Client Work Sheet to Evaluate Claim
       
Date of injury:_____________   Date injury discovered: ____________________________  
Note: Most claims must be brought within 2 years.  Immediate attorney consultation is recommended.
       
A. Please indicate the type of injury involved:  
1. Anesthesia accident _____ 10. Misidentification of patient _____
2. Blood transfusion _____ 11. Surgery technique _____
3. Consent issues _____ 12. Surgery unnecessary _____
4. Delay in diagnosis _____ 13. Treatment technique _____
5. Delayed/refused treatment _____ 14. Treatment unnecessary _____
6. Equipment failure _____ 15. Obstetrical procedure _____
7. Fall _____ 16. Vicarious liability _____
8. Medication error _____ 17. All other_____________________________ _____
9. Misdiagnosis _____    
       
B. Please indicate the location where the injury occurred:  
1. Critical care unit _____ 7. Physical therapy _____
2. Emergency room department _____ 8. Physician’s office _____
3. Labor and delivery room _____ 9. Radiology _____
4. Nursery/Peds _____ 10. Recovery room _____
5. Operating room _____ 11. Special procedure room _____
6. Patient’s room _____ 12. Other________________________________ _____
       
C. Please describe the severity of the injury:  
1. Emotional only _____ 6. Permanent significant _____
2. Temporary insignificant _____ 7. Permanent major _____
3. Temporary minor _____ 8. Permanent grave _____
4. Temporary major _____ 9. Death _____
5. Permanent minor _____    
       
D. Describe who the injured party is:  
1. Age _____    
2. Sex:      
Male
 _____    
Female
 _____    
3. Type:      
Patient
 _____    
Other
 _____    
       
E. Who paid medical expenses:  
Medicare ______________________________________________________  
Medicade ______________________________________________________  
Health Insurance ______________________________________________________  
Other ______________________________________________________  
Unknown ______________________________________________________