Medical Malpractice Intake Questionnaire

How to Complete This Form

Answer all questions that apply to your situation. Leave blank only those sections that do not apply to you.
Be specific and accurate. Dates, names, and details matter. If you're unsure of a date, provide your best estimate.
Attach documents if possible: Medical records, hospital discharge summaries, test results, bills, and any written communications from healthcare providers are very helpful.
Time is critical in medical malpractice cases. Louisiana law imposes strict deadlines. Do not delay in contacting us.
Your information will be kept confidential under Louisiana Rules of Professional Conduct Rule 1.18, which protects prospective client communications. An attorney-client relationship is not established until a written engagement agreement is signed.
Medical records authorization: If we take your case, we will ask you to sign a HIPAA authorization so we can obtain your medical records directly from your healthcare providers. This is essential for evaluating your claim.

2 Healthcare Provider(s) Involved

Medical malpractice cases involve one or more healthcare providers. Please list each provider, facility, or entity involved in your care. If more than 4 providers are involved, please attach a separate sheet with additional information.

Healthcare Provider #1

Provider Name (Full Legal Name)

Type of Provider

Medical Specialty (if applicable)

Facility/Hospital Name Where Treatment Occurred

Facility Address

Date Treatment Began

Date Treatment Ended

Nature of Treatment / Procedure Performed

Is This Your Regular or Primary Care Doctor?

Yes No

3 What Happened

In Your Own Words, What Do You Believe Went Wrong With Your Medical Care?

When Did You First Realize Something Was Wrong?

What Condition or Symptoms Were You Being Treated For Originally?

What Procedure, Surgery, or Treatment Was Performed?

Were You Informed of the Risks Before the Procedure or Treatment?

Yes, I was fully informed of the risks Somewhat, but not all risks were explained No, I was not informed of the risks I'm unsure what information I was given

Did You Sign Any Consent Forms? Do You Have Copies?

Yes, and I have copies Yes, but I don't have copies No consent forms were signed I'm unsure

Were There Any Complications During or After the Procedure?

What Is Your Current Medical Condition as a Result?

Important Dates — In Louisiana, there are strict time limits for filing medical malpractice claims. It is very important that you provide accurate dates.

Date(s) of the Medical Treatment or Procedure at Issue

Date You First Noticed Something Was Wrong

Date You Realized a Medical Error May Have Occurred

Date of Any Corrective Surgery or Treatment

Have You Filed Any Complaints or Claims Related to This Matter? If So, When?

4 Your Medical History

What Condition or Symptoms Led You to Seek Treatment From This Provider?

How Long Had You Been Experiencing These Symptoms Before Treatment?

Were You Treated by Any Other Providers for the Same Condition? If So, Who and When?

Do You Have Any Pre-Existing Medical Conditions Relevant to the Area of Treatment?

Are You Currently Taking Any Medications? Please List Them

Do You Have Any Drug Allergies or Other Allergies?

5 Current Medical Status

Are You Still Receiving Treatment for the Injuries Caused by the Medical Error?

Yes No

Current Treating Physician(s) — Name, Specialty, and Facility

Have You Had Any Corrective Surgeries or Procedures? If So, Describe

What Symptoms Are You Currently Experiencing?

How Has This Affected Your Daily Life? (Work, Household Activities, Emotional Wellbeing, etc.)

Prognosis — What Do Your Doctors Say to Expect Going Forward?

6 Other Providers & Second Opinions

Have You Obtained a Second Opinion About What Happened?

Yes No

If Yes: Doctor Name, Facility, and What They Told You

Have You Filed a Complaint With the Hospital, Medical Board, or Any Other Entity?

Yes No

If Yes, With Which Entity and When?

Have You Contacted Any Other Attorneys About This Matter?

Yes No

If Yes, Which Attorney(s) and What Did They Say?

7 Financial Impact

Medical Expenses Incurred as a Result of the Medical Error (Approximate Total)

Have You Missed Work? How Many Days or Weeks?

Employer Name and Job Title

Hourly or Salary Rate

Are You Currently Able to Work?

Yes, full-time Yes, part-time only No, I cannot work

Have You Lost Income or Earning Capacity?

Health Insurance Carrier

Did Health Insurance Pay for the Original Treatment and/or Corrective Treatment?

Medicare or Medicaid Involvement?

8 Witnesses & Documentation

Were Any Family Members or Friends Present During the Treatment or When Complications Arose?

Do You Have Copies of Your Medical Records?

Yes No Partial

Do You Have Photos of Injuries (Surgical Site, Wounds, Scars, etc.)?

Yes No

Have You Kept a Journal or Diary of Your Symptoms and Recovery?

Yes No

Any Other Relevant Documentation (Bills, Receipts, Correspondence, etc.)?

9 Conflicts Check

Full Legal Names of ALL Healthcare Providers, Facilities, and Any Other Parties Involved

Have You or Any Family Member Been a Client of Aertker Legal?

Do You Have Any Known Connection Between the Providers and This Firm?

10 Your Goals & Additional Information

What Outcome Are You Hoping to Achieve?

Is There Anything Else Important That We Should Know?

How Did You Hear About Aertker Legal, LLC?

Google / Online search Facebook Personal referral Other

If Referred by Someone, Please Provide Their Name

11 Acknowledgment

I certify that the information provided in this questionnaire is true, accurate, and complete to the best of my knowledge. I understand that this questionnaire does not create an attorney-client relationship, and that no legal advice has been provided. I have read and understand the confidentiality notice above. I authorize Aertker Legal, LLC to contact me regarding my inquiry and to gather additional information as necessary to evaluate my claim.

Printed Name

Signature

Date

Supporting Documents (optional)

Attach up to three documents relevant to your matter — for example an existing will, deed, contract, police report, or correspondence. PDF, Word, or image. You may bring or email additional documents to your consultation.

Maximum ~10 MB. For larger or highly sensitive files, please bring them to your appointment.

Medical Malpractice Intake Questionnaire

How to Complete This Form

Healthcare Provider #1

Healthcare Provider #2

Healthcare Provider #3

Healthcare Provider #4