Post-Treatment Questionnaire

We're happy to hear you're finished with your medical treatment and back on the road to feeling better. 

Thank you for taking a few minutes to answer these important questions about your treatment and recovery. Your honest answers are completely confidential and will help us do our best job as we work to resolve your case and maximize your recovery. Once we receive your completed questionnaire, we will request all your related medical records and bills. This is a process that may take several weeks as we wait for each provider to send us their records. 

As always, please give us a call at 512 329 6800 and we will be happy to help you.

Client Name *
Client Name
Date
Date
Have you ever received medical treatment for any of the injuries/symptoms listed above prior to this collision/incident?
Same or similar injuries won't hurt your case, but we need to know about them in order to explain them.
List the specific names of all the medical providers you saw for your injuries related to this incident, from the ambulance on down to your last medical appointment.
Do you have any other medical conditions unrelated to this collision/incident?
Again, this won't hurt your case, but we need to know how to explain it.
Have you ever been on or applied for disability benefits?
This won't hurt your case, but we need to know why and when.
(Detail amount of expense, type of expense, and whether or not you have a receipt)
Did you miss any time from work as a result of your injuries related to this incident?
Actual time missed from work due to injuries and related medical treatment (even if you used sick or vacation paid time off). You will need a doctor's excuse for the amount of time missed.
If you are self-employed or paid with commission-based compensation, please describe your lost income here. Include the amount of lost income and the calculations you did to arrive at that amount (I am a commission-based salesperson. I normally make $3,000 in commissions each month. After my injuries, I was not able to work for two weeks. My commissions for the month after my surgery were only $1,000. Therefore I estimate I lost about $2,000 in income).
Have you ever filed a claim for personal injuries before?
This includes previous auto, slip and fall, workers compensation claims, etc. It won't hurt your case, but we need to know about it.
Have you ever filed for bankruptcy?
It won't hurt your case, but we need to know about it.
Date filed, status (pending/discharged), name of bankruptcy lawyer and trustee, etc.
Do you owe any money for child support?
This won't hurt your case, but we need to know about it to deal with any potential lien issues.
Do you owe any money for unpaid taxes?
This won't hurt your case, but we need to know about it to deal with any potential lien issues.
Health insurance, self-pay, payment plan, letter of protection, etc.
Has your health insurance company told you it wants information about this case?
This won't hurt your case, but it's very important we know about it in order to protect your rights.
Name of insurance company, etc.
Do you have any government-sponsored health insurance?
(Medicaid/Medicare/TriCare/Champus/ChampVA, etc.) Again, this won't hurt your case, but it's very important we know about it so we can protect your rights.
Don't hold back, this is your opportunity to tell us how this incident and your injuries affected your day-to-day life.