West Palm Beach Florida car accident INJURY AND PAIN ASSOCIATED WITH YOUR WEST PALM BEACH FLORIDA CAR ACCIDENT QUESTIONNAIRE – Call 1-800-74-TRIAL

Interviewer: ________________________________________

Name of client: ________________________________________

Address and
daytime phone
number of client: ________________________________________

Date: ________________________________________

1. Describe the accident or circumstances which led up to your injury and resulting pain associated with your West Palm Beach Florida car accident .

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2. When and where did you first become aware of the pain associated with your West Palm Beach Florida car accident associated with the injury?

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3. In what part or parts of your body did the pain associated with your West Palm Beach Florida car accident first occur?
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4. In what part or parts of your body does the pain associated with your West Palm Beach Florida car accident now occur?
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5. Has the pain associated with your West Palm Beach Florida car accident ever been localized?____
If so, where? ______________________________________________

6. Describe as best you can how the pain associated with your West Palm Beach Florida car accident feels to you. (Include in your answer how severe the pain associated with your West Palm Beach Florida car accident is, whether the pain associated with your West Palm Beach Florida car accident is continuous or intermittent, how long it lasts and whether it ever changes).
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7. Are there any circumstances which intensify or lessen the pain associated with your West Palm Beach Florida car accident ?___
If so, please describe in detail.
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8. Does the pain associated with your West Palm Beach Florida car accident lead to any other difficulties (e.g., inability to move your arms or legs, headaches, nausea, irritability)? . If so, explain.
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9. Does the pain associated with your West Palm Beach Florida car accident ever interfere with your daily activities?
If so, please explain.
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10. Do you ever have to stop your activities to alleviate the pain associated with your West Palm Beach Florida car accident ? ____
If so, please explain.
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11. Do you ever have to lie down and rest to alleviate the pain associated with your West Palm Beach Florida car accident ? ____
If so, please state when and how often. ______________________________________________
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12. Do you ever have to take off from work because of the pain associated with your West Palm Beach Florida car accident ?_____
If so, please explain how often this happens.
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13. Has anything helped to lessen the pain associated with your West Palm Beach Florida car accident (e.g. medication, relaxation, massage, rest, counseling)?
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14. If so, how long does it take for these remedies to work? ______________________________________________

15. How long do these remedies last before the pain associated with your West Palm Beach Florida car accident returns? ______________________________________________

16. What have you told your doctor about your pain associated with your West Palm Beach Florida car accident ?
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17. Has any doctor ever told you that you are imagining your pain associated with your West Palm Beach Florida car accident ? ______________________________________________

How did you feel when you were told this? ______________________________________________

What did you say in response? ______________________________________________

18. Has any doctor explained the cause of your pain associated with your West Palm Beach Florida car accident ?____
If so, what did he say?
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19. Are you satisfied with the doctor's explanation, or do you think the pain associated with your West Palm Beach Florida car accident is due to some cause or reason other than what the doctor has told you?
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20. List all persons you have consulted for treatment of your pain associated with your West Palm Beach Florida car accident and injury. If any of these persons are doctors, specify their specialties (e.g., cardiologist, internist, neurologist, orthopedist, chiropractor, osteopath, psychologist, plastic surgeon).
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21. Has any doctor recommended an operation to alleviate the pain associated with your West Palm Beach Florida car accident ? .. If so, please state the doctor's name and address, and when the recommendation was made.
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22. Have you had any operations for your pain associated with your West Palm Beach Florida car accident ? If so, please list dates of operations.
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23. Did any of the operations help? If so, which ones, and how long did they help?
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24. List all medications (both prescription and non-prescription) which you are taking; include the name of the medication, its dosage, and how often you take it.
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25. Do any of these medications alleviate your pain associated with your West Palm Beach Florida car accident ? ____
If so, specify which ones work and for how long each works.
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26. Have you ever had any nerve blocks for pain associated with your West Palm Beach Florida car accident ? ______________________________________________

If so, give the dates.
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27. Did any of these injections bring relief?
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28. Who prescribed the nerve blocks? ______________________________________________

29. Have you ever used a TENS unit for the pain associated with your West Palm Beach Florida car accident ? ______________________________________________

If so, who prescribed it for you? ______________________________________________
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30. Did the TENS unit provide relief? ______________________________________________

31. Before this injury, did you ever experience any severe pain associated with your West Palm Beach Florida car accident over a period of time?
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32. If so, please give the circumstances and dates. ______________________________________________
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33. Did you consider yourself a "sickly" person? ______________________________________________

34. What is your current treatment? ______________________________________________

35. What do you expect from your treatment? ______________________________________________

36. Do you think your treatment plan is working?
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37. Do you think your treatment plan is helping to alleviate your pain associated with your West Palm Beach Florida car accident ? ______________________________________________

38. Are you satisfied with your doctors and your treatment plan? If not, what changes would you like to make?
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39. Have you ever had any psychological treatment for your pain associated with your West Palm Beach Florida car accident ? If so, when and from whom?
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40. Have you ever had any psychological treatment for any other condition or problem? If so, when and from whom?
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4 1. Has the pain associated with your West Palm Beach Florida car accident interfered with your social life? ______ If so, be as specific as possible in describing any activities or hobbies in which you can no longer participate or which you can no longer enjoy. ______________________________________________
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42. Did you consider yourself an active and energetic person before your injury and the resulting pain associated with your West Palm Beach Florida car accident ?
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43. Are there any activities or hobbies you still enjoy? ____ What are they
and to what extent can you still participate in them? ______________________________________________
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44. Do you have any desire to participate In social or recreational activities? If not, why don't you have the desire?
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45. Has the pain associated with your West Palm Beach Florida car accident and injury affected your sexual activities?
If so, please explain.
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46. Does talking about your pain associated with your West Palm Beach Florida car accident and injury help in any way? if so, please explain.
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47. Are you receiving any counseling for your pain associated with your West Palm Beach Florida car accident ? ______________________________________________

If so, from whom?
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48. Do you consider yourself to be an irritable and impatient person? ______________________________________________
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49. How often do you get angry? ______________________________________________

50. Do you feel that your anger or irritability is associated with your pain associated with your West Palm Beach Florida car accident ?
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51. Do you feel that your pain associated with your West Palm Beach Florida car accident is causing you to have emotional difficulties? ______________________________________________

If so, explain. ______________________________________________

52. How do you think your spouse reacts to your pain associated with your West Palm Beach Florida car accident ? ______________________________________________

53. How do you think your children react to your pain associated with your West Palm Beach Florida car accident ? ______________________________________________

54. How do you think your friends react to your pain associated with your West Palm Beach Florida car accident ? ______________________________________________

55. What was your general outlook on life before the injury and pain associated with your West Palm Beach Florida car accident ? ______________________________________________

56. What is your general outlook on life now? ______________________________________________

57. Do you ever feel that your situation is hopeless?____
If so, what do you think can be done to remedy this feelings______________________________________________
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58. Do you consider that you have a positive outlook with respect to your injury and pain associated with your West Palm Beach Florida car accident ?
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If not, what can you do or what can be done to achieve a
positive outlook?
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59. What do you think is the cause of your pain associated with your West Palm Beach Florida car accident ?
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60. What do you feel can be done to alleviate your pain associated with your West Palm Beach Florida car accident ?
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61. What do you feel your attorney can do to help?
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62. With respect to your pain associated with your West Palm Beach Florida car accident and injury, what do you expect from your attorney in this case?
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Attorney's notes and comments: