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Intake Questionnaire

Client Information

First & Last Name *

Date of birth *

Street Address, City, State, Zip *

Contact Number(s) *

Best Time to Contact

Email Address *

Relationship to Injured Party

Does Client have Power of Attorney?

Injured Party Information

First & Last Name (Injured Party)

Date of Birth (Injured Party)

Social Security Number (Injured Party)

Street Address, City, State, Zip (Injured Party)

Contact Number (Injured Party)

Best Time to Contact (Injured Party)

Is the Injured Party deceased? If yes, what is the cause of death?

Emergency Contact Information

First & Last Name (Emergency)

Relationship to Injured Party (Emergency)

Contact Number (Emergency)

Usage Information

Exposure type

Exposure dates

Duration of exposure

Location of exposure

Employment history for commercial usage/exposure

Diagnosis Information

Type of Cancer

Cancer Stage

Diagnosis Date

First Treatment Date

Last Treatment Date

Treatment Information

Chemotherapy treatment information

Date started and stopped

Residence state during treatments

Facility/Provider Information

Hospital/Facility/Provider Name

Date admitted and discharged

Phone number and address

Surgeon information

Oncologist information

PCP information

Additional specialist information

Roundup Additional Information

Smoking history

Medical history

Proof of use

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