Name:

Email Address:

Phone Number:

How were you injured?

Who do you believe caused your injuries?

What are your injuries?

What body part functioning has been impaired?

What activites are you precluded from doing because of your injuries?

What medical devices do you use to assist you?

Do any health care professionals provide you treatment in your home?

Does anyone assist you with your daily living needs?

Do you ever leave your home? How?

Has your health care insurance or medicaid/medicare paid your medical bills?

Have you altered your home in order to conduct your daily living activities? In what way(s)?

Have you received any assistance in performing your daily activities from family members? Have they been paid? Do they expect to be paid? How much?

Have your physicians told you how long you will be disabled?

Have you received any psychological care as a result of the accident?

Were you employed at the time of the accident?

Yes

No

Did the accident happen while you were working?

Will you ever be able to return to the same type of employment?

Will you ever be able to return to restricted employment?

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