Form

Personal Injury Assessment Questionaire
Answer the questions below to the best of your ability.
ABOUT YOU...
Name: *
Date of Injury or Loss
State of Injury *
Date of Birth
Phone (cell)
Phone (home)
Email (home)
Address (home)
Type of Case	Auto Accident Discrimination Slip and Fall Burn Poison Lead Paint Wrongful Death Medical Malpractice Premises Liability Pedestrian Negligence Other

EMPLOYMENT
Were you working at time of injury	Yes No In between
Were you employed at time of injury	Yes No
Address (work)
Email (work)
Phone (work)
Did you lose time from work due to your injury?	Yes No
When did you start to miss work and when did you return, if you have. If not full duty (explain):
HEALTH INSURANCE INFORMATION
Do you have health insurance	Yes No
Your Health Ins. Info Provider or Company
Insured Subscriber
Insurance Card No.:
PHYSICIANS OR TREATING DOCTORS
...
Hospital Name and City or Town Visited
Your Primary Care Physician or Doctor
Specialist Name and Address
...
Specialist II Name and Address
Test Locations
Other Test Locations
Physical Therapy
Physical Therapy Location
....
Chiropractor Location
Counseling
Pharmacy Information
Your description:
Check all that apply to your case, injury, or treatment:	Ambulance Emergency Room Hospital Primary Care Specialist X-Ray MRI CT-Scan Ultrasound Blood Tests Other Tests Neurologist Orthopedic Plastic Surgeon Fractures Broken Bones Stitches Burns Scarring Abrasions Physical Therapy Chiropractor Prescription Drugs Crutches Brace Other Support Surgery Laser Permanent Disability Partial Disability Work Injury Missed Work Other
Explain Other:
Click submit to send this information and data to Wilson & Whitaker, LLC through a non-secure email account. You are advised that communication sent via this form or electronic email is not the safest mode of communication and has definite safety concerns. If you are not comfortable with the risks associated with this form of communication, then do not use this form and do not hit "Submit". Instead, you may fax us at 781-335-0089, write us, or call us at 781-335-0024. We must inform you your submission of this form does not create an attorney-client relationship. We reserve the right to decline any and all cases until we have accepted a case in writing. Before proceeding please see and review our full disclaimer located at our webiste www.wilsonwhitaker.com.