Medical History Questionnaire

Medical History Questionnaire 

To speed up the appointment process, we ask that you complete this form at least 24-hours before your appointment.  This will give us adequate time to review the information.

Directions: Answer all questions to the best of your ability, and click “Submit” when you are finished. Only click “Submit” once.

Medical Information Questionnaire

FIRST NAME *
LAST NAME *

CURRENT INJURIES RELATED TO THE AUTO/WORK ACCIDENT

Select All That Apply

Headache
Loss of Sleep
Difficult Sleeping
Numbness in Legs
Numbness in Arms
Chest Pain
Nausea
Shoulder Pain
Muscle Weakness
Twitching
Stiff Neck
Neck Pain
Back Pain - Upper
Back Pain - Lower
Swollen Joints
Tremors
Foot Trouble
Painful Tail Bones
Hernia
Spinal Curvature
Faulty Posture
Bursitis
Knee Pain
Other

MEDICAL HISTORY

Please review the following list of medical symptoms and conditions, and check all that apply.

Why do we need this information? In the event that your case is litigated, having this information in the early stages of your case can will enable us to better defend you.

Alcoholism
Anemia
Arthritis
Asthma
Bleeding Disorders
Bronchitis
Cancer
Cataracts
Chemical Dependency
Depression
Diabetes
Emphysema
Epilepsy
Fractures
Glaucoma
Goiter
Gout
Heart Disease
Hepatitis
Hernia
Herniated/Bulging Disc
Kidney Disease
Liver Disease
Migraine Headaches
Multiple Sclerosis
Osteoporosis
Pacemaker
Parkinson's Disease
Pinched Nerve
Pneumonia
Polio
Prostate Problems
Prosthesis
Psychiatric Care
Rheumatoid Arthritis
Rheumatic Fever
Scarlet Fever
Stroke
Suicide Attempts
Thyroid Problems
Tonsillitis
Tuberculosis
Tumors / Growths
Ulcers
Other

IMPORTANT NOTICE: Although this information will be kept confidential, this questionnaire shall not give rise to legal representation. We would like to earn the opportunity to represent you if your case is appropriate. However, representation will only be undertaken after a written agreement is completed and signed. By electronically signing this form, you indicate that you understand that you will not be represented by Murphy Law Firm, LLC until a Fee Agreement is completed and signed by all parties."

E-Signature (Please type your full name):

If there are any issues during the submission process, please contact Murphy Law Firm at 770-577-3020.