Fill and Sign the Re General Information Questionnaire

General Information Questionnaire Personal and Family History Full name __Present home address __Home phone ______________________________Business phone Have you ever used, or been known by, any other name than that shown above? If so, list here each other name, and state when and why each other name was used: __________ State the addresses where you have resided during the past 10 years, and the period of time at each residence, including dates:_____________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________Place of birth ___________________________________Date __ Have you ever used any other date or place of birth? _______ If so, explain: _______________________________________________ ___Are you presently married? ___ Date of marriage ____________________Place of marriage Full name of spouse ___ Have you ever been divorced or legally separated? List the names, ages and addresses of all those (including children) who are dependent upon you for support, and your relationship to each:NAME ADDRESSAGE RELA TIONSHIP _____________________ ______ Employment History Social Security number __ Most recent employer __Employers address __Ending date _______________________________Beginning date Job classification ___ Beginning pay rate ____________________________Ending pay rate Reason(s) for leaving ___Employer prior to last listed _Employers address _Ending date ________________________________Beginning date Job classification ___Beginning pay rate _____________________________Ending pay rate Reason(s) for leaving ___ Educational Background What education have you had, including any special job training? ______________ Military Background Have you been in the military service? If so, give service number __Type of discharge __Dates of service __Have you ever been rejected for military service because of physical, mental or other reasons? _______If so, explain: ___________ _____________________________________________________________________________________ Do you have any service -connected injuries or disabilities? If so, give details: ____________________ __ Percentage of disability __ Present condition of service-connected injury or disability Do you receive payments for service-connected injuries? ________ If so, explain; _______________________________________________________________________ _____________________________________________________________________________________ Prior Claims and Lawsuits Many cases have been damaged beyond repair by a history of other claims and lawsuits which your attorney did not know about. It is NOT the fact that one has had other claims or lawsuits that is important, for one will not be penalized by a court or jury if the claims are reasonable and genuine. It is the DENIAL of previous claims and suits that damages the case. List every claim you have ever made for personal injury or property damage, and give details:a) Date _____________________________ Nature of claim Against whom ________________________________Suit filed? Result ____ b) Date _____________________________ Nature of claim _ Against whom ________________________________Suit filed? Result ___ c) Date _____________________________Nature of claim Against whom ________________________________Suit filed? Result ____ Police Record Under the rules of evidence, there are circumstances under which a person s prior criminal record may be relevant in a proceeding. The other attorney will make a complete investigation of your background, and we must be PREPARED AGAINST development of unfavorable evidence. List here any arrest(s) and state the date, place, charge, court, case number and outcome: _____________ Workers Compensation Have you ever made a claim for Workers Compensation? If so, when was the date of your injury? Are you receiving payments at present? If so, explain: ______________ _____________________________________________________________________________________ _ Who is handling your Workers Compensation action? _______________________________________________ Are you receiving disability payments from any source other than Workers Compensation at present? If so, explain: _______________ For Personal Injury Litigation Clients Date of Injury or Accident (If you are not certain about a specific date, please discuss with the lawyer immediately).Location of Accident/Injury: _________________________Names of other people involved in the accident/injury: Have you missed any time from work as a result of your injury? If so, list the dates you were unable to workFROM: __________TO: ___________ FROM: __________TO: ___________ FROM: __________TO: ___________ FROM: __________TO: ___________ FROM: __________TO: ___________ Prior Physical Examinations List here EVERY physical examination you have ever had during the last five years, for any purpose, including employment, promotion, insurance, selective service, armed forces, etc. State: date, name of doctor, and result, as fully as you can recall.a) Date Place ___ Name of doctor ___ Purpose ____ Result ___b) Date Place ___ Name of doctor ____ Purpose ___ Result ____ c) Date Place ___ Name of doctor ___Purpose ____ Result ____ Prior Accidents and Injuries Failure to mention other accidents or injuries can undermine a lawsuit, no matter how trivial they may seem. List here every such incident, whether it resulted in a claim for damages or not, stating the date, place, nature of the accident and extent of your injuries. If none, so state: ________________ Illness or Disease No matter how trivial an illness, either before or since your accident, we must know about it. This is particularly true if there is any connection with your present physical complaints. At the trial, the defendant will have a complete history of your past physical condition, made available through medical and hospital records, veterans records, insurance records, etc.Date Nature of illness _____ Duration Treated by _____________________________________________________________________________Hospitalized? If so, give dates: __ Name and address of hospital _ ________ b) Date Nature of illness ___ Duration Treated by _Hospitalized? If so, give dates: __ Name and address of hospital _ _________ Date Nature of illness ____ Duration Treated by Hospitalized? If so, give dates: __ Name and address of hospital _________ Do you now, or have you ever had trouble with: eyes? ears? If so, give details: Have you ever worn glasses? an artificial eye? a hearing aid? _______ If so, give details: __________________________________________________ Have you ever worked with radioactive substances, asbestos or any other substance alleged to cause diseases, such as cancer? __________ If so, give________________________________________________ details_______________________________________________________________________________ ______________ Have you ever been denied life or health insurance? If so, by which company and why? Alcoholism, Drug Addiction, and Venereal Disease If you have ever been treated for these conditions, please be sure to discuss it with your attorney CONFIDENTIALLY, long before your case goes to trial. The Injury State all injuries known to be a result of the accident: _ _ ________________________________________ Length of time confined to bed _Length of time confined to house _State present physical condition, including scars, disabilities, deformities, discomforts, etc., due to the injuries: _______________ List all physicians and surgeons you have seen for your injury/injuries.a) Name ___ _ Address _ __ Nature of treatment ___ Still under care? ___ b) Name _ ___ Address _ ____ Nature of treatment _Still under care? __ c) Name _ __ Address __ _ Nature of treatment __ Still under care? ___ d) Name ___ Address ___ Nature of treatment ___Still under care? __ e) Name __ __ Address ___ Nature of treatment ___________________ Still under care? ______________________________________________________________________ CONTINUE ON BACK, IF NECESSARY List all nurses, therapists or other health care professionals that you have seen.a) Name ____ Address ___ Nature of treatment __ Still under care? __ b) Name ____ Address ___ Nature of treatment ___ Still under care? ___ c) Name ___Address ____ Nature of treatment ___ Still under care? __