Lost Earnings Evaluation: Medical Malpractice

Plaintiff's Information

First Name: Last Name:

Street Address:

City: State: Zip Code:

Phone: (i.e. 702-263-8044)

Email:

Demographic Information

Date of Birth: (i.e. YYYY/MM/DD)

Race: Please Choose African American Asian Caucasian Hispanic Origin Native American Descent Others Citizenship: Please Choose Natural Born U.S. Naturalized Others

If Others, please specify:

Gender: Choose Female Male Marital Status: Please Choose Single Married Widowed

Highest grade of school completed/degrees received: Please Choose Did not graduate highschool G.E.D. Highschool 2-yr College 4-yr University Master's Doctorate

Children?

Date of injury: (i.e. YYYY/MM/DD)

Last Day Working: (i.e. YYYY/MM/DD)

Additional Information

Please limit to less than 200 words...

Prognosis for Recovery

What is the condition of victim?

Current? Please Choose Able Bodied Partially Disabled Totally Disabled Long-Term Prognosis? Please Choose Able Bodied Partially Disabled Totally Disabled Uncertain

Has the victim retuned to work? Choose YES NO

Are there any pre-existing medical conditions or disabilities?

Does the medical conditions or disabilities restrict any type or amount of work the victim can perform?

Has the victim started any vocational training and or rehabilitation? Choose YES NO

Post injury occupation:

Other Considerations

Hours of free time:

Hourly cost of replacement help: Past and or expected future medical expenses:

Lost quality of life:

Attachment1:

Attachment2:

Attachment3:

Attachment4:

Attachment5:

Please Provide the following:

1. If disabled, evidence (i.e. doctor's report, Social Security Disability Rating, etc)

2. Copy of complaint

3. Relevant expert reports

4. Copy of relevant depositions

5. Earnings & benefits history (pre & post injury)