Update Client Questionnaire

PERSONAL INJURY UPDATE QUESTIONNAIRE

 

INSTRUCTIONS: This questionnaire is intended to update me with any new information regarding you and your case. If you have new information regarding a specific request, please provide me with it in the space provided. If you have no new information, simply give your name and provide the date so that I will know how current my information is. I appreciate your cooperation with this matter.

1.  Date: __________________________________________________

2.  Original Name: __________________________________________

3.  New Name:_____________________________________________

4.  New Address:___________________________________________

5.  New phone numbers: (home)______ (work)_______ (other)______

6.  Please list all new health care providers, their addresses, and your dates of treatment:

_________________________________________________________

_________________________________________________________

 

 

 

7.  Please list all new medical bills, their amounts, whether they have been paid and by whom, and the dates you received them. Also, please provide a copy of these bills when you return this questionnaire. Documents Enclosed (yes[ ]  /no [ ] ).

_________________________________________________________

_________________________________________________________

 

 

 

8.  Please describe the progress of your recovery, any changes in your medical condition, and any procedures you have undergone which are related to your injuries.  Please provide any medical records you may have which document this information. Documents Enclosed (yes  [ ]/ no [ ] ).

_________________________________________________________

_________________________________________________________

 

 

9.  Please describe any changes in your medical condition which are unrelated to the incident which is the subject matter of your lawsuit.  Please provide any medical records you may have which document this information.  Documents Enclosed (yes [ ]/ no [ ] ).

_________________________________________________________

_________________________________________________________

 

 

10.  Please describe any changes in your employment status which are due to your injuries. Also include an estimate of your lost wages to date which are attributable to your injuries.  If you have a recent earnings statement which documents a decrease in earnings, please provide a copy of same.  Documents Enclosed (yes [ ] / no [ ] ).

_________________________________________________________

_________________________________________________________

 

 

11.  Please provide me with any other information regarding any changes in your life which are attributable to your accident and/or your injuries.

_________________________________________________________

 

 

12.  Please provide me with the names, telephone numbers, and addresses of any new witnesses you have discovered which have information regarding your accident, injuries, and/or recovery.  Also, briefly describe what type of knowledge they have and what you believe they know.

_________________________________________________________

 

13.  Please provide me with any additional information or comments you may have which you feel are important to your case.

_________________________________________________________

 

14.  Please provide me with any comments or concerns which you may have regarding my representation of you in this matter.

_________________________________________________________

 

15.  If you have a spouse or other loved one which would like to comment about your case, let them make their remarks below.

_________________________________________________________

_________________________________________________________

_________________________________________________________

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Attorney Specific Forms

–For Attorney Specific Forms you can download in Word format, go to

http://www.uslegalforms.com/forattorneys/

 

 

 

 


Inside Update Client Questionnaire