Client medical history questionnaire

Client medical history questionnaire

Your personal injury attorney will need your medical history. Your attorney may have his or her own questionnaire for you to fill out. It will probably ask questions similar to those in the following questionnaire. Unless your attorney provides you with a different questionnaire, you may find it helpful to complete this one and bring it with you to your first appointment.

Date: _____________________
Name: _____________________

General Information

  1. When was the last time you had a complete physical by a physician?
  2. ___________________________________________________

    ___________________________________________________

  3. (Women) When was the last tame that you had an OB/GYN examination including a breast examination and/or Pap smear?
  4. ___________________________________________________

    ___________________________________________________

  5. When was the last time that you had any treatment or examination by your physician for any condition?
  6. ___________________________________________________

  7. Have you ever been referred to a specialist for an examination or treatment?
    If so, give complete details including date, name of specialist, condition requiring examination or treatment, name of referring physician.
  8. ___________________________________________________

    ___________________________________________________

    ___________________________________________________

  9. When was the last time you had any diagnostic test or study performed (e.g. X ray, CAT scan, EKG, myelogram, thermogram, MRI, lab study, etc.)?
  10. ___________________________________________________

  11. When was the last time you had an injury of any nature for which you consulted or contacted a physician?
  12. ___________________________________________________

  13. Do you presently have any condition for which you are scheduled to be examined by a physician? __________If so, give complete details.________________________________________________________________________________________________________
  14. Do you presently have any condition for which you are considering scheduling an examination by a physician? __________If so, give complete details.__________________________________________________________________________________________________________
  15. When was the last time you had an illness or condition that was treated by a physician including date, name of physician, type of illness or condition, and treatment that you received?
  16. _____________________________________________________

    _____________________________________________________

  17. When was the last time you were hospitalized, including date, hospital, treating physician, condition?
  18. _____________________________________________________

    _____________________________________________________

    _____________________________________________________

  19. Are you currently suffering from any chronic conditions (for example diabetes, arthritis, asthma, depression, etc.)?
    If so, state nature of condition, treatment which you have received or are receiving, name of treating physician and identify any medications.
  20. _____________________________________________________

    _____________________________________________________

  21. Have you ever been seen by a psychiatrist/psychologist? If so, include date, name of psychiatrist/psychologist, diagnosis of condition and medications prescribed.
  22. _____________________________________________________

    _____________________________________________________

  23. When was the last time you had a condition requiring prescription medication? Include date, physician and condition.
  24. _____________________________________________________

    _____________________________________________________

Medications

  1. Have you taken over-the-counter medication for any condition within the past year? __________If so, describe the condition, the type of medication, the dosage and approximately when you took the medication._____________________________________________________
  2. Have you taken any prescription medication within the past year? ______If so, describe the medication, the dosage, the physician who prescribed it, the illness or condition being treated and approximately when you took the medication._____________________________________________________
  3. List all medications which you are currently taking. Include the type of medication, the dosage, the physician who prescribed it and the condition which is being treated.
  4. _____________________________________________________

    _____________________________________________________

  5. List those prescription medications and dosages you take regularly (for example insulin, asthma medication, nitroglycerin, etc.).
  6. _____________________________________________________

    _____________________________________________________

    _____________________________________________________

  7. Have you ever been told you are allergic to any medication? ___________If so, state the type of medication and the identity of the person who told you of this allergy.
    __________________________________________________________________________________________________________
  8. Have you ever been diagnosed as having any other allergies? ___________If so, give complete details including nature of allergies, treatment received, and the names of the physicians from whom you have received treatment.
    __________________________________________________________________________________________________________

Head

  1. Have you received any injury to your head in the last five years? If so, give complete details including nature of injury, how injury occurred, treatment you received and identity of treating physician.
  2. _____________________________________________________

    _____________________________________________________

  3. Have you required treatment for your head for any reason other than an injury? __________If so, give condition, type of treatment and identity of treating physician.
    __________________________________________________________________________________________________________

Ears

  1. Have you suffered from an ear infection within the last year? ____________If so, give date, treating physician and medications received.
    __________________________________________________________________________________________________________
  2. Do you suffer, or have you ever suffered from any hearing loss?
    If so, give dates of condition, treatment received and identity of treating physician.
  3. _____________________________________________________

    _____________________________________________________

Eyes

  1. Have you ever worn, or do you now wear corrective lenses? _____________If so, give dates that you saw, as well as the identity of, any prescribing physician or eye care professional:
    ________________________________________________________________________________________________________
  2. Do you presently have any visual problems which have been treated by any means other than corrective lenses? __________If so, specify the condition, dates and identity of treating physician or eye care professional:
    ________________________________________________________________________________________________________

Nose

  1. Have you ever suffered from any sinus problems? __________If so, give nature of condition, treatment received, and identity of treating physician.
    ________________________________________________________________________________________________________

Throat

  1. Have you ever suffered from a chronic sore throat? __________
    If so, give dates, treatment received and identity of treating physician.
  2. ____________________________________________________

    ____________________________________________________

  3. Have you ever had any other problems with your throat? ___________If so, give dates, nature of problems, treatment received, and the identity of treating physician.
    __________________________________________________________________________________________________________

Neck and Back

  1. Have you ever had any problems with your neck and/or back? _________If so, give date, nature of problem, treatment received, and the identity of treating physician.
    ____________________________________________________________________________________________________________

    ______________________________________________________

  2. Have you ever had any limitations placed upon you with respect to your neck and/or back?
  3. ______________________________________________________

    ______________________________________________________

    If so, give dates, nature of restrictions, any treatment received and identity of treating physician.

    ______________________________________________________

    ______________________________________________________

Cardiac

  1. Have you ever been told that you had high blood pressure? __________If so, give dates, treatment received, identity of diagnosing and treating physician.
    ____________________________________________________________________________________________________________
  2. Have you ever been told that you have angina? __________If so, give dates, treatment received, identity of diagnosing and treating physician.
    ____________________________________________________________________________________________________________
  3. Have you ever suffered a heart attack? __________If so, give dates, treatment received and identity of treating physician.
    ____________________________________________________________________________________________________________
  4. Have you ever had any restrictions placed upon you because of heart problems?
    __________
    If so, give dates, nature of restrictions and identity of treating physician.
  5. ______________________________________________________

    ______________________________________________________

Pulmonary

  1. Have you ever suffered from pneumonia? __________If so, give dates, treatment received and identity of treating physician.
    ______________________________________________________________________________________________________________
  2. Have you ever suffered from bronchitis? __________If so, give dates, treatment received and identity of treating physician.
    ______________________________________________________________________________________________________________
  3. Have you ever suffered from emphysema? __________If so, give dates, treatment received and identity of treating physician.
    ______________________________________________________________________________________________________________
  4. Have you ever suffered from any other lung problems? __________If so, give dates, nature of problem, treatment received and identity of treating physician.
    ______________________________________________________________________________________________________________

Gastrointestinal

  1. Have you ever had appendicitis? __________If so, give date, treatment received and identity of treating physician.
    ______________________________________________________________________________________________________________
  2. Have you ever had gall bladder problems? __________If so, give date, treatment received and identity of treating physician.
    ________________________________________________________________________________________________________________
  3. Have you ever had ulcers? __________If so, give date, treatment received and identity of treating physician.
    ________________________________________________________________________________________________________________