CASE REVIEW QUESTIONNAIRE

It is very important that you read these various questions carefully and answer them clearly, completely and specifically. We need your help in order to get a full and thorough review of your prospective case.

Please keep in mind that we have not yet agreed to undertake representation; we are simply going to undertake an initial, investigative overview of the situation you have.

These are difficult cases, routinely hard fought, lengthy, expensive, time-consuming and quite distracting. Many factors must be considered including: 1) liability (who, if anyone, did something wrong); 2) damages (bills, permanent injuries, disruption of life or lives, etc); 3) time limitations as applied by law and many other factors.

We, upon receipt and review of this requested information, will be in touch with you. Please make sure we have an address and telephone number in order that we may make contact with you.

PLEASE WRITE CLEARLY OR TYPE.

NOTE: If extra room is needed for answering any of the questions below, please attach extra sheets of paper to the questionnaire with the number of the section you are answering.

Date Completed:

Section 1

Submitter's Name:

Victim's Full Name (if different from submitter):
Address:
City:
State: Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:
Cell:
EMAIL:
Telephone:
(home)
(work)
Social Security No.:
Date of Birth:
Employer:
Position Held:
Name, addresses and telephone numbers of persons to contact in case of an emergency:

Name of Victim's Spouse:
Spouse's Social Security No.:
Spouse's Date of Birth:
Date Married:
Spouse's Telephone No.:
(home)
(work)
Spouse's Employer & Position Held:

Children: Name, Address, Date of Birth

SECTION 2

If victim is deceased, was an autopsy prepared?
Yes No;
if so, who has a copy of 1) Autopsy and 2) Death Certificate; Please attach a copy.

(A) If the victim is deceased, has an estate been opened? If so, please attach a copy of the Certificate of Appointment showing who is responsible for the estate.

(B) If the victim was under 18 years of age, please complete the questions below:
Father's Name:
Mother's Name:

If parents of minor are divorced or separated, list the custodial parent's name, address and telephone number:

(C) If victim is incompetent to handle his/her own affairs, has someone been appointed guardian or conservator for the victim? If so, give name, address and telephone number of person appointed and send copies of documents showing appointment:

Section 3

Have you conferred with any other attorney regarding your complaint of medical malpractice?
Yes No.
If the answer is yes, please state with whom you conferred and whether you have signed a fee contact with that attorney.

Who referred you to this office?

Have you been involved in any previous lawsuits?
Yes No.
If the answer is yes, please state details and list your previous: 1) claims made; and 2) lawsuits filed:

Section 4

Date of incident you believe medical malpractice was committed:
What made you think the doctor, hospital employees or other healthcare providers may have been guilty of medical malpractice?

List all doctors and/or hospitals who you feel committed medical malpractice:

* Name of Hospital or doctor:
Address:
Dates of Treatment:
Reason for Treatment:
Complications:
Name treated under:
Date of Last Treatment:

* Name of Hospital or doctor:
Address:
Dates of Treatment:
Reason for Treatment:
Complications:
Name treated under:
Date of Last Treatment:

* Name of Hospital or doctor:
Address:
Dates of Treatment:
Reason for Treatment:
Complications:
Name treated under:
Date of Last Treatment:

* Name of Hospital or doctor:
Address:
Dates of Treatment:
Reason for Treatment:
Complications:
Name treated under:
Date of Last Treatment:

Has any doctor, hospital employee or other healthcare provider told you there was negligence involved in the treatment?
Yes No
If the answer is yes, please state name, address and telephone number of person and the details of your conversation:

Section 5

List family members or friends who can furnish us information which may be helpful in evaluating the case:

Name:
Address:
Telephone No.
(Home)
(Work)
Relationship to victim:

Name:
Address:
Telephone No.
(Home)
(Work)
Relationship to victim:

Section 6

List all hospitals and doctors who treated the victim as a result of the malpractice, (including the ones who may have committed malpractice):

* Name of Hospital or Doctor:
Address:
Dates of Treatment:
Reason for Treatment:
Complications:
Name treated under:
Date of Last Treatment:

* Name of Hospital or Doctor:
Address:
Dates of Treatment:
Reason for Treatment:
Complications:
Name treated under:
Date of Last Treatment:

Section 7

Did medical insurance pay any of the medical bills?
Yes No.
If yes, please state name and address of company:

What are the approximate total medical bills (before health insurance paid any) as a result of the malpractice?
$
Did the victim miss any work as a result of the medical malpractice?
Yes No
If the answer is yes, total amount of lost wages.
$
List any other expenses or damages as a result of the alleged medical malpractice:

Section 8

Is there any other information you feel we need to know to assist us in evaluating the medical malpractice case? If the answer is yes, please state in detail:

Section 9

WRITE A COMPLETE STATEMENT OF ALL THAT HAPPENED THAT MAKES YOU FEEL THERE MAY HAVE BEEN MALPRACTICE. PLEASE INCLUDE A STATEMENT OF HOW THE INJURY HAS AFFECTED THE VICTIM AND/OR HIS/HER FAMILY. BE AS COMPLETE AS POSSIBLE. (Please use additional sheets).

Section 10

1. Do you feel there has been a conspiracy or a cover-up against the victim's interests in this matter? If so, please explain in detail.
   
2. Are you angry about what has happened? Please explain in detail. Why?
   
3. Are you bitter about what happened? Please explain in detail. Why?
   
4. Please explain in detail how this incident has damaged your life and your family's lives - please discuss your losses (emotional, physical, financial, etc).
   
5. Please list each person or business you think should be sued.
   
6. Have you done any investigating on your own about matters - interviews, research, study or materials assembly? Please describe in detail. If you have assembled information, please attach.
   
7. Have you or any member of the victim's family received any kind of counseling because of what has happened? (Clergy, psychiatrist, psychologist, etc.) Please explain in detail.
   
8. Please describe in specific detail all significant health history of the victim before the medical negligence happened. Please list: 1) all medical health problems; 2) how they were treated or being treated; and 3) what their status/condition was at the time of the claimed negligence.
   
9. Please provide work/employment history of victim (for entire adult life).
   
10. Copies of tax returns for the last five (5) years. Please attach copies of Federal Returns (first 2 sheets) and W-2s.
11. Please provide full educational history of victim.
    
12. Please provide full criminal history of victim, if any.
    
13. Please provide full mental health/substance abuse history of victim, if any.
    
14. Had the victim in this matter ever applied for any type of worker's compensation or disability benefits during the course of his life? If so, please describe.
    
15. Please describe victim's history of tobacco use.
    
16. Please describe victim's history of alcohol use.
    
17. Please describe victim's history of prescription drug use.
    
18. Please describe victim's history of illegal drug use.
    
19. Please provide any other information which you feel is significant that we should know about.
    
20. What are the "negative points" of the victim? What significant "bad things" are there about the life of the victim? We must have all information. This information is strictly confidential. We appreciate your honesty.
    
21. How much money should be awarded by a jury if this case were to go to trial? Why? Explain.
    
22. Please attach legible copies of all bills and medical records you have assembled.

Upon completion, please mail or deliver this questionnaire and attachments to the address given on this page.

We will be in touch as soon as all materials are received and reviewed.

THANK YOU.

E. Vernon F. Glenn