Medical Malpractice Questionnaire

Current Prescription Medications Being Taken, Including Current Dosage and Name of Prescribing Physician or Medical Provider

A. Do your injuries prohibit performance of any daily living activities?example: Can you brush your hair? Perform household tasks such as cleaning and cooking?) If so, for how long have you been unable to perform these activities?YesNo

B. Do you have a history of treatment for chemical dependency?YesNo

C. Do you have any hobbies or interests which are limited due to your injury?YesNo

D. Do you have a history of psychiatric or psychological treatment?YesNo

E. Do you have a criminal record?YesNo

F. Have you ever made any previous claims for personal injuries, medical malpractice, workers’ compensation, or social security disability?YesNo

Injury Information

Employment Information

Current Prescription Medications Being Taken, Including Current Dosage and Name of Prescribing Physician or Medical Provider