 This form might be useful to you if you think you have been exposed to toxic chemicals which have caused health problems. It could help you organize your information and provide a basis on which to evaluate your particular circumstances. This Case History is intended to be used soley by you and your attorney, should you elect to seek legal counsel. This form is not intended for electronic use or transmittal. To complete this form, you must first print it. If you have questions about this form or if you wish to contact Rober M. Fellheimer, P.C., please call (215) 345-7090 or e-mail us at info@toxictort.com. 1. Date prepared ______________________________________________________ 2. Client name _______________________________________________________ 3. Current address ____________________________________________________ 4. Current telephone (h) _______________ (w) _____________________ 5. Type of case _______________________________________________ 6. Date of occurrence ____________________________ 7. Birth Date ___________ 8. Social Security __________________ 9. Married ( ) Divorced ( ) Separated ( ) 10. Dependant children – names and ages ___________________________________ ______________________________________________________________________ DEFENDANT INFORMATION 11. Defendant’s Name (#1) _______________________________ 12. Current address _____________________________________ 13. Telephone __________________________ 14. Insurance carrier/coverage ______________________________ 15. Address __________________________________ 16. Policy # ______________ Claim # _____________________ 17. Defendant name (#3) ____________________________ 18. Current address _________________________________ 19. Telephone ___________ 20. Insurance carrier/coverage _____________________________ 21. Address _____________________ 22. Policy # ____________ Claim # ___________ DESCRIPTION OF EXPOSURE / OCCURRENCE: 23. Date _____________ Time _____________ 24. Exact location ________________________ 25. Municipality ____________________ County _______________ 26. Description ________________________________________________________ ___________________________________________________________ ___________________________________________________________ 27. Witnesses : Name Address Phone Location 1.____________________________________________________________________ 2.____________________________________________________________________ 3.____________________________________________________________________ 4.____________________________________________________________________ 28. Investigation by _____________________________________________________ 29. Charges: Plaintiff ___________________ Defendant _______________________ 30. Municipal hearings __________________________________________ 31. Any Admissions or statements: By whom ________________________ When _____________________ Those present _________________________ Written or oral ________ Signed ______________ Recorded __________________________ MEDICAL DATA: 32. Nature of injuries __________________________________________________ ____________________________________________________________________ Detailed Injuries 33. I. Central Nervous System Headaches___________________________________________________________ Memory Loss_________________________________________________________ Personality Changes Anxiety______________________________________________________________ Depression____________________________________________________________ Mood swings__________________________________________________________ Loss of impulse control__________________________________________________ Irritability sleep disorder_________________________________________________ Appetite changes_______________________________________________________ Eyes_________________________________________________________________ Ears-Ringing__________________________________________________________ PNS Numbness and tingling extremities_________________________________________ 34. II. Chronic Fatigue, Fibromylagia, Chemical Sensitivity Sensitive to other chemicals, gasoline, smoking, solvents, pesticides, perfume _____________________________________________________________________ _____________________________________________________________________ Fatigue, tiredness and muscle fatigue________________________________________________________________ 35. III. Respiratory Upper and Lower________________________________________________________ Shortness of breath, trouble breathing with or without exposure 36. IV. IMMUNE/ AUTOIMMUNE Fatigue, illnesses, flu____________________________________________________________________ 37. V. ENDOCRINE Thyroid, adrenal, pituitary__________________________________________________ 38. VI. LIVER Blood testing____________________________________________________________ Related mcs____________________________________________________________ 39. VII. GI ______________________________________________________________________ 40. VIII. RASHES, ALLERGIES ______________________________________________________________________ 41. IX. CANCER 42. DO YOUR SYMPTOMS SEEM TO BE AGGRAVATED BY A SPECIFIC
ACTIVITY?_____________________________________________________________ 43. HAVE THERE BEEN ANY INCIDENCES OF BIRTH DEFECTS SINCE THE EXPOSURE/OCCURRENCE? PLEASE EXPLAIN. _________________________ _____________________________________________________________________ 44. Names and addresses of current treating physicians: 1. ___________________________________________ 2. ___________________________________________ 3. ___________________________________________ 45. Hospital care _____________________________________________ ___________________________________________________________ 46. X rays _____________________________ 47. Diagnostic testing___________________________________________________ _____________________________________________________________________ 48. Previous traumatic injuries: 1. __________________________________ 2. __________________________________ 3. ___________________________________ 49. Previous NON traumatic injuries: 1. _____________________________ 2. _____________________________ 3. ________________________________ 50. Name and address of family physician _________________________________ ______________________________ 51. Date of last visit _________________ 52. Reason for visit __________________ 53. Current medical program, if any ___________________________________ PERSONAL INTERESTS: 54. Hobbies ______________________________________________________ 55. Educational background _________________________________________ 56. Remarks ______________________________________________________ _________________________________________________________________ _________________________________________________________________ ATTACHMENTS: 1. 2. 3. 4. 5. EMPLOYMENT HISTORY: 57. Name and address of present employer(or if disabled, last employer) _____________________________ ______________________________________________________ 58. Job classification ____________________ 59. Length of employment _______________ 60. Union ___________________ 61. Base pay at date of accident hourly__________ weekly___________ 63. Hours per week _______ 64. Commissions (if any ____________ 65. Date stopped work _____________ 66. Date returned to work __________ 67. PART TIME EMPLOYMENT (NAME AND ADDRESS). IF SELF EMPLOYED, PLEASE STATE ________________________________________________ _______________________________________________ 68. Earnings: Weekly ___________ Monthly _____________ Annually ________________ 69. Prior employment _____________________________________________ 70. Disability benefits______________________________________________ Robert M. Fellheimer, P.C. The information provided at this web site is provided solely for information purposes and is not intended to be legal advice. The information is not provided in the course of an attorney-client relationship, and is not a viable substitute for obtaining legal advice from a licensed attorney. The information in these pages is provided only as general information which may or may not reflect the most current legal developments. Internet viewers should not act upon this information without first seeking qualified professional counsel. This web site is not intended for those viewers in any state where the web fails to comply with all laws and ethical rules of that state. The law firm of Robert M. Fellheimer, P.C. is licensed in the Commonwealth of Pennsylvania for the practice of law. For additional information you may also contact the law firm directly. |