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Name

Address

Home Phone

Work Phone

Relation to Injured Party (self, spouse, child, etc.)

How did you learn about our firm?

Please Explain

Have you seen another attorney?

If so, whom?

Answers To The Following Questions Should Pertain To The Injured Or Deceased Person

Name of Injured Party

Date of Birth

Social Security Number

List every auto accident you have ever been involved in as a driver. Include the year and location.

List every auto accident you have been involved in as a passenger. Year and location.

List all accidents you were involved in where you got a ticket.

Have you ever been arrested before

If so when?

Where?

Charges

List each and every address where you have lived in the past 20 years.

List each and every law suit you have filed including a divorce, custody dispute, probate, and personal injury.

List every deposition that you have given. If you are not certain list each occasion you can remember where you were gave a sworn statement.

Have you ever filed for bankruptcy? If so, what state, who was the attorney or trustee, and the date of discharge.

List all social media websites you are a member of including Facebook, Twitter, Instagram, Linked In, etc.

List the name of a person other than a family member who knows you best. Give their name, address, and phone number.

Medical

List all the times you have been to the emergency room or were hospitalized (Do not leave anything out).

List each time you can think of where you had X-rays taken. Give the location, reason for, and approximate date.

List each time you can think of where you had a CT scan taken. Give the location, reason, and approximate date.

List all the pharmacies where you purchased medications from.

List all the pharmacies where you purchased medications from. (copy)

List any psychiatrists, psychologist, or counselors you have seen in the past. Give the name, date, and location.

Employment

List each and every job you have had in your lifetime. Do not leave anything out.

Automobiles

List each and every automobile you have owned for the last ten years. Make, Model, Year.

Licenses

List all licenses that you hold and the number if available. (Driver's License, Professional License, etc.)

Medical Malpractice Questionnaire

All Consultations are Free and Confidential

Please enable JavaScript in your browser to complete this form.

Name

Address

Home Phone

Employer

Position

Relation to Injured Party (self, spouse, child, etc.)

How did you learn about our firm?

Please explain

Have you seen another attorney?

If so, whom?

Answers To The Following Questions Should Pertain To The Injured Or Deceased Person

Name of Injured Party

Date of Birth

Social Security Number

Date of Injury/Incident

Approximate Time

Facility and Doctor Where Injury Occurred

Facility Address

Injury Details

Please state in detail your version of the incident which resulted in the injury complained of:

Were any relatives a witness to the occurrence in question? If so, please identify those persons.

What injuries were sustained as a result of this incident?

What physical or mental impairments were incurred as a result of this incident?

Please list all medication being taken by the injured person.

What pharmacies do you use to fill the prescriptions?

Please list the EMS, Doctors, hospitals, clinics, labs, which have treated you for the injuries sustained as a result of this incident.

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Name

Phone

Address

Date

Treatment Received

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Name

Phone

Address

Date

Treatment Received

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Name

Phone

Address

Date

Treatment Received

Prior Medical History

List all prior injuries, surgeries, major illnesses, hospitalizations, and/or MRIs the injured party may have had:

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Name of Facility

Phone

Address

Treatment for:

How did this injury occur?

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Name of Facility

Phone

Address

Treatment for:

How did this injury occur?

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Name of Facility

Phone

Address

Treatment for:

How did this injury occur?

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Name of Facility

Phone

Address

Treatment for:

How did this injury occur?

Have you previously been treated by a psychiatrist, psychologist, counselor or therapist?

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Name of Facility

Phone

Condition for treatment received:

Employment History

Please list your employment over the past 10 years.

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Name of Employer

Pay Rate

Address

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Date Range

Position

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Name of Employer

Pay Rate

Address

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Date Range

Position

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Name of Employer

Pay Rate

Address

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Date Range

Position

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Name of Employer

Pay Rate

Address

Layout

Date Range

Position

Residence History

Please list all residences of the injured person and the dates they resided at each for the past 20 years:

Address

Address Dates

Address

Address Dates

Address

Address Dates

Social Media

Please be aware that all social media content can be used against you. We ask that you disable all accounts. List “user names” for all your social media websites (FaceBook, Youtube, Twitter, Instagram, LinkedIn, etc)

Please list all accounts here

Criminal History

Has the injured party ever been arrested?

If so, please provide details below.

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Address

Charges

Address

Charges

County

Result

County

Result

Claims History

Has the injured party had any previous claims (including Workers' Compensation claims) for personal injuries?

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Type of Claim

Against Whom?

Have you ever had your sworn statement taken by an attorney or insurance adjuster?

Have you ever been a party to any lawsuits?

Where was the lawsuit filed?

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Where was the lawsuit filed?

Result

Have you ever filed for bankruptcy? If so, list the court, name of your attorney, and the date of discharge.

Health Insurance/Medicaid/Medicare

Is the injured party covered under any health insurance?

If so, what?

Medicare or Medicaid

Child Support Liens

Are you obligated to pay child support?

If no, do you receive child support?

If yes, please provide the following information:

Name of Parent to whom child support is paid

Names and ages of children for whom child support is paid

County where the child support order was filed

Are you current with your child support obligations?

If not, what is the total amount of child support owed?

By submitting this document, I promise that I have completed it to the best of my ability. I understand that a misrepresentation made in this document can be grounds for terminating the Attorney/Client relationship with CDA.

Wrongful Death Questionnaire

All Consultations are Free and Confidential

Please enable JavaScript in your browser to complete this form.

Your Name

Address

Phone

Employer

Position

Your DOB

Relation to Injured Party (self, spouse, child, etc.)

How did you learn about our firm?

Have you seen another attorney?

If so, whom?

Name of Deceased

Deceased's DOB

Deceased's SSN

Date of Death

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Date of Injury/Incident

Approximate Time

Location and/or name of facility where incident occured

Address

Children of the Deceased

Probate Information

Was there a Last Will & Testament?

Has the Will been probated?

Name of the attorney handling the probate of the will

Who is the Executor/Executrix of the Estate?

If there was not a Will, has an Administrator of the Estate been appointed by the Court?

Name and Address of Administrator

If the deceased did not have a will or it is unknown if a will exists, provide the following information:

List the name of the spouse and all children of the deceased, indicating their current address and phone number. If the spouse or a child is deceased, please indicate below:

If the deceased is not survived by a spouse or children, identify the parents and brothers and sisters of the deceased indicating their current address and phone number. If the parents and/or a brother or sister are also deceased, please indicate below:

Please list the hobbies and interests of the deceased:

This Accident

Please state in detail what you know of the incident which resulted in death:

Do you know if anyone gave a statement regarding this injury?

If so, to whom?

Were any relatives a witness to the occurrence in question?

If so, please identify those persons.

Were any other persons injured because of the occurrence?

If so, please identify those persons.

Were any other persons injured because of the occurrence?

If so, please identify those persons.

Please list all medications being taken by the injured person at the time of death

Please list the EMS, Doctors, hospitals, clinics, and labs which have treated the deceased for the injuries sustained because of this incident.

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Name

Phone

Address

Date

Treatment Received

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Name

Phone

Address

Date

Treatment Received

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Name

Phone

Address

Date

Treatment Received

Medical History

List all prior injuries, surgeries, major illnesses, and hospitalizations the deceased had.

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Name

Phone

Address

Date

Treatment Received

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Name

Phone

Address

Date

Treatment Received

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Name

Phone

Address

Date

Treatment Received

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Name

Phone

Address

Date

Treatment Received

Was the deceased being treated by a psychiatrist, psychologist, counselor or therapist?

If so, please list the following details:

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Name of Facility

Phone

Condition for which treatment received

Deceased's Employment History

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Present Employer

Pay Rate

Address

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How long was the injured party employed here?

Previous Employer

Position

Pay Rate

Address

Layout

How long was the injured party employed here?

Position

Has the deceased ever been fired or let go from an employer?

Residence History

Please list all residences of the injured person to the best of your knowledge and the dates they resided at each for the past 20 years.

Address

Dates the injured person resided at this address

Address Dates

Address

Dates the injured person resided at this address:

Address Dates

Address

Dates the injured person resided at this address:

Address Dates

Address

Dates the injured person resided at this address:

Address Dates

Social Media

Please list all accounts here

Criminal History

Has the injured party ever been arrested?

Has the injured party ever been arrested to your knowledge?

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Address

Charges

Address

Charges

County

Result

County

Result

Health Insurance/Medicaid/Medicare

Is the injured party covered under any health insurance?

Medicare or Medicaid

Child Support Liens

Are you obligated to pay child support?

If no, do you receive child support?

If yes, please provide the following information:

Name of Parent to whom child support is paid

Names and ages of children for whom child support is paid

County where the child support order was filed

Are you current with your child support obligations?

If not, what is the total amount of child support owed?

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Log In

Contact Us Today!

Answers To The Following Questions Should Pertain To The Injured Or Deceased Person

Medical

Employment

Automobiles

Licenses

Medical Malpractice Questionnaire

Answers To The Following Questions Should Pertain To The Injured Or Deceased Person

Injury Details

Prior Medical History

Employment History

Residence History

Social Media

Criminal History

Claims History

Health Insurance/Medicaid/Medicare

Child Support Liens

Wrongful Death Questionnaire

Probate Information

This Accident

Medical History

Deceased's Employment History

Residence History

Social Media

Criminal History

Health Insurance/Medicaid/Medicare

Child Support Liens