Personal Injury Doctor Questionaire

BRIEF DOCTOR QUESTIONNAIRE

Doctor Name:____________________________

Doctor Phone:____________________________

Patient Name: ____________________________

1. Based on reasonable medical probability, is the patient’s condition or disability permanent or continuing in nature? ____________

2. Was the patient’s injury, condition or disability (as referenced in the previous question) caused or aggravated by the car accident of ________________? ______________

3. What is the patient’s permanent impairment rating? ____________________

4. What are the patient’s estimated future medical expenses?

Average Per year_________________

For this many years_______________

5. What type of future medical care and prescriptions will the patient need, and for how long?

Future medical care_______________________________________

Years of medical care_____________

Prescriptions_____________________________________________

Years of prescriptions ____________

6. When can the patient go back to work, and what are her work restrictions?

When can go back to work_______________

What are work restrictions________________________________

How long will those last____________________________________

7. Date maximum medical improvement reached:_______________________

____________________________ Date:_________________

Doctor Signature

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