Information for Your Lawyer: Medical Background

Created by FindLaw's team of legal writers and editors | Last updated December 03, 2018

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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:

_____________________________________________________________

Length of Time at that Address: _______ years _______ months

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

_____________________________________________________________

Home Telephone Number: _______________

Work Telephone Number: ____________________

Facsimile Number: ____________________

E-mail Address: ____________________

Former Name(s): ________________________________________

Current Employer: ____________________

Job Position/Title: ____________________

Employer’s Address:

______________________________

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?

_______________ _________ _______________

Do you have medical or health insurance? ___________________Yes/No

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

_____________________________________________________________

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

If No, provide explanation: ___________________________________________

_____________________________________________________________

Date of Onset of Illness or Dates of Hospitalization: _____________________________

Present Medical Diagnosis: _________________________________________________

_____________________________________________________________

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

_____________________________________________________________

Names and Locations of All Medical Providers Seen for Illness:

_____________________________________________________________

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

_____________________________________________________________

Description of Medical Attention Received:

_____________________________________________________________

Current Medical Condition:

_____________________________________________________________

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

_____________________________________________________________

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

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

_____________________________________________________________

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:

_____________________________________________________________

Current Over-the-Counter Medicines Being Taken

_____________________________________________________________

Previous Medical History:

_____________________________________________________________

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

_____________________________________________________________

Previous Over-the-Counter Medicines Being Taken:

_____________________________________________________________

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

_____________________________________________________________

Significant Family History for Diseases, Illnesses or Medical Conditions:

_____________________________________________________________

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

_____________________________________________________________

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

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

_____________________________________________________________

Hobbies/Interests:

_____________________________________________________________

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

Explain: _________________________________________________

_____________________________________________________________

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

Explain: ______________________________________________________

_____________________________________________________________

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

Explain: ______________________________________________________

_____________________________________________________________

Do you have a criminal record? ___________________Yes/No

Explain: ______________________________________________________

_____________________________________________________________

Other Important Information:

_____________________________________________________________

Questions to Ask My Attorney:

_____________________________________________________________

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.

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Contact a qualified medical malpractice attorney to make sure your rights are protected.

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Information for Your Lawyer: Medical Background

Intake Form: Illness & Hospitalization

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