illness:

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Names and Locations of All Hospitals Where You Are/Were a Patient:

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Description of Medical Attention Received:

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Current Medical Condition:

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Surgeries Performed or Scheduled As a Result of Illness or Hospitalization:

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Did your doctor discuss the risks of the surgical procedure with you? ______________Yes/No

If Yes, what were you told about the procedure? ____________________

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If Yes, did you sign an informed consent form? _____________Yes/No

 

Current Prescription Medications Being Taken, Including Current Dosage and Name of Prescribing Physician or Medical Provider:

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Current Over-the-Counter Medicines Being Taken

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Previous Medical History:

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Previous Prescription Medications Being Taken, Including Dosage and Name of Prescribing Physician:

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Previous Over-the-Counter Medicines Being Taken:

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Any History of Similar/Same Illness or Need for Hospitalization:

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Significant Family History for Diseases, Illnesses or Medical Conditions:

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Does illness prohibit performance of any daily living activities? (Examples: Can you brush your hair? Dress yourself? Drive a Car?):

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Did you lose time from work since illness?_______________Yes/No

 

Amount of time lost including specific dates, if known: _________________________________________________________________

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Hobbies/Interests:

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Does illness prevent you from engaging in these hobbies/interests?_______Yes/No

Explain: _________________________________________________

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Do you have a history of treatment for chemical dependency? _________Yes/No

Explain: ______________________________________________________

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Do you have a history of psychiatric or psychological treatment? _______________Yes/No

Explain: ______________________________________________________

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Do you have a criminal record? ___________________Yes/No

Explain: ______________________________________________________

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Other Important Information:

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Questions to Ask My Attorney:

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Get Legal Help for Your Medical Malpractice Claim

If you have lost time from work due to your illness or hospitalization, your attorney may be able to help you recover those lost wages. As you can probably tell from the intake form, medical malpractice claims are quite complex and require an experienced hand. Contact a skilled medical malpractice attorney to explore your potential claim.