Medical Malpractice Intake Sheet

Personal Injury Intake Sheet

PERSONAL INFORMATION

Client's Name:

Aliases:

Date:

Address:

Phone H: W:

SSN: Race: Sex:

Age: DOB:

Marital Status: M S D

Resides With:

List addresses where client has resided during the past 10 years and period of time at each residence

Address: From: To:

Address: From: To:

Address: From: To:

EDUCATION

Educational background, listing names of schools attended, addresses, years attended and any degrees obtained

School: Years attended: Degree:

School: Years attended: Degree:

CHILDREN

Child(ren) Name(s): Age: Date of Birth:

Child(ren) Name(s): Age: Date of Birth:

Father's Name:

Address:

Phone H: W:

Employer: Position Held:

Employer's Address:

Mother's Name:

Address:

Phone H: W:

Employer: Position Held:

Employer's Address:

If client is acting on behalf of a deceased relative, list the names, addresses, telephone numbers and relationships to decedent of the decedent's immediate family

Name: Address: Telephone: Relation:

Spouse's Name:

Is your spouse employed? Yes No

If so, indicate Employer's name: Telephone:

Address of spouse's employer:

Present rate of pay: $ per

Average yearly income of spouse: $ How long with this employer?

EMPLOYMENT INFORMATION

Name of employer (if unemployed, last employer):

Address of employer:

Telephone number:

Personnel Director/Supervisor:

Job title/type of work:

Present rate of pay: $ Per Week Month Year

Hours worked each week: Do you regularly work overtime? Yes No

If so, indicate approximate amount of time & rate of pay: Hours Rate of Pay

Do you receive tips or other type of income? Yes No If so, indicate

Type of income: Amount: $ Per week/month/year:

When did you first begin working for this employer?

If unemployed, when did you leave this employer?

Reason for leaving:

What was your reported income in the year before your accident? $

Were you working for your employer at the time the injury occurred? Yes No

Did you apply for worker's compensation benefits because of your accident? Yes No

If so, indicate the amounts paid to or received by you to date: $

POLICE RECORD

Have you ever been convicted of a felony? Yes No

Place: Charge: Result: Date of conviction:

Is there now, or has there ever been, a restriction on your driver's license? Yes No

If so, describe the details of such restriction:

CLAIMS AND LAWSUITS

Have you ever been involved in any claim or lawsuit, excluding divorce? Yes No

Date: Place:

Against whom:

Nature of claim:

Result:

INSURANCE INFORMATION

Name of insurance company:

Address:

Adjuster's name: Telephone:

Policy number: Policy limits: $

Do you have insurance covering damage to your car? Yes No

Deductible amount: $

How much does your insurance cover if you hurt someone else with your car? $

Uninsured motorist policy limits: $ Med Pay Amount: $

MEDICAL HISTORY BEFORE ACCIDENT

Have you been hospitalized at any time before this accident? Yes No

Date: Name of Hospital and Doctor: Duration: Nature of illness:

Have you had any physical examinations before this accident? Yes No

Date: Name of Doctor and Address: Purpose:

Have you had any accidents or injuries before this accident? Yes No

Date: Place:

Nature of accident/injury:

Name of treating physician:

Claim? Yes No

Have you had any chronic illnesses or diseases before this accident? Yes No

If so, list every such illness or disease suffered in the five years before this accident:

Have you had any other chronic health problems or disabilities? Yes No

If so, list them below:

Did you use any drugs or medication regularly before the accident? Yes No

If so, list the type of drug and reason for use:

Have you ever had any broken bones? Yes No

If so, give date and circumstances:

Date: Circumstances:

MILITARY BACKGROUND

Were you in the military service? Yes No Branch of service:

Dates from to

Type of discharge:

Any service-connected injuries? Yes No If so, describe details:

Have you received or do you receive payments from VA, social security or other source? Yes No Claim number:

FACTS OF THE ACCIDENT

Date: Day: Time:

Weather conditions:

Were seat belts in use in your vehicle? Yes No

If so, who in your vehicle was using a seat belt and who was not using a seat belt?

Were police called to the scene of the accident? Yes No

If so, did the police take photographs of the accident scene? Yes No

If so, which police department has possession of such photographs?

Describe what happened:

DIAGRAM: Indicate on a diagram in the space below what happened. Write in street or highway names or numbers and show direction of travel by arrows. Also, show north by putting an arrow in a circle.

FACTS CONCERNING THE DEFENDANT - (person responsible for accident)

Full name of defendant:

Address:

Name of defendant's employer:

Name of defendant's spouse:

Name of defendant's insurance company:

Address:

Adjuster's name: Phone:

Policy No.: Claim No.: Policy limits: $

Do you know what the defendant's financial circumstances are, excluding any insurance coverage? If so, specify:

Give your observations about the defendant as a person:

Name of 2nd person responsible for accident:

Address:

Name of 2nd person's insurance company:

Address:

Adjuster's name: Phone:

Policy No.: Claim No.: Policy limits: $

Name of 3rd person responsible for accident:

Address:

Name of 3rd person's insurance company:

Address:

Adjuster's name: Phone:

Policy No.: Claim No.: Policy limits: $

OTHER INJURED PARTIES

Were other parties, other than the defendant, injured in this accident? Yes No

Name of 2nd injured party (2nd plaintiff):

Address:

Relationship to you: Telephone number: Birthdate:

WITNESSES TO THE ACCIDENT

Name of 1st witness:

Address:

Telephone: Age:

Employment:

Nature of testimony:

STATEMENTS MADE

Have you talked with any police officer, investigator, insurance adjuster or any other person about this incident? Yes No

Name: Address: Telephone:

Have you given a written or recorded statement to any person about this incident? Yes No

Name of person to whom statement was given:

Date given: If written, do you have a copy? Yes No

Persons present at time:

Did you sign the statement? Yes No

Did the defendant make any statement to you or in your presence concerning this incident? Yes No

If so, indicate what was said and to whom:

When and where was the above statement made?

Date: Place:

List the names and addresses of any persons who may have heard it

Name: Address:

DAMAGES FROM ACCIDENT

State in full detail all injuries you received as a result of this accident:

State your present physical condition such as scars, deformities, headaches, etc.

Describe "loss of enjoyment of life" by listing what normal activities, including sports, hobbies or other activities you enjoyed before this accident and cannot do now as a result of the accident

Activity: Times/week prior to accident: Times/week after accident:

Have you missed time from work as a result of your injuries? Yes No

If so, indicate the following From To

Did you lose wages for the periods of time missed from work due to this accident? Yes No

If so, state the total wages lost to date and the dates

Wages lost: Dates:

Have you had any increases or decreases in your pay since the accident? Yes No

If so, explain:

Did you lose any promotion or merit increase or fringe benefits due to the accident? Yes No

If so, describe:

If self employed, have you had to hire anyone to take your place? Yes No

If so, indicate the costs involved:

If you are a student, indicate time lost from school

From To

Indicate period of time you were confined to your home

From To

Indicate period of time you were confined to bed rest

From To

When is it expected you can return to work?

List any non-monetary compensation you have lost

Have you been forced to borrow any money as a result of your injuries and inability to work? Yes No

If so, describe:

Are you able to work part time? Yes No

If so, where or what kind of work could you do?

List all hospitals in which you were examined or treated or to which you were admitted as a patient as a result of the injuries sustained in this accident

Name of hospital: Address: From: To: Total costs: $

List the full name, address and telephone number of each physician who has examined or treated you for your injuries

Doctor's name: Telephone:

Address:

Specialty:

Type of treatment:

Have you used any of the following in connection with treatment?

Wheelchair Back or neck brace/collar Crutches Traction Physical therapy Other

List all medications which you have taken for injuries, the name of the doctor prescribing each medication and length of time you took the medication

Type of medication: Prescribing doctor's name: Length of time:

Indicate the amount of all bills/expenses incurred to date as a result of this accident (attach copies of all such bills, whether paid or unpaid.) $

Have you sustained any other injuries since this accident? Yes No

If so, indicate date, nature of injury and whether you received medical treatment for said injuries

Date of injury: Nature of injury: Medical treatment:

PROPERTY DAMAGE

If your vehicle was damaged and has been repaired, indicate name and address of party who made repairs

Name of Person who performed repairs:

Address: Telephone number:

Have you incurred car rental expenses? Yes No Total Rental Expense: $

Where is your vehicle presently located?

If any other personal property was damaged, describe said property

Total medical & related expenses to date: $ Date:

Total of property damage amount to date: $ Date:

IMPORTANT

Please collect and attach copies of all medical and related bills incurred to date as a result of this accident, indicating which have been paid and which are still due. Please be sure to forward copies of all future medical bills, drug/medication bills, etc., as they are incurred, even if paid by insurance. See the following two pages for list of items to provide to your attorney and a list of general instructions that will require your attention. In completing this intake sheet, have you thought of any information which I have not asked which may be of some assistance to me in representing you? If so, state it on the back of this form no matter how silly, trivial or embarrassing it may seem.

Instructions to Client

Please be sure to provide me with the following

1. All medical and hospital records

2. Photographs (of scene of accident, of client showing injuries, braces, casts, etc., of automobile or other damaged property)

3. All hospital, medical and related bills, either paid or unpaid (physicians, surgeons, ambulance, hospitals, private nursing care, therapy, drugs/medication, crutches, braces, x-rays, domestic help, car rental, clothing, etc.)

4. Income tax returns for the last five years

5. Your automobile insurance policy or policies

6. Insurance policy that may require aid of attorney to notify and collect (income protection, hospitalization, etc.)

7. Copies of any statements previously made to anyone (opposing side, your insurance carrier, etc.)

8. Repair bill on any damaged property

9. Repair estimates on any damaged property

10. Purchase invoices and estimates of value of personal property damaged or lost in accident (including clothing, jewelry, cameras, and all other property damaged in accident)

11. Correspondence with insurance company, insurance adjusters

12. Business cards from insurance company agents and adjusters, opposing driver, etc.

13. Copy of any accident reports

14. Statement from employer regarding lost wages showing time and wages lost from work

15. Copies of check stubs and/or other records showing hourly rate of pay

16. Copies of any application for other insurance benefits

17. Copy of any application for unemployment benefits

18. Copy of social security card

19. Make copy of current driver's license

Please note the following general instructions

1. Do not talk to insurance adjuster

2. Do not discuss the facts of the accident with anyone before having your first conference with the attorney

3. Do not sign anything without your attorney's permission

4. Keep a diary of your trips to all doctors, hospitals, therapists and notes of your pain with times and dates

5. Keep all your medicine bottles and containers (as possible evidence at trial)

6. Bring or send all future medical bills to attorney's office

7. When you return to treating physicians for follow-up examinations, be sure to advise them at each examination the nature of all of your continuing problems resulting from the accident

8. Keep a record of all out-of-pocket expenses, including travel expenses for medical treatment

9. Report to your attorney any suspicious actions, such as someone taking pictures, movies, etc.

Employment Contract and Power of Attorney in a Personal Injury Case

THIS AGREEMENT made this date at , , by and between , Attorney at Law, hereinafter known as ATTORNEY and hereinafter known as CLIENT.

CLIENT retains ATTORNEY to represent him as his Attorney at Law in a cause of action against regarding the following facts, to-wit:

This contract empowers ATTORNEY to institute such legal action as may be advisable in his judgment and to compromise and settle the matter at any time, with the consent of the CLIENT, and CLIENT agrees to pay ATTORNEY for his services, percent (%) of the amount recovered if settled without suit, or, (%) of the amount recovered after suit is instituted by filing the first paper therein for litigation through Circuit, Chancery, or Federal Court.

In the event of an appeal to the State Supreme Court or the Federal Appellate Courts, ATTORNEY shall be further entitled to all penalties assessed against the Defendant, as his fee. All costs and expenses advanced by the ATTORNEY shall be deducted from the CLIENT'S share.

CLIENT hereby assigns and gives ATTORNEY a lien on said claim, cause of action, and/or any sum recovered by way of settlement or judgment thereon for the sum and share hereinabove mentioned as his fee.

CLIENT agrees that if this employment agreement is terminated by CLIENT for any reasons after employment begins but prior to a settlement offer being extended, that ATTORNEY is entitled to be paid for his time expended to the date of termination at a liquidated rate of dollars ($) per hour, plus reimbursement of all advanced cost and expenses.

CLIENT hereby gives ATTORNEY his POWER OF ATTORNEY to execute all complaints, claims, contracts, checks, settlements, drafts, compromises, releases, verifications, dismissals, deposits and orders as he would himself.

Medical Authorization

TO WHOM IT MAY CONCERN:

I, the undersigned , hereby authorize any physician, hospital, nurse, chiropractor, dentist, psychologist, or other medical attendant to furnish full and complete medical reports, records, and other information herewith requested by , Attorney at Law, or to any representative, attorney or investigator from his firm.

The purpose of this authorization is to allow the above attorney to obtain all medical records which will aid in or are necessary for the prosecution of claims I am making.

This authorization includes the right to examine all x-rays and records of any kind, and the right to receive full and complete information pertaining thereto, including copies of all such records.

This authorization is intended to and will allow the above attorney to obtain any and all medical records, and shall include any and all records prior to or subsequent to the date of the claim referred to above.

In addition, it is expected that I may need further treatment beyond the date of this authorization, and you are therefore authorized and requested to provide to the above attorney any and all medical records related to examinations and treatment which take place subsequent to the date of the execution of this authorization, so long as this authorization has not been cancelled or revoked by me in writing.

Your full cooperation with my attorney is requested. You are further requested to disclose no information nor discuss my medical condition with any insurance adjuster or other person without my written authority to do so.

This authority shall be valid until cancelled or revoked by me in writing.

A photostatic copy of this authorization shall be considered as effective and as valid as the original.

ALL PRIOR AUTHORIZATION IS HEREBY CANCELLED

Form 4506 Request for Copy of Tax Form or Individual Income Tax Account Information

1. Name of taxpayer as shown on tax form:

Current name and address:

2. If information is to be mailed to someone else, show the third party's name and address

Name:

Address:

3. If name in third party's records differs from item 1 above, show here:

5. Social security or employer identification number as shown on tax form:

Spouse's social security number as shown on tax form:

Spouse's name:

7. Tax form number (Form 1041, 941, etc.):

8. Tax period(s) (No more than 4 per request):

9. Amount due (Make check payable to IRS): $

10. Describe what you want (Check only one box)

$5.00 each Copy of tax return and all attachments (including forms W-2)

Note: if you need these copies certified for court or administrative proceedings, check here also

$2.50 each Tax account information only (do not use for income averaging)

$2.50 each Form 1040a or form 1040ez verification only

Telephone:

Out of Pocket Expenses

Client:

DOCTOR BILLS

$

$

TOTAL DOCTOR BILLS $

DRUGS

$

$

TOTAL DRUG BILLS $

HOSPITAL

$

$

TOTAL HOSPITAL BILLS $

PROPERTY DAMAGE

$

$

TOTAL PROPERTY LOSS $

EARNINGS LOSS

$

$

TOTAL EARNINGS LOSS $

OTHER LOSS

$

$

TOTAL OTHER LOSS $

TOTAL OUT OF POCKET LOSS $