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General Medical Malpractice Wrongful Death

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Address:

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Phone

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RelationToInjured:

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LearnAboutFirm

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Explain:

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Have you seen another attorney?

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Whom:

Answers To The Following Questions Should Pertain To The Injured Or Deceased Person

NameOfInjured:

Please enter the name of the injured party.
DOB:

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SSNumber:

Please enter your social security number.
ListAccidents

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PassengerAccident

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TicketAccident

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Have you ever been arrested before?

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IfSoWhen:
Where:
Charges:
ListAddresses

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ListLawSuit

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Deposition

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Bankruptcy

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SocialMedia

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FamilyMember

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Medical

EmergencyRoom

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XRays

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MRI

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CTScan

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Medications

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Counselors

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Employment

EveryJob

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Automobiles

EveryAutomobile

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Licenses

Licenses

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Medical Malpractice Questionnaire

All Consultations are Free and Confidential

Name:

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Address:

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Phone

This isn't a valid phone number.
Email:

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Employer:
Position:
RelationToInjured:

Please enter your relationship.
LearnAboutFirm

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Explain:

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Have you seen another attorney?

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Whom:

Answers To The Following Questions Should Pertain To The Injured Or Deceased Person

NameOfInjured:

Please enter the name of the injured party.
DOB:

Please enter your date of birth.
SSNumber:

Please enter your social security number.
Date Of Injury:

Please enter your date of injury.
Approximate Time:

Please enter your date of injury.
Facility and Doctor Where Injury Occurred:

Please enter your date of injury.
Facility Address:

Please enter your date of injury.
Injury Details
Accident Details

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Were any relatives a witness to the occurrence in question? If so, please identify those persons.

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What injuries were sustained as a result of this incident?

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What physical or mental impairments were incurred as a result of this incident?

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Please list all medication being taken by the injured person.

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What pharmacies do you use to fill the prescriptions?

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Please list the EMS, Doctors, hospitals, clinics, labs, which have treated you for the injuries sustained as a result of this incident.
- Name:
  
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- Address:
  
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- Phone
  
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- Date:
  
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- Treatment Received:
  
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- Name:
  
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- Address:
  
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- Phone
  
  This isn't a valid phone number.
- Date:
  
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- Treatment Received:
  
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- Name:
  
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- Address:
  
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- Phone
  
  This isn't a valid phone number.
- Date:
  
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- Treatment Received:
  
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Prior Medical History

List all prior injuries, surgeries, major illnesses, hospitalizations, and/or MRIs the injured party may have had:
- Facility Name:
  
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- Facility Address:
  
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- Facility Phone
  
  This isn't a valid phone number.
- Treatment For:
  
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- How did this injury occur?:
  
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- Facility Name:
  
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- Facility Address:
  
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- Facility Phone
  
  This isn't a valid phone number.
- Treatment For:
  
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- How did this injury occur?:
  
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- Facility Name:
  
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- Facility Address:
  
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- Facility Phone
  
  This isn't a valid phone number.
- Treatment For:
  
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- How did this injury occur?
  
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- Facility Name:
  
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- Facility Address:
  
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- Facility Phone
  
  This isn't a valid phone number.
- Treatment For:
  
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- How did this injury occur?
  
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Have you previously been treated by a psychiatrist, psychologist, counselor or therapist?

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Name of Facility:

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Phone

This isn't a valid phone number.
Condition for treatment received:

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Employment History
Please list your employment over the past 10 years.
- Employer1:
  
  Please enter your response.
- Pay Rate:
- Employer Address:
  
  Please enter your response.
- Date Range:
  
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- Position:
  
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- Employer:
  
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- Pay Rate:
- Employer Address:
  
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- Date Range:
  
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- Position:
  
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- Employer:
  
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- Pay Rate:
- Employer Address:
  
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- Date Range:
  
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- Position:
  
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- Employer:
  
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- Pay Rate:
- Employer Address:
  
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- Date Range:
  
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- Position:
  
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Residence History
Please list all residences of the injured person and the dates they resided at each for the past 20 years:
Residence Address:

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Address Dates:

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Residence Address:

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Address Dates:

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Residence Address:

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Address Dates:

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Social Media

Please be aware that all social media content can be used against you. We ask that you disable all accounts. List “user names” for all your social media websites (FaceBook, Youtube, Twitter, Instagram, LinkedIn, etc)
Social Media Accounts:

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Criminal History
Has the injured party ever been arrested?

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If so, please provide details below.
Arrest Date:

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County:

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Charges:

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Result:

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Arrest Date:

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County:

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Charges:

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Result:

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Claims History
Has the injured party had any previous claims (including Workers’ Compensation claims) for personal injuries?

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Type of Claim:
Against Whom?
Have you ever had your sworn statement taken by an attorney or insurance adjuster?
Have you ever been a party to any lawsuits?

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Where was the lawsuit filed?
Who was your attorney?
Result
Have you ever filed for bankruptcy? If so, list the court, name of your attorney, and the date of discharge.

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Health Insurance/Medicaid/Medicare
Is the injured party covered under any health insurance?

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If so, what?
Medicare or Medicaid
Child Support Liens
Are you obligated to pay child support?

Please make a selection.
If no, do you receive child support?
If yes, please provide the following information:
Name of Parent to whom child support is paid
Names and ages of children for whom child support is paid
County where the child support order was filed
Are you current with your child support obligations?
If not, what is the total amount of child support owed?

By submitting this document, I promise that I have completed it to the best of my ability. I understand that a misrepresentation made in this document can be grounds for terminating the Attorney/Client relationship with CDA.

Wrongful Death Questionnaire

All Consultations are Free and Confidential

Your Name:

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Address:

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Phone

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Email:

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Employer:
Position:
Your DOB:
Relation to Injured Party (self, spouse, child, etc.)

Please enter your relationship.
How did you learn about our firm?

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Have you seen another attorney?

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If so, whom?:
Name of Deceased:

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DOB of Deceased:

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SSN of Deceased:

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Date of Death:

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Date of Injury/Incident:

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Approximate Time:

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Location and/or name of facility where incident occured:

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Address:

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Children of the Deceased

Probate Information

Was there a Last Will & Testament?

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Has the Will been probated?

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Name of the attorney handling the probate of the will:

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Who is the Executor/Executrix of the Estate?

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If there was not a Will, has an Administrator of the Estate been appointed by the Court?
Name and Address of Administrator:
- If the deceased did not have a will or it is unknown if a will exists, provide the following information:
- List the name of the spouse and all children of the deceased, indicating their current address and phone number. If the spouse or a child is deceased, please indicate below:
- If the deceased is not survived by a spouse or children, identify the parents and brothers and sisters of the deceased indicating their current address and phone number. If the parents and/or a brother or sister are also deceased, please indicate below:
Please list the hobbies and interests of the deceased:

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This Accident
Please state in detail what you know of the incident which resulted in death:

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Do you know if anyone gave a statement regarding this injury:

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If so, to whom?
Were any relatives a witness to the occurrence in question?

Please enter a response.
If so, please identify those persons.
Were any other persons injured because of the occurrence?

Please enter a response.
If so, please identify those persons.
Please list all medications being taken by the injured person at the time of death

Please enter a response.
Please list the EMS, Doctors, hospitals, clinics, and labs which have treated the deceased for the injuries sustained because of this incident.
Name1:

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Address1:

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Phone

This isn't a valid phone number.
Date:

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Treatment Received:

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Name:

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Address2:

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Phone2

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Date2:

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Treatment Received:

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Name:

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Address:

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Phone

This isn't a valid phone number.
Date:

Please enter your response.
Treatment Received:

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Medical History
List all prior injuries, surgeries, major illnesses, and hospitalizations the deceased had.
Facility Name:

Please enter your response.
Facility Address:

Please enter your response.
Phone

This isn't a valid phone number.
Date:

Please enter your response.
Treatment Received:

Please enter your response.
Facility Name:

Please enter your response.
Facility Address:

Please enter your response.
Facility Phone

This isn't a valid phone number.
Date Visited:

Please enter your response.
Treatment Received:

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Facility Name:

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Facility Address:

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Facility Phone

This isn't a valid phone number.
Date Visited:

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TreatmentReceived3:

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Facility Name:

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Facility Address:

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Facility Phone

This isn't a valid phone number.
Date Visited:

Please enter your response.
Treatment Received:

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Was the deceased being treated by a psychiatrist, psychologist, counselor or therapist?
If so, please list the following details:
- Name of Facility
  
  Please enter your response.
- Phone:
  
  Please enter your response.
- Condition for which treatment received:
  
  Please enter your response.
Deceased's Employment History
Present Employer:

Please enter your response.
Pay Rate:
EmployerAddress1:

Please enter your response.
How long was the injured party employed here?

Please enter your response.
Position:

Please enter your response.
Previous Employer:

Please enter your response.
Pay Rate:
Employer Address:

Please enter your response.
How long was the injured party employed here?:

Please enter your response.
Position:

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Has the deceased ever been fired or let go from an employer?

Please enter your response.
Residence History

Please list all residences of the injured person to the best of your knowledge and the dates they resided at each for the past 20 years.
- Address:
  
  Please enter your response.
- Dates the injured person resided at this address:
  
  Please enter your response.
- Address:
  
  Please enter your response.
- Dates the injured person resided at this address:
  
  Please enter your response.
- Address:
  
  Please enter your response.
- Dates the injured person resided at this address:
  
  Please enter your response.
- Address:
  
  Please enter your response.
- Dates the injured person resided at this address:
  
  Please enter your response.
Social Media

Please be aware that all social media content can be used against you. We ask that you disable all accounts. List “user names” for all your social media websites (FaceBook, Youtube, Twitter, Instagram, LinkedIn, etc)
SocialMediaAccounts:

Please enter your response.
Criminal History
Has the injured party ever been arrested?

Please make a selection.
Arrest Date:

Please enter your response.
County:

Please enter your response.
Charges:

Please enter your response.
Result:

Please enter your response.
Arrest Date:

Please enter your response.
County:

Please enter your response.
Charges:

Please enter your response.
Result:

Please enter your response.
Health Insurance/Medicaid/Medicare
Is the injured party covered under any health insurance?

Please enter your response.
If so, what?
Medicare or Medicaid
Child Support Liens
Are you obligated to pay child support?

Please make a selection.
If no, do you receive child support?
If yes, please provide the following information:
Name of Parent to whom child support is paid
Names and ages of children for whom child support is paid
County where the child support order was filed
Are you current with your child support obligations?
If not, what is the total amount of child support owed?

Answers To The Following Questions Should Pertain To The Injured Or Deceased Person

Medical

Employment

Automobiles

Licenses

Answers To The Following Questions Should Pertain To The Injured Or Deceased Person

Injury Details

Prior Medical History

Employment History

Residence History

Social Media

Criminal History

Claims History

Health Insurance/Medicaid/Medicare

Child Support Liens

Probate Information

This Accident

Medical History

Deceased's Employment History

Residence History

Social Media

Criminal History

Health Insurance/Medicaid/Medicare

Child Support Liens