Medical Malpractice Questionnaire | Richardson Richardson Boudreaux Injury and Accident Attorneys

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Name of injured party*

First

Phone Number*

Email Address*

Relationship to injured party*

Date of birth of injured party*

MM slash DD slash YYYY

Date of incident*

MM slash DD slash YYYY

Date the injury was discovered*

MM slash DD slash YYYY

If deceased, date of death

MM slash DD slash YYYY

Location of incident*

(city, state)

Health care facility/health system involved*

Check all boxes that apply

Hillcrest Medical Center (Tulsa)

Hillcrest Medical Center (Claremore)

Hillcrest Medical Center (South)

Saint Francis Hospital (61st & Yale)

Saint Francis Hospital South

Saint John Medical Center (Tulsa)

Saint John Medical Center (Bartlesville)

Saint John Medical Center (Owasso)

Saint John Medical Center (Broken Arrow)

Saint Francis Hospital (Muskogee)

OSU Regional Hospital

OSU Medical Facilities

OU Medical Facilities

Oklahoma Surgical Hospital

Other

Other, please specify.*

Name of doctor(s)or other healthcare provider*

Type of medical malpractice*

Check all boxes that apply

Death

Birth Injury

Failure to diagnose the mother's medical condition during pregnancy

Failure to diagnose a birth defect

Complications during the delivery process

Failure to order a cesarean section when necessary

Failure to handle complications in a competent manner

Fetal Monitor issues

Medication error

Delayed Diagnosis

Misdiagnosis

Failure to treat

Defective medical device

Retained surgical instruments or other objects

Unnecessary surgery

Anesthesia errors

Poor surgical technique of surgeon

Wrong surgical site

Wrong surgical procedure

Inadequate informed consent for surgery

Failure to screen for fall risk, implement fall prevention interventions and/or provide immediate intervention and treatment, following both witnessed and unwitnessed falls

Failure to screen for skin breakdown and/or implement interventions to prevent pressure injuries

Failure of nursing staff to notify provider of a change in patient status

Bed sores

Premature discharge

Prescription or drug-caused injury

Falls or patient being dropped

Dental-related error

Other

Other, please specify.*

Please provide a brief summary of the event(s)*

Injuries / damages related to the above issues*

Check all boxes that apply

Death

Catastrophic injury that resulted in need for life-long care or special accommodations

Permanent disability/loss of functioning

Severe disfigurement, deformity, loss of limb or scarring

Lost wages

Inability to perform any gainful employment

Pain and suffering

Loss of consortium (loss of companionship, comfort, sexual relations or the ability to bear children)

Other

Other, please specify.*

Patient height*

Patient weight*

If you are a smoker, please indicate the # of packs per day and # of years that you have been a smoker

Please describe any chronic health conditions*

For which you take medications and/or receive ongoing treatment

Please describe your CURRENT health condition*

Related to the injury mentioned above

Comments

This field is for validation purposes and should be left unchanged.

Medical Malpractice / Dental Malpractice / Nursing Home Neglect Questionnaire