MEDICAL AND NEGLIGENCE REVIEW

 
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Accident and Injury Form Follow Up

This questionnaire is a part of your confidential attorney-client file. Therefore, it is important and in your best interest to answer all of the questions and material fully and in very great detail. Even if something has occurred around the time of injury or accident and you don’t know if it is relevant please include it. It is easier and more efficient to exclude an irrelevant detail than it is to be surprised by an unknown relevant fact. Take your time, be sure you print and save your answers for your own records and be completely honest for this confidential document. It will help you and us process your claim.
INJURED PARTY INFORMATION

Last Name   First   MI
E-mail
Address
City    State   Zip
 Phone Home
Work
Cell
Date  of Injury

PLAINTIFF'S  INFORMATION

Traveling To:

Traveling From:

Direction of Travel
Weather  Conditions

If You Were Parked/Not Moving Where Were You Located?
 Address

Passengers
Name
  Injuredyesno  Seat Beltsyes no
Name
  Injuredyesno Seat Beltsyes no
Name
  Injuredyesno  Seat Beltsyes no

Driver Impairment
Alcohol yes  no
Drugs yes  no
Medical Condition yes  no
Loss of Consciousness yes  no
Were you issued a citation?
  yes   no
Your Detailed Story  of the Accident
 

Description of Accident Site
 

 
Auto  Year Make Model
Owner or Lessor (If not the client)
Name
Address
City    State   Zip
Phone
DL#   State
 
Auto Insurance Company Information
Name
Address
Claim #
Types of Coverage
     Uninsured Motorist Protections yes   no
     Underinsured Motorist Protections yes   no
     Uncoordinated Benefits yes   no
     Other Insurance Coverage in Household yes   no
 
DEFENDANT INFORMATION
Last Name   First  MI
Address
City    State   Zip
 Phone  Home
Work
Cell
License Plate #
DL#   State
Auto Year  Make Model
Auto Insurance Co.  
Policy #
 
Destination 
Direction of Travel
 

 

Passengers  

Injured
Name yes   no
Name yes   no
Name yes   no
   
Was the defendant issued a citation?
  yes   no
 
Driver Impairment
  None     yes   no
Alcohol    yes   no
Medical Condition yes   no
Drugs: prescription or recreational  yes   no
 
POLICE INVESTIGATION
Officer's Name   First   MI 
Badge Number
Precinct   
 
Witnesses
Name
Name
Name
On the scene statements
 
Do you have a copy of the accident report?
yes   no
If yes, please be able to furnish a copy to this office.

MEDICAL HISTORY

List names, addresses, phone numbers and dates of treatment for all healthcare providers and/or facilities that have treated you for your injury. Indicate type and nature of treatment at each visit

Date of Treatment
Type of Treatment
Healthcare Provider
Address
Phone
Date of Treatment
Type of Treatment
Healthcare Provider
Address
Phone
Date of Treatment
Type of Treatment
Healthcare Provider
Address
Phone
Did you have any health problems prior to the injury? yes   no
If yes, cause
 
What prescription drugs were you taking prior to the accident?
 
List all drugs and medications taken on the date of the injury?
 
List all treating physicians prior to your injury.

1. Physician

Reason for visit

Period of time for treatment
   

2. Physician

Reason for visit

Period of time for treatment
   

3. Physician

Reason for visit

Period of time for treatment
Previous Hospitalizations
Hospital Name
Dates
Condition
Physician
   
Hospital Name
Dates
Condition
Physician
   
Hospital Name
Dates
Condition
Physician

Previous Auto Accidents
Date
Injuries
Treatment
Physician
Was your recovery  Total Partial
If partial, what residual injury do you have?
 

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MEDICAL NEGLIGENCE REVIEW
Phone: (248) 540-4557
  
E-mail: rjg@medicalnegreview.com