Kevin Chaffin Law Offices in Ventura

Select your type of case and confidentially submit information for immediate attorney review and response.

Wrongful Death
Wrongful Termination
Sexual Harassment
Hostile Work Environment
Failure to Pay Wages
Overtime and Salary Claims
Retaliation and Whistleblower
Medical Malpractice
Elder Abuse & Nursing Homes
Train Accidents
Car & Motorcycle Accidents
Personal Injury

Home | Ventura County, California - Ph 805-650-8200 - | About Us

Medical Malpractice Questionare

This questionnaire is meant solely for the use of the consulting attorney for purposes of analyzing and evaluating the prospective client's case. The contents of this document are therefore protected by the attorney-client privilege and the attorney work product doctrine. It is very important that you be completely truthful, accurate and complete in answering the following questions. The defendant in this case will likely obtain all relevant records about you. Therefore, it is crucial that we are aware of all information, including information you may believe will damage your case, in order to best represent you. If we decline to take your case, it does not mean you do not have a case. Therefore, if we decline your case you should contact another attorney. Most of our clients are employees or injured persons. If you are an employer, or you are concerned you might be sued by someone else, do not complete a questionnaire. Instead, you must first contact our office by telephone.

1 What is your name?

2 What is your age?

3 What is your mobile cell phone number?

4 What is your home phone number?

5 What is your e-mail address?

6 What is your street address?



Zip Code

7 What is your Social Security Number?

8 What is your California Drivers License Number?

9 What is your Date of Birth?

10 Date of Incident Causing Injury?
(This is very important information. Please describe in detail if you are in doubt as to the date of the accident/incident giving rise to liability. Your ability to recover damages may be limited by a statute of limitations - if you fail to file a claim within the appropriate time restriction, your right to recover may be forever lost and barred.)
11 Where did the incident take place? (City, County, State, Street Address)

12 Name of Doctor, Hospital, Nurse, Therapist or Medical Professional Involved

13 Describe how the incident occurred:

14 Were there any witnesses to the accident/incident? If yes, list their names, addresses, telephone numbers and descriptions.

15 List all parties that were involved in the accident/incident: (For example, the hospital, doctor, nurse, therapist, pharmacist, etc.)

16 Who do you believe was at fault for the accident/incident? (For each party named, describe how they were at fault.)

17 Describe your injuries in detail:

18 Have you ever suffered any type of similar injury before? If yes, describe in detail.

19 Have you ever had a claim, case or settlement for any type of claim arising from Negligence, Automobile Accident, Motorcycle Accident, Bicycle Accident, Pedestrian Accident, Slip-n-Fall Accident, Products Liability, Assault & Battery, Wrongful Death, Medical Malpractice, Dog Bite, or Other (Please Describe):

20 Please list the name, address, telephone number of every medical care provider you have seen for your injury: (Including ambulance, emergency room, x-ray or diagnostic imaging, family or primary doctor, specialists, physical therapists, chiropractors, psychologist, psychiatrist, or other)

21 Chronology: Please provide the Date of the accident/incident, the date you first sought medical care, the date of each subsequent visit for medical care, and the date of any other event or fact that you consider to be significant:

22 Did you have automobile insurance at the time of the accident/incident?

If yes, list your Insurance Company, Policy Number, Claim Number, Insurance Agent's Name/Address/Phone

23 Did any other party involved in the have insurance?

If yes, provide their name, their Insurance Company, their Policy Number, their Claim Number, and any other information you know regarding their insurance.

24 Please list all medical bills you have incurred to date relating to the incident: (It does not matter if insurance paid the bills, list them)

25 Describe all financial loss resulting from the incident (medical bills, lost wages, lost income, lost opportunities, etc): If you have any doubt as to whether or not something is a loss that may be recovered, list it):

26 Were you working at the time of the incident?

If yes, please list your employer, supervisor, job title. If you have lost any wages, used any vacation or sick time, or suffered any type of employment related loss please describe:

27 Have you ever filed a lawsuit before or have you ever been sued before

If so, please explain:

28 Have you ever filed for bankruptcy before, or are you considering filing bankruptcy in the near future?

If so, please state the date you filed and the result, (or state the date you are planning on filing bankruptcy. (****Note if you are planning on filing bankruptcy anytime soon do not sign or file any bankruptcy documents without consulting with this office first, as filing a bankruptcy action could result in the termination of your lawsuit****)

29 Have you ever been arrested?

If so, please state the date, the charge/s and whether you were convicted.
30 Have you ever filed a workers compensation claim for any injuries sustained at work?

If so, state the date of complaint and the result?

Chaffin Law Office - P.O. Box 3076, Ventura, California 93006 - Phone 805-650-8200 - email: