
	MEDICAL AND NEGLIGENCE REVIEW

Medical Negligence
Malpractice 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 the claimed negligence and you don’t know if it s relevant please include it. It is easier and more efficient to exclude an irrelevance than it is to be surprised by an unknown relevant fact. Take your time, be sure you print and save your answers for your records and be completely honest for this confidential document. It will help you and me process your claim, as a matter of fact the advisory opinion you get from me will be only as accurate as the information you provide me.

Discovery of the Possible Malpractice Follow Up
Name	First MI
Email

Date of Injury Due to Malpractice.


Last Date of Treatment with Health Care provider whom you allege to have committed malpractice.


Do you have records, reports or photographs in your possession relating to this incident? If yes, please be ready to submit them to this office.
Yes No

Who do you feel was guilty of negligence/malpractice?


List all the hospitals and health care facilities in which or to which the client was admitted and/or treated as a patient for the complaint.


List all the medical doctors, osteopaths, chiropractors, psychiatrists/psychologists, clinics or other health care providers consulted or treating the injured party. Include the proposed defendant.


Facts It is essential that you prepare a chronological, factual statement of what happened. Start with the ailment or condition for which the health care provider was consulted. In detail include the dates, names of persons present, conversations with anyone present. Ask others who were present to help you fill in the details. Try to reconstruct conversations exactly; quote the doctor exactly; try to exactly relate what complaints you described to the doctor; were any tests run; what were the tests; were there any witnesses there. (names and addresses)


Detail fully all the injuries you received as a result of the malpractice and when you were first aware of them.


Describe your present physical condition including scars, deformities, headaches, pain and other complaints due to the injuries.


There will be additional questions later about arbitration agreements and whether you signed one with full disclosure of the limitations it imposes on your ability to sue and recover damages.

MEDICAL NEGLIGENCE REVIEW
Phone: (248) 540-4557

E-mail: rjg@medicalnegreview.com

MEDICAL AND NEGLIGENCE REVIEW

Medical Negligence Malpractice Follow Up

Discovery of the Possible Malpractice Follow Up

Medical Negligence
Malpractice Follow Up