Chaffin Law Office - Elder Abuse

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Home | 674 County Square Dr. - Suite 310, Ventura CA 93003 - Ph 805-650-8200 - info@chaffinlaw.com

Elder Abuse Questionare

PLEASE NOTE:
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.

GENERAL BACKGROUND INFORMATION
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? City State Zip Code
7	What is your Social Security Number?
8	What is your California Drivers License Number?
9	What is your Date of Birth?
GENERAL BACKGROUND INFORMATION
10	What is the name, age, and date of birth of the person injured or abused?
11	How are you related to the person injured or abused?
12	Date of Incident/Accident 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.)
13	Where did the accident/incident take place? (City, County, State, Street Address)
14	Describe how the accident/incident occurred
15	Was there a police report or written report generated? If yes, list the report number and agency that wrote the report.
16	Were there any witnesses to the accident/incident? If yes, list their names, addresses, telephone numbers and descriptions.
17	List all parties that were involved in the accident/incident: (For example, the nurse, doctor, caregiver, nursing home, hospital, ambulance company, therapists, etc.)
18	Who do you believe was at fault for the accident/incident? (For each party named, describe how they were at fault.)
GENERAL BACKGROUND INFORMATION
19	What type of injury was sustained? (Check all that apply) Bed Sores Physical Abuse Mental/Emotional Abuse Financial Abuse Failure to Provide Medical Care / Medication Inadequate Medical Care / Medication Withholding Food, Water, Medication, Etc. Muscle Strain/Sprain Broken Bone Internal Injury Wrongful Death Dizziness/Nausea/Vomiting Loss of Memory or Cognitive Function
20	Describe the injuries in detail
21	Has the person suffered any type of similar injury before? If yes, describe in detail.
22	Has the elderly/disabled person 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):
23	Please list the name, address, telephone number of every medical care provider 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)
24	Chronology: Please provide the Date of the accident/incident, the date you first sought help or 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:
25	Describe any documents that you believe support your case?
26	Does any party involved have insurance (Medical, Automobile, Homeowners, Liability, Medicare, etc? If yes, provide their name, their Insurance Company, their Policy Number, their Claim Number, and any other information you know regarding their insurance.
DAMAGES
27	Please list all medical bills incurred to date relating to the incident: (It does not matter if insurance paid the bills, list them)
28	Describe all property loss resulting from the incident (damage to property, possessions, theft, etc):

Chaffin Law Office - 674 County Square Dr. - Suite 310, Ventura CA 93003 - Phone 805-650-8200 - email: info@chaffinlaw.com