BRIEF DOCTOR QUESTIONNAIRE
Patient Name: ____________________________
1. Based on reasonable medical probability, is the patient’s condition or disability permanent or continuing in nature? ____________
2. Was the patient’s injury, condition or disability (as referenced in the previous question) caused or aggravated by the car accident of ________________? ______________
3. What is the patient’s permanent impairment rating? ____________________
4. What are the patient’s estimated future medical expenses?
Average Per year_________________
For this many years_______________
5. What type of future medical care and prescriptions will the patient need and for how long?
Future medical care_______________________________________
Years of medical care_____________
Years of prescriptions ____________
6. When can the patient go back to work and what are her work restrictions?
When can go back to work_______________
What are work restrictions________________________________
How long will those last____________________________________
7. Date maximum medical improvement reached:_______________________