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
*
Please Select
Massachusetts
Other
Non-US
Date of Birth
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
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Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
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2015
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Year
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:
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