You will need an experienced attorney to help you and assist you with legal documents, especially if the one you are suing is a doctor, hospital, pharmaceutical company, medical device manufacturer, or other similar person or entity. During your first few meetings with that attorney, there is a lot of information you will have to provide. Even before the actual meetings, you can already fill out the following form. This form will enable your attorney to learn a little bit about your background, and a lot about your case. For example, your attorney will obviously need to know about your medical situation. In addition, he or she may want to know about your employment status and your income. If you were unable to work because of the injury that you have suffered, you can also ask your lawyer to help you recover the lost wages.

Intake Form: Illness & Hospitalization

Name: ________________________________

Date of Birth: ___________________________

Social Security Number: ____________________

Address:

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Length of Time at that Address:  _______ years _______ months

Previous Address(es) (for last 10 years):

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Home Telephone Number:      ____________________

Work Telephone Number:       ____________________

Facsimile Number:                  ____________________

E-mail Address:                      ____________________

Former Name(s):                     _____________________

Current Employer:                  ____________________

Job Position/Title:                   ____________________

Employer’s Address:

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Length of Time with Employer:  _______ years

Gross Monthly Income:  $_________________

Marital Status: _________________________________

Previous Marriage(s):  Yes  ____   No  ____              How ended?_________________

Children

Name                           Date of Birth   Living in home?

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Do you have medical or health insurance? ___________________Yes/No

If Yes, provide information on policy (insurance company, etc.) : _____________

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Are your premium payments up-to-date? ______________Yes/No

If No, provide explanation:  ___________________________________________

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Date of Onset of Illness or Dates of Hospitalization:  _____________________________

Present Medical Diagnosis:  _________________________________________________

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Description of How Illness Was Contracted or Why Hospitalization Was Required:

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Names and Locations of All Medical Providers Seen for Illness:

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Names and Locations of All Hospitals Where You Are/Were a Patient:

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Description of Medical Attention Received:

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Current Medical Condition:

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Surgeries Performed or Scheduled As a Result of Illness or Hospitalization:

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Did your doctor discuss the risks of the surgical procedure with you? ______________Yes/No

If Yes, what were you told about the procedure? _____________________________

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If Yes, did you sign an informed consent form? _____________Yes/No

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

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Current Over-the-Counter Medicines Being Taken

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Previous Medical History:

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Previous Prescription Medications Being Taken, Including Dosage and Name of Prescribing Physician:

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Previous Over-the-Counter Medicines Being Taken:

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Any History of Similar/Same Illness or Need for Hospitalization:

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Significant Family History for Diseases, Illnesses or Medical Conditions:

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Does illness prohibit performance of any daily living activities? (Examples: Can you brush your hair? Dress yourself? Drive a Car?):

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Did you lose time from work since illness?_______________Yes/No

Amount of time lost including specific dates, if known:  __________________________________________________________________

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Hobbies/Interests:

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Does illness prevent you from engaging in these hobbies/interests?_________ Yes/No

Explain:  ___________________________________________________________

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Do you have a history of treatment for chemical dependency? ______________Yes/No

Explain: ___________________________________________________________

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Do you have a history of psychiatric or psychological treatment? _______________Yes/No

Explain: ____________________________________________________________

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Do you have a criminal record? ___________________Yes/No

Explain: ____________________________________________________________

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Other Important Information:

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Questions to Ask My Attorney:

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