Client Questionnaire

  1. What is your name, residential address, occupation, business address, date of birth and social security number and Medicare number with the correct letter?
  2. What is the name, residential address, occupation, business address and telephone number of any witness to the accident?
  3. Describe in full and complete detail how the alleged accident happened.
  4. Describe in full and complete detail all injuries which you suffered as a result of the accident.
  5. What is the name and address of any and all hospital, doctors, therapists and other health care providers from whom you received medical or other health care treatment for your injuries?
  6. When you received treatment, where and for what including a full andcomplete description of all treatment, medication and tests, including but not limited to MRI’s, CT scans, x-rays, electrocardiograms and other diagnostic tests rendered to you on each date?
  7. Do your best to provide an itemized account of all expenses incurred for the above referenced treatment.
  8. What is the name and contact information for your health care provider, e.g. BC-BS or HCHP, and what is the member number?
  9. If you lost any time from work, what was your job or occupation and the full name and address of your employer the dates on or between which you were unable to work.
  10. What was your gross and net annual income and average weekly gross income for the calendar year immediately before the accident?
  11. What injuries, pains, disabilities or scars are you now suffering or if you have fully recovered, please state the approximate date on which you recovered from each such injury that you suffered in the accident.
  12. If you had any prior injuries to the same area involved in this accident, please provide details.

Please provide answers to these questions by accumulating the documents necessary to respond and jotting down the necessary details; then call the office 781-239-1005, and schedule an update client conference to go over the information.