QUESTIONNAIRE
General Information
Today’s date: Referred by:
Name: Address: City/State/Zip:
Home Telephone: Work Telephone:
Mobile Telephone: E-mail Address:
Date of Birth: Social Security No.:
Do you have Medi-Cal? Yes No If yes, Medical No.: Employer Information (Time of Injury/Illness)
Employer: Address: City/State/Zip:
Telephone: Date of Hire:
Job Title: Pay Rate:
Hours Per Week: Union Member? Yes No
If Union Member, name of Union: Description of Job Duties:
Work Overtime? Yes No If yes, paid at time-and-a-half? Yes No Terminated or Laid Off from Work? Yes No
If yes, please explain:
Interested in returning to the same job? Yes No
If necessary, are you interested in a modified job with the same employer? Yes No Do you know if your employer would consider job modification? Yes No
If yes, what date did you give the claim form to your employer: Also, bring a copy to consultation. Did your employer answer (complete the bottom portion of the claim form) and return a copy to you marked “Employee’s Copy”? Yes No
Have you given a statement about your injury to anyone other than your doctor? Yes No If yes, please identify:
Other Employment
Did you have a second job at the time of injury? Yes No Do you have a second job now? Yes No
Current Employer:
If working, date of return to work: If not working, date last worked: Other employer in past year:
Address: City/State/Zip:
Job Title: Date of Hire:
Pay Rate: Hours Per Week:
Injury/Illness Information
Have you consulted another attorney about this injury/illness prior to today? Yes No Date of injury/illness (if more than one date, please list):
Place of injury/illness:
Type of injury/illness: Parts of body injured: How did the injury/illness happen?
Responsibility for injury/illness (check all that apply): Employer Co-worker Chemical Substance Machinery Unsafe Condition Someone else Please explain if you checked one or more of the above:
Medical Treatment for Injury/Illness
Doctor: Address: City/State/Zip:
Date last seen: Treatment:
Doctor: Address: City/State/Zip:
Date last seen: Treatment:
Below, please list all other doctors/hospitals seen for the injury/illness. Doctor:
Address: City/State/Zip:
Date last seen: Treatment:
Doctor: Address: City/State/Zip:
Date last seen: Treatment:
Were you hospitalized overnight for the injury/illness: Yes No Who do you believe is your treating doctor?
Was the doctor selected by your employer? Yes No
Before the date of injury/illness, did you give your employer the name of a doctor to treat you? Yes No Do you have objections to changing to a doctor of our choice? Yes No
Insurance Information
Insurance Company: Claim Number:
Address: City/State/Zip:
Adjuster: Telephone: Do you have health insurance: Yes No If yes, name:
Who paid/is paying for your medical treatment (check all that apply)? Workers’ Comp Insurance Company Private health insurance Medi-Cal Yourself Below, please list all unpaid medical bills related to the injury/illness, and all medical bills paid by you for which you have not been reimbursed.
Unpaid Paid (But Not Reimbursed)
Information for Calculation of Disability Benefits*
Periods you did not work due to this injury/illness: Periods you received workers’ compensation benefits: From: To: From: To: From: To: From: To: From: To: From: To: From: To: From: To: Have you applied for State Disability Insurance (SDI): Yes No
Below, please list the benefits received, if any, from other sources.
State Disability Insurance Date: Amounts:
Unemployment Date: Amounts:
Social Security Date: Amounts:
Long-Term Disability Date: Amounts:
Retirement/Pension Date: Amounts:
NDI (State Employees Only) Dates: Amounts:
Other: Dates: Amounts:
*Bring a copy of last two (2) years’ W2 forms (years prior to injury/illness). *Bring a copy of your last pay stub prior to injury/illness.
Other Injuries/Illnesses
Have you ever had any other on the job injuries/illnesses? Yes No
Dates Parts of Body Injured How it Occurred Fully Recovered Yes No Yes No Yes No Have you ever had any other off the job injuries/illnesses? Yes No
Dates Parts of Body Injured How it Occurred Fully Recovered Yes No Yes No Yes No Below, please list the names, addresses, and dates of all doctors/hospitals seen for each of the above
injuries/illnesses (use an extra sheet of paper if additional space is needed).
Dates Doctors/Hospitals Address
Have you ever filed a claim or lawsuit for a work injury or personal injury? Yes No If yes, please explain:
Below, please list the names, addresses, and dates of all doctors/hospitals seen for each of the above injuries/illnesses (use an extra sheet of paper if additional space is needed).
Dates Doctors/Hospitals Address
TO BE COMPLETED BY ATTORNEY
Third Party? Yes No Discussed? Yes No Serious & Willful? Yes No Discussed? Yes No
