Free Case Evaluation

Name
First Middle Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Date of Birth
S.S.#
Best time to be reached
Martial Status
- Single
- Married
- Divorced
- Widowed
Spouse's Name
Name of Injured Child’s Biological Father
Biological Father’s Date of Birth
Biological Father’s Address (if different from above):
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
PEOPLE WHO ALWAYS KNOW HOW TO CONTACT YOU:
Name
First Last
Relationship
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
DRUG USE
Did you take the name brand Zofran or the generic, Ondansetron:
Did you have morning sickness/nausea during pregnancy?
Where you given Zofran/Ondansetron to treat morning sickenss/nausea during pregnancy?
Doctor Who Prescribed:
Doctor Phone:
Doctor Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Drug Start Date
Drug Stop Date
Dosage
Reason for taking Drug:
Pharmacy where Drug was filled:
Pharmacy where Drug was filled Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Pharmacy Phone Number:
Approximate date you found out you were pregnant:
OB/Gyn Name
First Last
OB/Gyn Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
OB/Gyn Phone
INJURED CHILD’S INFORMATION
Name
First Last
Date of Birth
S.S.#
Present Age:
Hospital where child was born:
Were you told before you child’s birth that there may be a problem:
- Yes
- No
What were you told, by whom and when:
Name and address of doctor (Address, City, State, Zip):
Type of birth defect:
Date child was diagnosed with birth defect:
Name and address of doctor who diagnosed birth defect:
Has your child undergone surgery for his/her condition:
- Yes
- No
If yes, date of surgery(ies):
Hospital:
Address of hospital where surgery was performed:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Name, address, and phone of surgeon (Address, City, State, Zip):
Name and address of child’s current doctor (Address, City, State, Zip)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Has your child been diagnosed or treated for any of the following: (check all that apply)
Heart Defects
- ASD (Atrial Septal Defect)
- Valvular Abnormalities
- VSD (Ventricular Septal Defect)
- Heart Murmor
- Tetalogy of Fallot
- Coarctation of Aorta
- Congenital Deformity
- Other
Skelatal/Bone Abnormalities:
- Cleft Palate
- Club Foot
- Cranial/Skull Defects
- Malformation of Fingers/Toes
- Malformation of Limbs
- Missing Fingers/Toes
- Missing of Limbs
- Congenital Deformity
MOTHER’S MEDICAL HISTORY:
Do you have a family history of any of the following:
- Coronary Artery Disease
- Hypertension
- Heart Defects
- Congenital Birth Defects
- Cleft Palate
- Cleft Lip
- Valvular Abnormalities
Please Explain:
SSRI USE (Check if taken during pregnancy)
- Zoloft
- Paxil
- Prozac
- Celexa
- Wellbutrin
- Depakote
- Lexapro
- Other
Was the prescription drug taken during pregnancy:
- Yes
- No
Usage Start Date:
Usage Stop Date:
Dosage:
Comments
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Phone
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Free Case Evaluation

PEOPLE WHO ALWAYS KNOW HOW TO CONTACT YOU:

DRUG USE

INJURED CHILD’S INFORMATION

MOTHER’S MEDICAL HISTORY:

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