Client Progress Form

Please fill out the following form to update us on your current physical condition and medical treatment. All information you provide is sent directly to your attorney and is protected by the attorney-client privilege.

If you would prefer to fill out a hard copy of this form, or would like additional copies of this form, please call our office.

If you have medical bills that you have not submitted to us yet you can send them via Email or Fax to the addresses below, or give us a call and we’ll be happy to assist you!

Email: info@FlahavanLawOffice.com
Fax: (818) 344-8007
Office Phone: (818) 708-7894

Your Name *

Phone Number *

Your Email *

Date *

1. During the past 3 months, have you suffered any pains from your injuries?
yesno

If yes, state:
(a) Where were these pains;
(b) How often did they occur,
(c) How long did they last, AND
(d) Were they mild, moderate or severe?

2. During the past 3 months, did you have any visible signs of injury, such as a bruise, discoloration, cut, scar, swelling, or lump?
yesno

If yes, describe each:

3. Please provide:
(a) The name of each doctor, therapist and laboratory you have seen in the past 3 months because of your injuries.
(b) What dates did you go to each? AND
(c) What was done for you by each?

4. During the past 3 months, did you receive any examination, tests or care in any hospital?
yesno

If yes, state the names for each and describe what was done for you:

5. During the past 3 months, did you take any medicine for your pain or injuries?
yesno

If yes, please state:
(a) What did you take?
(b) How often did you take it?
(c) Was this prescription medication?
(d) Who prescribed it?

6. If you used any of the following medical aids in the past 3 months, please indicate which ones by checking the boxes that apply:

If you checked any boxes besides "NONE", please describe:
(a) Each item;
(b) How often used; AND
(c) Who prescribed it (if anyone)

7. During the past 3 months, did you take any home treatments (such as heat lamp, electric pad, hot water bottle, hot bath or shower, massage, special exercise, etc.)?
yesno

If yes, please describe:
(a) The treatment; AND
(b) How often performed:

8(a) During the past 3 months, was there anything at work, home or elsewhere THAT YOU COULD NOT DO because of your injuries?
yesno

If yes, please describe to the best of your ability. (These can include such things such as job performance, caring for family members or children, performing tasks around the house, activities or hobbies, interaction with friends or family members, trips or events that were missed, etc.):

8(b) During the past 3 months, was there anything at work, home or elsewhere THAT YOU FOUND MORE DIFFICULT TO DO because of your injuries?
yesno

If yes, please describe AND state the names of any witnesses who can confirm this.

9. During the past 3 months, did you receive any new injuries not related to this accident?
yesno

If yes, please describe.

10. During the past 3 months, did you receive any hospital, doctor or other medical consultation or treatment for any cause other than your injuries in this case?
yesno

If yes, please describe.

11. During the past 3 months, did you lose any time from work because of your injuries?
yesno

If yes, please provide:
(a) The dates you missed from work;
(b) The wages you lost

Please provide anything else you think may be important with regard to your injuries, treatment or recovery: