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 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.

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