Personal Injury Doctor Questionaire

6 Sep 2014

Personal Injury Doctor Questionaire

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BRIEF DOCTOR QUESTIONNAIRE

Doctor Name:____________________________

Doctor Phone:____________________________

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_____________

Prescriptions_____________________________________________

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:_______________________

____________________________ Date:_________________

Doctor Signature

About the Author:

Massey & Duffy has existed since October, 2003. We focus exclusively on civil litigation, including wrongful death, overtime cases, car and trucking accidents, insurance claims, breach of contract, general employment law, and serious personal injury lawsuits.