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 very 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 or months 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 assist you.

Thanks again!

Client Name *
Client Name
Date *
Date
Was your vehicle or any other personal property damaged in this incident? *
Please also send any property damage photos you have to email@jsclegal.com (this is VERY important and can literally mean thousands of dollars for your case).
Don't be shy. Tell us everything that hurt or you were diagnosed with by a medical professional. If you don't know the name of it, just tell us the body part that was injured. Please also send photos of your injuries to email@jsclegal.com (this is also VERY IMPORTANT as it can mean thousands—or tens of thousands—of dollars to your case).
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). Please be as specific as possible (names, addresses, and phone numbers are helpful). We will use this list to request your medical records. If we miss any, it could add unnecessary time and expense to your case or worse—could lead to us recovering less money for you.
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.
Were you using your cell phone at the time of the incident? *
This means talking, texting, tweeting, navigating, surfing, or anything else on a mobile device.
Don't worry, a lot of us use our phones while we drive (how else would be know how to get anywhere?), but we need to be able to explain it when the other side asks about 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? *
To prove this amount, we will need a letter from your employer and your last three years of tax returns. If you do not have this information, please let us know.
Have you ever been in any other similar incidents (including any other car accidents)? *
Have you ever made a claim for injuries before? *
This includes previous auto, slip and fall, workers compensation claims, other personal injury claims or lawsuits, etc.
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.